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1149 Cards in this Set
- Front
- Back
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The nurse is administering sublingual nitroglycerin to a client. Immediately afterward, the client may experience:
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throbbing headache or dizziness.
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A client with iron deficiency anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of this type of anemia?
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Dyspnea, tachycardia, and pallor
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The nurse is caring for a client taking an anticoagulant. Which instruction regarding anticoagulant therapy should the nurse give the client?
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Limit foods high in vitamin K.
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The nurse delivers a client's 10 a.m. medications. The client is away from his room for a diagnostic study. Which action is most appropriate for the nurse to take?
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Lock the medications in the medicine preparation area until the client returns.
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The nurse is caring for a client receiving patient-controlled analgesia (PCA) for pain management. Which statement about PCA is true?
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Pain relief is initiated by the client as needed.
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The nurse is caring for a client with type 1 diabetes mellitus who exhibits confusion, light-headedness, and aberrant behavior. The client is still conscious. The nurse should first administer:
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15 to 20 g of a fast-acting carbohydrate such as orange juice.
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The nurse is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication?
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Bone fracture
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The nurse is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 47. Following the American Cancer Society guidelines, the nurse should recommend that the women:
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have a mammogram annually.
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The nurse is instructing a premenopausal woman about breast self-examination. The nurse should tell the client to do her self-examination:
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immediately after her menses.
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The nurse is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of performing the examination is to discover:
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changes from previous self-examinations.
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The American Cancer Society recommends routine screening to detect colorectal cancer. Which screening test for colorectal cancer should the nurse recommend?
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Flexible sigmoidoscopy beginning at age 50
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Which nursing diagnosis should the nurse expect to see in a care plan for a client in sickle cell crisis?
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Acute pain related to sickle cell crisis
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What can the nurse do to prevent lipodystrophy when administering insulin to a diabetic client?
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Rotate the injection sites.
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For a diabetic client with a foot ulcer, the physician orders bed rest, a wet-to-dry dressing change every shift, and blood glucose monitoring before meals and at bedtime. Why are the wet-to-dry dressings used for this client?
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Because they debride the wound and promote healing by secondary intention.
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An obese client is admitted to the hospital for abusing amphetamines in an attempt to lose weight. Which nursing intervention is appropriate for this client?
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Identify alternative ways for the client to lose weight.
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suggest referral to a sex counselor or other appropriate professional.
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Policy and procedure dictate that hand washing is a requirement when caring for clients. Which statement about hand washing is true?
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Frequent hand washing reduces transmission of pathogens from one client to another.
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The nurse is evaluating a postoperative client for infection. Which sign or symptom would be most indicative of infection?
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Red, warm, tender incision
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The nurse is caring for a client with a fractured hip. The client is combative, confused, and trying to get out of bed. The nurse should:
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obtain a physician's order to restrain the client when less restrictive interventions fail.
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The nurse is caring for a bedridden, elderly adult. To prevent pressure ulcers, which intervention should the nurse include in the care plan?
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Post a turning schedule at the client's bedside.
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Disturbed body image
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Refer the client to the American Cancer Society's Reach for Recovery program or another support program.
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Situational low self-esteem
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A client who has recently had surgery for prostate cancer expresses to the nurse feelings of anger toward God, his church, and the clergy. Which intervention is appropriate for this client?
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Encouraging the client to discuss concerns with the clergy
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The nurse is working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Which point about preventing transmission of the human immunodeficiency virus (HIV) is most important for the nurse to stress?
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Following safer-sex practices
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The nurse is preparing to begin one-person cardiopulmonary resuscitation. The nurse should first:
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establish unresponsiveness.
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notify the physician about cloudy or foul-smelling urine.
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The nurse is providing home care instructions to a client who has recently had a skin graft. It's most important that the client remember to:
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protect the graft from direct sunlight.
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The nurse is caring for a client who underwent a subtotal gastrectomy 24 hours earlier. The client has a nasogastric (NG) tube. The nurse should:
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irrigate the NG tube gently with normal saline solution as prescribed.
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A client is to be discharged from an acute care facility following treatment for right leg thrombophlebitis. The nurse notes that the client's leg is pain-free, without redness or edema. The nurse's actions reflect which step of the nursing process?
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Evaluation
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The nurse is caring for a client who recently underwent a total hip replacement. The nurse should:
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limit client hip flexion while sitting.
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When caring for a client who's being treated for hyperthyroidism, it's important to:
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balance the client's periods of activity and rest.
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Which intervention should the nurse try first with a client who exhibits signs of sleep disturbance?
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Provide the client with sleep aids, such as pillows, back rubs, and snacks.
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When preparing a client for an enema, the nurse should help him into the:
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left-lateral Sims' position.
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The nurse is caring for a client with a right ankle sprain. When applying cold to the client's injury, the nurse should:
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apply it immediately after the injury occurs.
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The nurse is teaching a client with a family history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse should encourage the client to:
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increase his activity level.
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The nurse is teaching a client diagnosed with basal cell epithelioma. The most common cause of basal cell epithelioma is:
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exposure to the sun.
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The nurse is giving instructions to a client who's going home with a cast on his leg. Which point is most critical?
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Reporting signs of impaired circulation
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A client undergoes a surgical procedure that requires the use of general anesthesia. Following general anesthesia, the client is most at risk for:
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atelectasis.
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The nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is:
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keeping his airway patent.
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The nurse is working on a surgical floor. The nurse must logroll a client following a:
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laminectomy.
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A client underwent cataract removal with an intraocular lens implant. The nurse is giving the client discharge instructions. These instructions should include which of the following?
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Avoid straining during bowel movements.
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When caring for a client with a nursing diagnosis of <i>Impaired swallowing</i> related to neuromuscular impairment, the nurse should:
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elevate the head of the bed 90 degrees during meals.
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When performing an assessment, the nurse collects the following data: impaired coordination, decreased muscle strength, limited range of motion, and the client's reluctance to move. This data indicates which nursing diagnosis?
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Impaired mobility
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The nurse is teaching a client with genital herpes. Education for this client should include an explanation of:
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the importance of informing his partner of the disease.
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A 25-year-old client asks the nurse how often and when she should perform breast self-examinations. The nurse should tell her:
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every month, 7 to 10 days after menses starts.
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A male client should be taught about testicular examinations:
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before age 20.
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When performing an abdominal assessment, the nurse should follow which examination sequence?
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Inspection, auscultation, percussion, and palpation
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"I'll only need chemotherapy therapy before receiving my bone marrow transplant."
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The nurse is providing teaching to a client who's at risk for coronary artery disease (CAD). The nurse tells the client that CAD has many risk factors. Risk factors that can be controlled or modified include:
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obesity, inactivity, diet, and smoking.
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The nurse is collecting data on a client admitted with a diagnosis of small bowel obstruction. When assessing the client's pulse rate, the nurse should:
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count the apical or radial pulse for 60 seconds.
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When inserting a urinary catheter, the nurse can facilitate the insertion by asking the client to:
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breathe deeply.
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The nurse is caring for a client with a colostomy. The client tells the nurse that he makes small pin holes in the drainage bag to help relieve gas. The nurse should teach him that this action:
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destroys the odor-proof seal.
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A client is prescribed transcutaneous electrical nerve stimulation (TENS) for pain relief. The rationale for using TENS is to:
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block painful stimuli traveling over small nerve fibers.
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The nurse must assess skin turgor of an elderly client. When evaluating skin turgor, the nurse should remember that:
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inelastic skin turgor is a normal part of aging.
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The nurse is assessing a client who may be in the early stages of dehydration. Early manifestations of dehydration include:
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thirst or confusion.
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A client who recently had a stroke requires a cane to ambulate. When teaching about cane use, the rationale for holding a cane on the uninvolved side is to:
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distribute weight away from the involved side.
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The nurse is developing a teaching plan for a client who must undergo an above-the-knee amputation of the left leg. After a leg amputation, exercise of the remaining limb:
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should begin the day after surgery.
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The nurse is preparing to remove a previously applied topical medication from a client. The rationale for removing previously applied topical medications before applying new medications is to:
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avoid administering more than the prescribed dose.
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The nurse is administering eyedrops to a client with glaucoma. To achieve maximum absorption, the nurse should instill the eyedrop into the:
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conjunctival sac.
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The nurse is administering eardrops to an adult client. To straighten the ear canal in an adult client before instilling the drops, the nurse should gently pull the:
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auricle up and back.
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The nurse is teaching a client about using vaginal medications. The nurse should instruct the client to:
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use only a water-soluble lubricant when inserting a suppository.
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The nurse is administering sublingual nitroglycerin to a client with chest pain. The nurse should place the medication:
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under the tongue.
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A client has an order for 5,000 units of subcutaneous heparin every 12 hours. When injecting heparin subcutaneously, the nurse should:
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use a 45- to 90-degree angle to insert.
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The nurse is collecting data on a client who has developed a paralytic ileus. The client's bowel sounds will be:
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hypoactive.
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The nurse is instructing a client about the use of antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by:
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forcing blood into the deep venous system.
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The nurse is caring for a client who's showing signs of hypoglycemia. This client will most likely have a blood glucose level:
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below 70 mg/dl.
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A client has sustained a right tibial fracture and has just had a cast applied. Which instruction should the nurse provide regarding cast care?
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Keep your right leg elevated above heart level.
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The nurse is developing a teaching plan for a client with diabetes mellitus. A client with diabetes mellitus should:
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wash and inspect feet daily.
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The nurse is with a group of patient-care attendants reviewing infection-control measures. The nurse tells the group that the first line of intervention for preventing the spread of infection is:
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washing hands.
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A client receiving total parental nutrition is prescribed a 24-hour urine test. When initiating a 24-hour urine specimen, the collection time should:
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start after a known voiding.
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A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client?
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Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer
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When developing a care plan for an older adult (age 65 and older), the nurse should consider which challenges faced by clients in this age-group?
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Adjusting to retirement, deaths of family members, and decreased physical strength
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The nurse is administering I.M. injections to an older client. The nurse should remember that an older client has:
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less subcutaneous tissue and muscle mass than a younger client.
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The nurse is collecting data on an elderly client. When collecting data, the nurse should consider that one normal aging change is:
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diminished reflexes.
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A person's psychosocial needs during the dying process of a relative may include:
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flexible visitation, participation in client care, and rest breaks.
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When taking a dietary history from a newly admitted client, the nurse should remember that which of the following foods is a common allergen?
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Strawberries
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While obtaining a health history, the nurse learns that the client is allergic to bee stings. When obtaining this client's medication history, the nurse should determine if the client keeps which medication on hand?
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Diphenhydramine hydrochloride (Benadryl)
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Which behavior suggests that a client has obtained relief from urticaria?
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The client no longer scratches his arms.
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Which nursing intervention is most appropriate for a client with multiple myeloma?
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Preventing bone injury
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When prioritizing a client's care plan based on Maslow's hierarchy of needs, the nurse's first priority would be:
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administering pain medication.
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When developing a therapeutic relationship with a client, the nurse should begin preparing the client for termination of the relationship:
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during the first meeting.
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In the stages of death and dying as defined by Elizabeth Kubler-Ross, feelings of loss, grief, and intense sadness are symptoms of:
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depression.
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To maintain a therapeutic environment with a client and his family, the nurse can use communication techniques such as the clarification technique. An example of the clarification technique is:
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"What do you mean when you say...?"
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The nurse is caring for a client admitted to the hospital with a bowel obstruction. The nurse should wear sterile gloves when:
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inserting an indwelling urinary catheter.
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The nurse is placing a client on airborne precautions. The client asks the nurse to leave his door open. The best reply to this is:
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"I must keep your door closed to prevent the spread of infection. I'll open the curtains so that you don't feel so closed in."
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A client is confused and continuously attempts to get out of bed. The physician prescribes a vest restraint. When applying a vest restraint, the nurse should:
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allow room for the client to turn.
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The nurse is about to administer a medication to a client. To verify the client's identity, the nurse should:
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check the client's identification bracelet.
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The nurse is caring for a client with end-stage heart failure. Which statement by the client best demonstrates understanding of an advanced directive?
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"A living will allows my decisions for health care to be known if I'm not able to speak for myself."
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A client has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. The nurse's first response is to:
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place saline-soaked sterile dressings on the wound.
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The nurse is caring for a client who has suffered a severe stroke. During data collection, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are:
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progressively deeper breaths followed by shallower breaths with apneic periods.
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A triple-lumen indwelling urinary catheter is inserted for continuous bladder irrigation following a transurethral resection of the prostate. In addition to balloon inflation, the functions of the three lumens include:
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continuous inflow and outflow of irrigation solution.
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A client with seizure disorder is having a grand mal seizure. During the active seizure phase, the nurse should:
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place the client on his side, remove dangerous objects, and protect his head.
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A client's blood glucose level is 45 mg/dl. The nurse should be alert for which signs and symptoms?
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Decreased level of consciousness (LOC), anxiety, confusion, headache, and cool, moist skin.
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afebrile, tachycardia, normal respiratory rate, and hypotension.
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The nurse is providing care for a client who has a sacral pressure ulcer with a wet-to-dry dressing. Which guideline is appropriate for a wet-to-dry dressing?
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The wound should remain moist from the dressing.
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As a nurse is talking to a client, the client begins choking on his lunch. He's coughing forcefully. The nurse should:
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stay with him but not intervene at this time.
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In community-based nursing, primary responsibility for decisions related to health care belongs to the:
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client.
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A client's left leg is in skeletal traction with a Thomas leg splint and Pearson attachment. Which intervention should the nurse include in this client's care plan?
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Teach the client how to prevent problems caused by immobility.
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A client with rheumatoid arthritis reports GI irritation after taking piroxicam (Feldene). To prevent GI upset, the nurse should provide which instruction?
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Take piroxicam with food or an antacid.
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The nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is to:
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walk from his room to the end of the hall and back before discharge.
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The nurse is caring for a client who was given pain medication before leaving the postanesthesia care unit. Upon returning to her room, the client complains of pain and requests more pain medication. Which is the best action for the nurse to take?
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Notify the physician that the client is continuing to complain of pain.
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The nurse is caring for a client infected with methicillin-resistant <i>Staphylococcus aureus</i> (MRSA). What's the major infection control measure to reduce MRSA and other nosocomial pathogens in a health care setting?
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Ensuring that personnel wash their hands before and after contact with every client
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A nurse received an accidental needle stick while giving an I.M. injection. The greatest threat for the nurse is:
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hepatitis B (HBV).
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The nurse is caring for a client with a history of falls. The first priority when caring for a client at risk for falls is:
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keeping the bed in the lowest possible position.
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A client has three children and his mother lives with them. This is called:
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an extended family.
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The nurse is collecting data on a 47-year-old client who has come to the physician's office for his annual physical. One of the first physical signs of aging is:
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failing eyesight, especially close vision.
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The nurse is collecting data on an 80-year-old widow. Which statement best describes the developmental stage of the client at this age?
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The client realizes that she can provide others with an example of wisdom and courage.
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The nurse is taking the health history of an 85-year-old client. Which information will be most useful to the nurse for when planning care?
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Current health promotion activities
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The nurse is teaching a client about the importance of disease prevention. Why is disease prevention necessary in health promotion?
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Prevention is emphasized in the link between personal behavior and health.
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The nurse is collecting data on a 71-year-old female client with ulcerative colitis. Which factor related to the family will have the greatest impact on the client's rehabilitation after discharge?
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Emotional support from the family
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The nurse is caring for an 85-year-old client. What's the most important factor directly influencing this client's mental health?
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The client's attitude toward life circumstances
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The nurse is instructing a client with a left fractured tibia how to walk with crutches. Which instruction would be appropriate?
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All weight should be on the hands.
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Hyperthyroidism is caused by increased levels of thyroxine in blood plasma. A client with this endocrine dysfunction would experience:
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heat intolerance.
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The nurse is caring for a client dying of lung cancer. According to Maslow's hierarchy of needs, which dimension of care is considered primary in importance when caring for a dying client?
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Physiological
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The nurse is giving a bath to a client with a decreased level of consciousness who has a normal body temperature. When giving a bed bath, what temperature should the water be?
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110<font face="LWWSYM">%</font> to 115<font face="LWWSYM">%</font> F (43.3<font face="LWWSYM">%</font> to 46.1<font face="LWWSYM">%</font> C)
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The nurse is admitting a client with a suspected fluid imbalance. The most sensitive indicator of body fluid balance is:
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daily weight.
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When performing oral care on a comatose client; the nurse should:
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place the client in a side-lying position, with the head of the bed lowered.
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The nurse is providing care for an immobilized client. For this client, the most appropriate and most effective nursing intervention would be:
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repositioning the client on alternate sides at least every 2 hours.
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Clients commonly confuse adverse effects of a drug with allergic reactions to the drug. Which of the following would most likely be an adverse effect, not an allergic reaction?
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Nausea and occasional vomiting after taking the drug
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The nurse is administering neomycin to a client. Which adverse effect should the nurse ask the client to report?
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Hearing loss
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A client with cholecystitis is receiving propantheline bromide (Pro-Banthine). The client is given this medication because it:
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inhibits contraction of the bile duct and gallbladder.
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The nurse is preparing to administer morphine to a postoperative client. Before administering morphine, the nurse should assess the client's:
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respiratory rate.
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A 78-year-old client with sensorineural hearing loss is admitted to a rehabilitation center after hip replacement surgery. A risk factor for this client would be:
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altered perceptions.
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The nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to:
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drink liquids only between meals.
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The nurse is administering preoperative sedation to a client going to the operating room for a aortobifemoral bypass. After administering preoperative sedation to the client, the nurse should:
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place the bed in low position with the side rails up.
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The nurse is teaching the client about risk factors for diabetes mellitus. Which of the following risk factors for diabetes mellitus is nonmodifiable?
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Advanced age
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The client most at risk for sensory overload is:
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an 80-year-old client in the intensive care unit (ICU).
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A client has just finished his glucose tolerance test. How many hours should it take for his blood glucose level to return to normal?
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3 hours
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The nurse is teaching a client recently diagnosed with myasthenia gravis. The nurse should teach the client that myasthenia gravis is caused by:
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a lower motor neuron lesion.
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A client underwent a modified mastectomy and has a pressure dressing encircling her chest. Which postoperative nursing care function should the nurse anticipate to be difficult?
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Promoting turning, coughing, and deep breathing
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A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:
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auscultate bowel sounds.
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The nurse is caring for a comatose client who has suffered a closed head injury. What intervention should the nurse implement to prevent an increase in intracranial pressure (ICP)?
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Elevate the head of the bed 30 to 45 degrees.
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The nurse is caring for a client with active upper GI bleeding. What's the appropriate diet for this client during the first 24 hours after admission?
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Nothing by mouth
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The nurse is teaching a client who suspects that she has a lump in her breast. The nurse instructs the client that a diagnosis of breast cancer is confirmed by:
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fine needle aspiration.
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A client who has discovered a breast lump is tearful and expresses concern over her situation. The best way for the nurse to respond to her is by:
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encouraging a discussion of her problems and fears.
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The nurse is developing a teaching plan for a client with genital herpes. She should include information about:
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acyclovir (Zovirax).
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A female client is being treated for genital herpes. The client should receive teaching on the:
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need to abstain from sexual contact.
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A 68-year-old male is being admitted to the hospital with abdominal pain, anemia, and bloody stools. He complains of feeling weak and dizzy. He has rectal pressure and needs to urinate and move his bowels. The nurse should help him:
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onto the bedpan.
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The nurse is collecting data on a client about his past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer?
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Polyps
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For a client with an exacerbation of rheumatoid arthritis, the physician prescribes prednisone (Deltasone). When caring for this client, the nurse should monitor for which adverse drug reactions?
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Weight gain, hypertension, and insomnia
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A client is suspected of having herpes zoster. The nurse knows that the lesions of herpes zoster are typically:
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grouped vesicles in linear patches along a dermatome.
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a panic attack.
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What should the nurse do for a client who's having a seizure?
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Loosen the clothing around the client's neck.
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To encourage adequate nutritional intake for a client with Alzheimer's disease, the nurse should:
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stay with the client and encourage him to eat.
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An elderly client with Alzheimer's disease begins supplemental tube feedings through a gastrostomy tube to provide adequate calorie intake. The nurse should be concerned most with the potential for:
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aspiration.
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Which of the following nursing interventions should the nurse perform for a client receiving enteral feedings through a gastrostomy tube?
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Change the tube feeding solutions and tubing at least every 24 hours.
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Bibasilar fine crackles
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The nurse is caring for a client with left-sided heart failure. To reduce fluid volume excess, the nurse can anticipate using:
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diuretics.
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A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these as signs and symptoms of:
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acute pulmonary edema.
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The nurse is caring for a client with suspected acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, the nurse should:
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place the client in high Fowler's position.
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The physician inserts a chest tube into a client to treat a pneumothorax. The tube is connected to water-seal drainage. The nurse can prevent chest tube air leaks by:
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checking and taping all connections.
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A client is unable to take a deep breath and doesn't want to get out of bed because his chest tube is causing discomfort. To increase client compliance with activity and deep breathing, the nurse should:
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administer pain medication before having the client deep breathe, cough, or get out of bed.
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To assess effectiveness of incentive spirometry, the nurse can use a pulse oximeter to monitor the client's:
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oxygen saturation.
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The nurse is caring for a client who required chest tube insertion for a pneumothorax. To confirm pneumothorax resolution, the nurse can anticipate that the client will require:
|
a chest X-ray.
|
|
|
A 50-year-old male is diagnosed with multiple myeloma and the prognosis is poor. He's tearful and trying to express his feelings, but he's having difficulty. The nurse should first:
|
ask if he would like her to sit with him while he collects his thoughts.
|
|
|
A client is undergoing tests for multiple myeloma. Diagnostic study findings in multiple myeloma include:
|
Bence Jones protein in the urine.
|
|
|
The nurse is providing care for a client with multiple myeloma, a disorder characterized by episodes of remissions and exacerbations. Which resource may best help the client adapt to the disease?
|
Support group
|
|
|
The nurse is caring for a client with multiple myeloma. A sign that a client with multiple myeloma isn't coping well with his prognosis is that he:
|
avoids any conversation concerning his health.
|
|
|
The nurse is collecting data on a client with possible osteoarthritis. The most significant risk factor for osteoarthritis is:
|
age.
|
|
|
A client with possible osteoarthritis is having X-rays performed on both knees. X-rays of an osteoarthritic joint reveal:
|
osteophyte formation.
|
|
|
The nurse is developing a teaching plan for a client diagnosed with osteoarthritis. To minimize injury to the osteoarthritic client, the nurse should instruct the client to:
|
install safety devices in his home.
|
|
|
The nurse is managing the care of a client with osteoarthritis. Appropriate treatment strategies for osteoarthritis include:
|
administration of nonsteroidal anti-inflammatory drugs (NSAIDs).
|
|
|
The nurse is collecting data on a postcraniotomy client and finds the urine output from a catheter is 1,500 ml for the first hour and the same for the second hour. The nurse should suspect:
|
diabetes insipidus.
|
|
|
The nurse is developing a teaching plan for a client diagnosed with diabetes insipidus. The nurse should include information about the deficiency of which hormone?
|
antidiuretic hormone (ADH).
|
|
|
The nurse is caring for a client with diabetes insipidus. The nurse should anticipate the administration of:
|
vasopressin (Pitressin).
|
|
|
A client who sustained a closed head injury is deteriorating and the prognosis is poor. The client meets brain-death criteria. Which nursing intervention is most appropriate at this time?
|
Approach the client's family about organ donation.
|
|
|
An 82-year-old client is admitted to the hospital with a diagnosis of pneumonia. The nurse learns that the client lives alone and hasn't been eating or drinking. When assessing him for dehydration, the nurse would expect to find:
|
tachycardia.
|
|
|
The nurse is helping a client with her meal choices. Which breakfast selection indicates that the client understands her low-potassium diet?
|
Scrambled eggs and toast with tea
|
|
|
A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body?
|
27%
|
|
|
A 52-year-old married man with two adolescent children is beginning rehabilitation following a stroke. When planning the client's care, the nurse should recognize that his condition will affect:
|
him and his entire family.
|
|
|
A client who has suffered a stroke is too weak to move on his own. To help the client avoid pressure ulcers, the nurse should:
|
turn him frequently.
|
|
|
The nurse is assisting with a screening for testicular cancer. Which client has the highest risk of developing testicular cancer?
|
A 28-year-old man
|
|
|
The nurse is teaching breast self-examination to a college student. The nurse knows that the client understands the best time to examine her breasts when the client says:
|
"I'll examine my breasts a week after my period starts."
|
|
|
A client with an indwelling urinary catheter is suspected of having a urinary tract infection. The nurse should collect a urine specimen for culture and sensitivity by:
|
wiping the self-sealing aspiration port with antiseptic solution and aspirating urine with a sterile needle.
|
|
|
A 78-year-old client has a history of osteoarthritis. Which signs and symptoms would the nurse expect to find on physical assessment?
|
Joint pain, crepitus, Heberden's nodes
|
|
|
A client undergoes a total hip replacement. Which statement made by the client would indicate to the nurse that the client requires further teaching?
|
"I don't know if I'll be able to get off that low toilet seat at home by myself."
|
|
|
The nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP?
|
Provide rest periods in between nursing interventions.
|
|
|
The nurse is administering neostigmine (Prostigmin) to a client with myasthenia gravis. Which nursing intervention should the nurse implement?
|
Schedule the medication before meals.
|
|
|
A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate?
|
Alternately patch one eye every 2 hours.
|
|
|
The nurse is assisting with a screening for colorectal cancer. The client with the highest risk of colorectal cancer is a:
|
52-year-old man with a family history of polyposis.
|
|
|
The nurse is teaching a client how to irrigate his stoma. Which action indicates that the client needs more teaching?
|
Hanging the irrigation bag 24<font face="LWWSYM">"</font> to 36<font face="LWWSYM">"</font> (60 to 90 cm) above the stoma
|
|
|
The nurse is caring for a client on the first postoperative day following a surgical repair of an abdominal aortic aneurysm. Which nursing diagnosis is the most important for this client?
|
Ineffective peripheral tissue perfusion
|
|
|
A client is admitted to the hospital with an exacerbation of her chronic systemic lupus erythematosus (SLE). She gets angry when her call bell isn't answered immediately. The most appropriate response to her would be:
|
"You seem angry. Would you like to talk about it?"
|
|
|
The nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan?
|
Monitor body temperature.
|
|
|
The nurse is teaching a client with chronic bronchitis about breathing exercises. Which of the following should the nurse include in the teaching?
|
Use diaphragmatic breathing.
|
|
|
The nurse administered NPH insulin to a diabetic client at 7 a.m. At what time would the nurse expect the client to be most at risk for a hypoglycemic reaction?
|
4 p.m.
|
|
|
A client tells the nurse that she has been working hard for the last 3 months to control her type 2 diabetes mellitus with diet and exercise. To determine the effectiveness of the client's efforts, the nurse should check:
|
glycosylated hemoglobin level.
|
|
|
The nurse is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse would expect to find:
|
deposits of adipose tissue in the trunk and dorsocervical area.
|
|
|
Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?
|
Monitoring the patency of an indwelling urinary catheter
|
|
|
A client is receiving a blood transfusion. If this client experiences an acute hemolytic reaction, which nursing intervention is the most important?
|
Immediately stop the transfusion, infuse normal saline solution, notify the blood bank, and call the physician.
|
|
|
###############################################################################################################################################################################################################################################################
|
Tie the restraint to the bed frame.
|
|
|
The nurse is performing wound care on a foot ulcer in a client with type 1 diabetes mellitus. Which technique demonstrates surgical asepsis?
|
Changing the sterile field after sterile water is spilled on it
|
|
|
A client has a conductive hearing loss caused by otosclerosis and has repeatedly refused surgery. To facilitate communication with the client, the nurse should:
|
sit or stand in front of the client when speaking.
|
|
|
The nurse is assisting with developing a care plan for a client who's at risk for impaired coping due to the effects of chronic illness. Which factor provides the best evidence that the client is at risk for difficulty in coping with his illness?
|
Lack of social support
|
|
|
The nurse is caring for a client placed in traction to treat a fractured femur. Which nursing intervention has the highest priority?
|
Assessing the extremity for neurovascular integrity
|
|
|
The nurse administers basic cardiac life support to a client in cardiac arrest. Which action does the nurse perform?
|
Assessing the patency of the airway
|
|
|
The nurse is caring for an unconscious client. Which nursing intervention takes highest priority?
|
Maintaining a patent airway
|
|
|
The nurse is providing care for a postoperative client who has undergone a small bowel resection. The client has an epidural catheter. Which of the following can be administered through this catheter?
|
Analgesics
|
|
|
The nurse is collecting baseline data on a client's skin integrity. Which of the following is a key assessment parameter?
|
Overall risk of developing pressure ulcers
|
|
|
A client complaining of right, lower quadrant pain is admitted to the emergency department. Blood specimens are drawn and sent to the laboratory. Which laboratory finding should be reported to the physician immediately?
|
White blood cell (WBC) count of 22.8/mm<font face="LWWSUP">3</font>
|
|
|
The nurse is preparing to care for a client who was just transferred from the emergency care unit to the medical surgical floor. What's the most effective means of preventing microbial transmission?
|
Meticulous hand washing
|
|
|
###############################################################################################################################################################################################################################################################
|
Aspiration
|
|
|
Which phrase is used to describe the volume of air inspired and expired with a normal breath?
|
Tidal volume
|
|
|
The nurse is performing a painless, noninvasive procedure to measure Sa<font size="-2">O</font><font face="LWWSUB">2</font>. What procedure is it?
|
Pulse oximetry
|
|
|
The nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure?
|
Lateral recumbent, with chin resting on flexed knees
|
|
|
A client with bladder cancer undergoes a total cystectomy and ileal conduit. Postoperatively, the nurse notes mucus in the client's urine. Which nursing intervention is most appropriate?
|
Explaining to the client that this is normal after this type of surgery
|
|
|
The nurse is performing a mental status examination on a client diagnosed with subdural hematoma. This test assesses which of the following?
|
Cerebral function
|
|
|
The nurse is caring for a confused, elderly client. What's the nurse's most important consideration?
|
Protecting the client from injury
|
|
|
A client with cancer is receiving chemotherapeutic drugs. What adverse effects are most common?
|
Nausea and vomiting
|
|
|
To combat the most common adverse effects of chemotherapy, the nurse would administer an:
|
antiemetic.
|
|
|
The nurse administers furosemide (Lasix) to treat a client with heart failure. Which adverse effect must the nurse watch for most carefully?
|
Low serum potassium level
|
|
|
A client with type 1 diabetes mellitus asks the nurse about taking an oral antidiabetic agent. The nurse explains that these medications are effective only if the client:
|
has type 2 diabetes.
|
|
|
The nurse is teaching a client who receives nitrates for the relief of chest pain. Which of the following instructions should the nurse emphasize?
|
Lie down or sit in a chair for 5 to 10 minutes after taking the drug.
|
|
|
The nurse is teaching a client who has been prescribed allopurinol for the treatment of gout. Which instruction would the nurse give to the client?
|
Avoid foods that are rich in purine.
|
|
|
The nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first?
|
Cover the protruding internal organs with sterile gauze moistened with sterile saline solution.
|
|
|
The nurse provides care for a client receiving oxygen from a nonrebreathing mask. Which nursing intervention has the highest priority?
|
Assessing the client's respiratory status, orientation, and skin color
|
|
|
The nurse assesses a client's respiratory status. Which observation indicates that the client is experiencing difficulty breathing?
|
Use of accessory muscles
|
|
|
The nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs?
|
Auscultation
|
|
|
Which of the following clinical findings would the nurse look for in a client with chronic renal failure?
|
Uremia
|
|
|
The nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?
|
The system has an air leak.
|
|
|
The nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?
|
Call the physician immediately.
|
|
|
###############################################################################################################################################################################################################################################################
|
Excess fluid volume related to congestion of the cardiovascular system
|
|
|
A client who agreed to become an organ donor is pronounced dead. What is the most important factor in selecting a transplant recipient?
|
Compatible blood and tissue types
|
|
|
###############################################################################################################################################################################################################################################################
|
Talk to the client about his attitudes toward the medications.
|
|
|
A client with pulmonary edema is receiving furosemide (Lasix). To help evaluate the effectiveness of this diuretic, what should the nurse assess?
|
Breath sounds
|
|
|
A train accident sends a large number of injured passengers to the hospital. The hospital's disaster plan is put into effect. Which one of the following nursing actions will best serve the hospital in a disaster situation?
|
The nurse should know the hospital's disaster plan and what is expected of her during a disaster.
|
|
|
Which intervention will best help to prevent a client from falling?
|
Monitor the client regularly or continually if his condition warrants it.
|
|
|
The nurse is administering a purified protein derivative (PPD) test to a homeless client. Which of the following statements concerning PPD testing is true?
|
A positive reaction indicates that the client has been exposed to the disease.
|
|
|
A nurse working in a senior center encounters a client who recently lost his spouse as well as several friends and family members. What is the best way for the nurse to assist the client?
|
Encourage the client to participate in grief counseling.
|
|
|
The nurse is developing a teaching plan for a client with asthma. Which of the following teaching points has the highest priority?
|
Take prescribed medications as scheduled.
|
|
|
The nurse is assisting with a group teaching session on the topic of urinary tract infection (UTI) prevention. Which point would the nurse expect to be included?
|
Notify the physician if urinary urgency, burning, frequency, or difficulty occurs.
|
|
|
The nurse is teaching a client about breast self-examinations. The client asks if she should have an annual mammogram. According to the American Cancer Society, how should the nurse respond?
|
All women over 40 years of age should have an annual mammogram.
|
|
|
The nurse is teaching a male client to perform monthly testicular self-examinations. Which of the following points would be appropriate to make?
|
Testicular cancer is a highly curable type of cancer.
|
|
|
The nurse is teaching a client about maintaining a healthy heart. The nurse should include which recommendations?
|
Use alcohol in moderation.
|
|
|
The nurse is teaching a female client about preventing osteoporosis. Which of the following teaching points is correct?
|
The recommended daily allowance of calcium may be found in a wide variety of foods.
|
|
|
The nurse is preparing a client with a malignant tumor for colorectal surgery and subsequent colostomy. The client tells the nurse that he's anxious. What would the nurse's initial step be in working with this client?
|
Determining what the client already knows about colostomies
|
|
|
###############################################################################################################################################################################################################################################################
|
Investigating community resources for adult day care and other services
|
|
|
###############################################################################################################################################################################################################################################################
|
Help the client use effective coping strategies to ease spiritual discomfort.
|
|
|
###############################################################################################################################################################################################################################################################
|
Allowing the client to express her feelings without judging her
|
|
|
A client on long-term mechanical ventilation becomes frustrated when he tries to communicate. Which of the following interventions should the nurse perform to assist the client?
|
Ask the client to write, use a picture board, or spell words with an alphabet board.
|
|
|
Based on an assessment of a client's health and home environment, the nurse determines the need for assistive devices, such as a cane, walker, wheelchair, shower chair, or hearing aid. What is the purpose of providing assistive devices?
|
To help the client to remain independent and thereby improve self-confidence
|
|
|
###############################################################################################################################################################################################################################################################
|
Encouraging the client to express emotions associated with relocation
|
|
|
Which of the following statements describing urinary incontinence in the elderly is true?
|
Urinary incontinence isn't a disease.
|
|
|
The nurse is teaching an elderly client about good bowel habits. Which statement by the client would indicate to the nurse that additional teaching was required?
|
"I need to use laxatives regularly to prevent constipation."
|
|
|
A client is having trouble sleeping. Which of the following should the nurse suggest to the client?
|
Maintain the same schedule for waking and sleeping.
|
|
|
The nurse is changing a dressing and providing wound care. Which activity should she perform first?
|
Wash hands thoroughly.
|
|
|
A newly hired licensed practical nurse (LPN) and her preceptor are establishing priorities for their morning assessments. Which client should they assess first?
|
A newly admitted client with acute abdominal pain
|
|
|
The nurse is giving instructions to family members of a client with a self-care deficit. Family members must feed the client. Which of the following should the nurse recommend?
|
Determine foods best handled by the client, and feed these foods to him.
|
|
|
An elderly client who underwent total hip replacement exhibits a red, painful area on the calf of the affected leg. What test validates presence of a thromboembolism?
|
Homans'
|
|
|
A 55-year-old black male is found to have a blood pressure of 150/90 mm Hg during a work site health screening. What should the nurse do?
|
Recommend he have his blood pressure rechecked within 2 months.
|
|
|
###############################################################################################################################################################################################################################################################
|
Osteoporosis
|
|
|
A recent immigrant from Vietnam is diagnosed with pulmonary tuberculosis (TB). Which intervention is most important for the nurse to implement with this client?
|
Developing a list of people with whom the client has had contact
|
|
|
A quadriplegic client is in spinal shock. What should the nurse expect?
|
Absence of reflexes along with flaccid extremities
|
|
|
A client develops a pulmonary embolism after total knee surgery and must be converted from heparin to warfarin (Coumadin) anticoagulant therapy. What should the nurse tell the client?
|
Prothrombin time (PT) and international normalized ratio (INR) will be periodically checked for dose adjustment.
|
|
|
The nurse is planning care for a client who suffered a stroke in the right hemisphere of his brain. What should the nurse do?
|
Provide close supervision due to the client's impulsiveness and poor judgment.
|
|
|
The nurse is caring for an L1-L2 paraplegic undergoing rehabilitation. Which of the following goals is appropriate?
|
Establishing an intermittent catheterization routine every 4 hours
|
|
|
The nurse is giving home care instructions to a client who just had a cataract removed and an intraocular lens implanted. What should the nurse tell the client?
|
Don't sleep on the operated side.
|
|
|
The nurse is providing home care to a client with failing vision due to macular degeneration. The nurse is concerned about the client's safety. Which of the following activities would help to lessen the client's risk of a fall?
|
Installing handrails on steps and in hallways and bathrooms
|
|
|
A client underwent a retinal detachment repair. The nurse receives the following order from the client's physician: Keep client in upright sitting position, with head over the bed table, until first dressing change. What should the nurse do?
|
Follow the order because this position will help keep the retinal repair intact.
|
|
|
Which of the following statements about external otitis is true?
|
External otitis is characterized by pain when the pinna of the ear is pulled.
|
|
|
During a senior citizen health screening, the nurse observes a 75-year-old female with a severely increased thoracic curve or humpback. What is this condition called?
|
Kyphosis
|
|
|
A 69-year-old client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct?
|
"OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints."
|
|
|
The nurse is caring for a client who underwent a total hip replacement. What should the nurse and other caregivers do to prevent dislocation of the new prosthesis?
|
Prevent internal rotation of the affected leg.
|
|
|
The nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which of the following findings should the nurse consider abnormal?
|
Urine retention or incontinence
|
|
|
Which symptoms indicate that a client probably has a sinus infection?
|
Pain in the upper molars and tan or green drainage in the oropharynx
|
|
|
A 72-year-old client seeks help for chronic constipation. This is a common problem for elderly clients due to several factors related to aging. Which of the following is one such factor?
|
Decreased abdominal strength
|
|
|
The nurse is assisting with coordinating an immunization program for health care workers and clients. What information should be included as part of the program?
|
Hepatitis B immunization should be given to neonates before they leave the hospital.
|
|
|
A client with newly diagnosed type 2 diabetes mellitus is admitted to the metabolic unit. The primary goal for this admission is education. Which of the following goals should the nurse incorporate into her teaching plan?
|
Exercise and a weight reduction diet
|
|
|
Laboratory studies indicate a client's blood sugar level is 185 mg/dl. Two hours have passed since the client ate breakfast. Which test would yield the most conclusive diagnostic information about the client's glucose utilization?
|
A test of serum glycosylated hemoglobin (HbA<font face="LWWSUB">1c</font>)
|
|
|
Every morning, a client with type 1 diabetes receives 15 units of Humulin 70/30. What does this type of insulin contain?
|
70% NPH insulin and 30% regular insulin
|
|
|
The nurse is caring for a postthyroidectomy client at risk for hypocalcemia. What should the nurse do?
|
Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes.
|
|
|
To verify the placement of a gastric feeding tube, the nurse should perform at least two tests. One test requires instilling air into the tube with a syringe and listening with a stethoscope for air passing into the stomach. What is another test method?
|
Aspiration of gastric contents and testing for a pH less than 6.0
|
|
|
###############################################################################################################################################################################################################################################################
|
Phenazopyridine (Pyridium)
|
|
|
A female client has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client?
|
This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) test annually.
|
|
|
A 35-year-old female client is requesting information about mammograms and breast cancer. She isn't considered at high risk for breast cancer. What should the nurse tell this client?
|
She should eat a low-fat diet to further decrease her risk of breast cancer.
|
|
|
What should a male client over the age of 50 do to help ensure early identification of prostate cancer?
|
Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly.
|
|
|
Clients diagnosed with a chronic illness exhibit a general pattern of adaptation, which consists of three stages. What is the sequence of these stages?
|
Disbelief, developing awareness, integration
|
|
|
A client is admitted to the hospital with a possible electrolyte imbalance. The client is disoriented, weak, has an irregular pulse, and takes hydrochlorothiazide. The client most likely suffers from:
|
hypokalemia.
|
|
|
An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make?
|
Take a stool softener, such as docusate sodium (Colace), daily
|
|
|
The nurse is providing postoperative care for a client recovering from abdominal surgery. The client is receiving morphine through a client-controlled analgesia pump. Which finding would indicate that the client is obtaining adequate pain relief?
|
Pain rating of 2 or 3 on a scale of 0 to 10
|
|
|
A peripherally placed needle for intermittent infusion of antibiotics is a potential site for infection. When assessing the infusion site, the nurse should look for what signs of infection?
|
Redness and drainage around the insertion site of the needle
|
|
|
A client who experienced a stroke and developed left-sided paralysis is learning how to dress independently. What is the proper technique for upper extremity dressing?
|
Placing the affected arm in the shirt before the unaffected arm
|
|
|
A client taking aspirin for arthritis reports experiencing adverse effects. What adverse effect indicates that a decrease in dose may be necessary?
|
Tinnitus
|
|
|
###############################################################################################################################################################################################################################################################
|
"Would you like to meet with your family and your physician about this matter?"
|
|
|
When does a nurse use sterile technique?
|
When inserting an indwelling urinary catheter
|
|
|
While packing a client's abdominal wound with sterile, half-inch Iodoform gauze, the nurse drops some of the gauze onto the client's abdomen 2 inches away from the wound. What should the nurse do?
|
Discard the gauze packing and repack the wound with new Iodoform gauze.
|
|
|
The nurse is assisting with an exercise group for older adults who live in a retirement community. Which statement is appropriate for the nurse to make to this group of clients?
|
If you have arthritis, exercise your affected joints to the point of discomfort.
|
|
|
A complete blood count is commonly performed before a client goes into surgery. What does this test seek to identify?
|
Abnormally low hematocrit and hemoglobin levels
|
|
|
The nurse is caring for a client who just had surgery. What's the nurse's highest priority?
|
Maintaining a patent airway
|
|
|
A client receives fentanyl through an epidural catheter for control of postoperative pain. The nurse should observe for which common adverse effect?
|
Pruritus
|
|
|
###############################################################################################################################################################################################################################################################
|
Increase the I.V. rate, and continue to reassess vital signs and urine output hourly.
|
|
|
Which one of the following clients has the greatest risk for aspiration?
|
A stroke client with dysarthria
|
|
|
Several conditions may cause sexual dysfunction in men. Which condition represents one of the most common causes?
|
Diabetes mellitus
|
|
|
Hospice care is primarily geared toward which population?
|
Clients in the terminal stage of an illness
|
|
|
###############################################################################################################################################################################################################################################################
|
Acceptance
|
|
|
Clients taking certain drugs should be cautioned against using them with alcohol. What are some of these drugs?
|
Aspirin, antihistamines, and sedatives
|
|
|
The nurse is caring for a client undergoing I.V. antibiotic therapy with gentamicin sulfate. Which of the following interventions is most important?
|
Monitor blood urea nitrogen (BUN) and creatinine levels, throughout the course of therapy
|
|
|
During the assessment of a geriatric client, a nurse would expect which findings?
|
Eye structure and visual acuity changes
|
|
|
A client is frustrated and embarrassed by urinary incontinence. Which of the following measures should the nurse include in a bladder retraining program?
|
Assessing present elimination patterns
|
|
|
Which intervention has the highest priority when providing skin care to a bedridden client?
|
Keeping the skin clean and dry without using harsh soaps
|
|
|
The nurse is caring for a client with <i>Impaired gas exchange.</i> Which of the following outcomes is desired based on this nursing diagnosis?
|
The client has normal breath sounds in all lung fields.
|
|
|
The nurse is planning care for a client after a tracheotomy. One of the client's goals is to overcome verbal communication impairment. Which of the following interventions should the nurse include in the care plan?
|
Encourage the client to communicate by allowing him time to select or write words.
|
|
|
Which of the following nutritional deficiencies may delay wound healing?
|
Lack of vitamin C
|
|
|
The nurse must assess a client's splinted extremity for neurovascular damage. What should she do?
|
Compare capillary refill of both extremities, making sure it's the same bilaterally.
|
|
|
A client is admitted with a diagnosis of acute renal failure. The nurse should monitor closely for:
|
drug toxicity.
|
|
|
In a client who is having a myocardial infarction, which of the following assessment findings are typical?
|
Hypotension, rapid pulse, and chest pain
|
|
|
The nurse and assistant must put a rigid, comatose client back into bed. The client is currently propped up in a reclining chair that doesn't have removable arms. What is the best way to return the client to bed?
|
Use a mechanical lift.
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The nurse provides care for a client with deep partial-thickness burns. What could cause a reduced hematocrit level in this client?
|
Volume overload
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The nurse provides care for a client who experienced an extensive myocardial infarction. The client exhibits behavior characteristic of the denial stage of the grieving process. What should the nurse do?
|
Let the client know that the nurse is available to talk.
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The client underwent a transurethral resection of the prostate gland 24 hours ago and is on continuous bladder irrigation. The nurse suspects the catheter is blocked. Which of the following nursing interventions is appropriate?
|
Use sterile technique when irrigating the catheter.
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A client with coronary artery disease reports intermittent chest pain that occurs with exertion. The physician prescribes sublingual nitroglycerin. When teaching the client about nitroglycerin administration, the nurse should include which instruction?
|
Be careful after taking nitroglycerin because it may cause dizziness.
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When should the client with type 2 diabetes take the oral antidiabetic agent glipizide?
|
30 minutes before breakfast
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During a routine follow-up examination, the nurse updates the client's medication history. The client currently receives prednisone therapy. Which drug class increases the risk of peptic ulcer disease when taken with prednisone?
|
Nonsteroidal anti-inflammatory drugs (NSAIDs)
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The nurse asks a client who had abdominal surgery 3 days ago if he has moved his bowels since surgery. The client states, "I haven't moved my bowels, but I am passing gas." How should the nurse intervene?
|
Encourage the client to ambulate at least three times per day.
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On a routine visit, the client asks the nurse if he can cut his large enteric-coated tablets in half. The nurse tells the client no because dividing the medication will:
|
alter the medication's absorption.
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The nurse brings a client his prescribed antibiotic. The client tells the nurse that he usually takes a white tablet, not the yellow tablet in the medication cup. What should the nurse do?
|
Recheck the medication name and strength.
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A client comes to the emergency department with chest pain. After an electrocardiogram shows a heart rate of 116 beats/minute with irregular beats, the client is admitted to the intensive care unit. Which nursing diagnosis is the priority?
|
Anxiety related to the threat of death
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Practice meticulous foot care.
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The nurse is caring for a client with adult respiratory distress syndrome (ARDS). What is the most likely laboratory finding in the early stages of this disease?
|
Decreased partial pressure of arterial oxygen (Pa<font size="-2">O</font><font face="LWWSUB">2</font>)
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The nurse provides care for a client with chronic obstructive pulmonary disease (COPD). The nurse understands that administering high doses of oxygen may produce what result?
|
Diminished respiratory drive
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Conjunctivitis may be caused by bacteria, viruses, allergens, or irritants. What signs and symptoms differentiate bacterial conjunctivitis from other types?
|
Acute onset, moderate pain, and purulent discharge
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What finding would lead the nurse to conclude that treatment for conjunctivitis was effective?
|
Purulent discharge is resolved.
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A client arrives in the emergency department complaining of squeezing substernal pain that radiates to the left shoulder and jaw. He also complains of nausea, diaphoresis, and shortness of breath. What should the nurse do?
|
Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin
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What is the most appropriate nursing diagnosis for the client with acute pancreatitis?
|
Deficient fluid volume
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Peritoneal lavage is a diagnostic tool used to detect abdominal injuries. Which of the following is a contraindication for peritoneal lavage?
|
A distended bladder
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The nurse instructs a client on diuretic therapy to eat foods high in potassium. The selection of which food indicates teaching is effective?
|
Potatoes
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What does a positive Chvostek's sign indicate?
|
Hypocalcemia
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The nurse is about to begin teaching a client how to perform tracheostomy care. What is the most important principle in client teaching that the nurse needs to utilize?
|
Determining the client's readiness to learn new information
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The nurse is devising a teaching plan for a client diagnosed with type 1 diabetes. Which teaching method is most effective for teaching the client about self-administration of insulin?
|
A discussion and demonstration between the nurse and the client
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The nurse is planning care for a client with M<font face="LWWSYM">e</font>ni<font face="LWWSYM">c</font>re's disease. Which nursing diagnosis takes highest priority?
|
Risk for injury related to vertigo
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After stepping on a rusty nail in her backyard, a client comes to the emergency department for a tetanus immunization. Which bacterium is responsible for tetany?
|
Clostridium
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The nurse is repositioning a client in bed. What should the nurse do to maintain proper body mechanics?
|
Stand with her feet apart.
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The nurse must practice surgical asepsis when performing which procedure?
|
Indwelling urinary catheter insertion
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The nurse is transferring a client from the bed to a chair. What action should the nurse take during client transfer?
|
Help the client dangle his legs.
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A client is placed on a low-sodium diet. Which statement by the client indicates that the nurse's nutrition-teaching plan has been effective?
|
"I chose a baked potato with broiled chicken for dinner."
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When following standard precautions, the nurse should perform which of the following measures?
|
Change gloves after each client contact.
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The nurse is performing wound care. Which of the following practices violates surgical asepsis?
|
Pouring solution onto a sterile field barrier
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The nurse places a client in isolation. Isolation techniques attempt to break the chain of infection by interfering with:
|
the transmission mode.
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For a client who must undergo colon surgery, the physician orders preoperative cleansing enemas and neomycin (Mycifradin). What's the rationale for neomycin use in this client?
|
To decrease the intestinal bacteria count
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The nurse is demonstrating how to clean dentures to a nursing assistant. What should the nurse teach the nursing assistant to do?
|
Place a washcloth in the sink to prevent damage if the dentures are dropped.
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The nurse is about to give a back rub to a client after a complete bed bath. How should the nurse proceed?
|
Massage gently in areas directly over pressure points.
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The nurse is teaching a client with a leg ulcer about tissue repair and wound healing. Which of the following statements by the client indicates that teaching has been effective?
|
"I'll eat plenty of fruits and vegetables."
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|
The nurse wants to help a client maintain healthy skin. Which nursing intervention will help achieve this goal?
|
Keeping the client well-hydrated
|
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The nurse is caring for a client with burns on his legs. Which nursing intervention will help to prevent contractures?
|
Applying knee splints
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|
An obese client is admitted to the hospital for abusing amphetamines in an attempt to lose weight. Which nursing intervention is appropriate for this client?
|
Teaching the client alternative ways to lose weight
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The nurse is teaching a client with allergies how to prevent anaphylaxis. Which recommendation is most appropriate?
|
Wear medical identification.
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The nurse is caring for a client who had a stroke. Which nursing intervention promotes urinary continence?
|
Encouraging intake of at least 2 qt (2 L) of fluid daily
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|
The nurse is caring for a client who just underwent a colectomy. What should the nurse do to prevent postoperative thrombus formation in the legs?
|
Encourage the client to dorsiflex and plantar flex the feet.
|
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|
A client is scheduled for an appendectomy. The nurse must teach the client about incision splinting and leg exercises. When is the best time for the nurse to provide teaching?
|
Before the surgical procedure
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|
The nurse is providing postoperative care for a client who has had spinal anesthesia. The nurse should place the client in which position?
|
On the left side in Sims' position
|
|
|
The nurse is caring for a client who is unconscious. How should the nurse position the client?
|
On his side, with the head of the bed elevated
|
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|
The nurse is caring for a client admitted with an acute head injury. The client has stabilized and is ready to begin rehabilitation. When transferring the client from his bed to a chair, what should the nurse do to ensure client safety?
|
Lock the brakes on the bed
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|
The nurse is caring for a 45-year-old male client admitted with a retinal detachment in his left eye. What symptoms would the nurse expect to find during assessment?
|
Flashing lights in the visual field
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The nurse is planning care for a client with retinal detachment. The client has both eyes patched but is alert and oriented. What measure should the nurse include in the care plan to promote safety?
|
Placing the call bell within the client's reach and making sure he knows how to use it
|
|
|
The nurse provides care for a client with a detached retina who has both eyes patched. When communicating with the client, the nurse should:
|
identify herself every time she enters the room.
|
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|
I'll lie face down with my head turned to the left.
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|
The nurse is collecting data on a 32-year-old client with otosclerosis. The nurse should be aware that the client's hearing loss:
|
affects both ears.
|
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|
The nurse is caring for a client with otosclerosis scheduled to undergo a stapedectomy. The client asks the nurse when her hearing will improve. Which response by the nurse is most appropriate?
|
"It may take as long as 6 weeks for your hearing to improve."
|
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|
The nurse is caring for a client who underwent stapedectomy. To prevent postoperative complications, the nurse should instruct the client to:
|
sneeze with her mouth open.
|
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|
The nurse is collecting data on a male client diagnosed with gonorrhea. Which symptom most likely prompted the client to seek medical attention?
|
Foul-smelling discharge from the penis
|
|
|
The nurse is caring for a male client with gonorrhea. The client asks how he can reduce his risk of contracting another sexually transmitted disease (STD). The nurse should instruct the client to:
|
wear a condom every time he has intercourse.
|
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|
The nurse is caring for a client experiencing acute addisonian crisis. Which laboratory data would the nurse expect to find?
|
Hyperkalemia
|
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|
The nursing care for the client in addisonian crisis should include which of the following interventions?
|
Placing the client in a private room
|
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|
The nurse is administering captopril (Capoten) to a client with heart failure. Which assessment finding would prompt the nurse to withhold the next dose and notify the physician?
|
Hyperkalemia
|
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The nurse is caring for a client who complains of lower back pain. Which instructions should the nurse give to this client to prevent back injury?
|
Stand close to the object you're lifting.
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|
The nurse is caring for a client with lower back pain scheduled for myelography using a water-soluble contrast dye. After the test, the nurse should place the client in which position?
|
Head of the bed elevated 45 degrees
|
|
|
The nurse is planning care for a female client diagnosed with acute hepatitis A. What is the primary mode of transmission for hepatitis A?
|
Fecal contamination and oral ingestion
|
|
|
The nurse is teaching family members of a client with hepatitis A (HAV). Family members were exposed to the client and, therefore, should receive immunoglobulin (Ig). The nurse should tell the family members that Ig:
|
must be administered within 2 weeks of exposure.
|
|
|
The nurse is teaching a client with acute hepatitis about to be discharged to her home. Which activity guideline is most appropriate?
|
Maintain bed rest except for trips to the bathroom.
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|
The nurse is caring for a 32-year-old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?
|
Pallor, tachycardia, sore tongue
|
|
|
The nurse is teaching a client with pernicious anemia who requires vitamin B<font face="LWWSUB">12</font> replacement therapy. Which statement indicates that the client understands the treatment program?
|
"I'll need an injection of vitamin B<font face="LWWSUB">12</font> every month, for life."
|
|
|
The nurse is collecting data on a 38-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find?
|
Vision changes
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|
|
The nurse is teaching a client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to:
|
rest in an air-conditioned room.
|
|
|
The nurse is caring for a client with a fractured left femur. What signs indicate potential fat emboli?
|
Cyanosis, decreased Pa<font size="-2">O</font><font face="LWWSUB">2</font>
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|
Preparing the client for cast removal or bivalving of the cast
|
|
|
The nurse is caring for a postoperative client. What intervention should the nurse perform to prevent thrombophlebitis?
|
Applying a sequential compression device
|
|
|
The nurse is instructing a client about taking oral corticosteroids to control severe chronic asthma. Which statement indicates that the client understands his treatment plan?
|
"I'll tell my other health care providers that I'm taking a corticosteroid."
|
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|
The nurse is preparing a client with Crohn's disease for a barium enema. What should the nurse do the day before the test?
|
Encourage plenty of fluids.
|
|
|
The nurse is teaching a women's group about ovarian cancer. Which woman is at the highest risk for this disease?
|
45-year-old woman who has never been pregnant
|
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|
The nurse is caring for a client who just underwent cardiac catheterization through a femoral access site. Which nursing intervention should be included in the care plan for the next 8 hours?
|
Maintaining pressure over the femoral access site
|
|
|
The nurse is teaching a client about the use of sublingual nitroglycerin. Which statement indicates the client understands the teaching plan?
|
"I'll keep the nitroglycerin in its original dark, airtight container."
|
|
|
The nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to:
|
advance both crutches first.
|
|
|
The nurse is caring for a 74-year-old client with chronic open-angle glaucoma. After the nurse administers pilocarpine (Pilocar), the client reports blurred vision. Which nursing action is most appropriate?
|
Explaining that this is an expected adverse effect
|
|
|
The nurse is caring for a client with glaucoma who has gradually lost his eyesight. When assisting the client with ambulation, the nurse should walk:
|
slightly in front of the client offering an elbow for the client to hold.
|
|
|
The nurse is assessing a client diagnosed with appendicitis. Which of the following signs or symptoms should the nurse expect to find?
|
Rebound tenderness, McBurney's sign, low-grade fever
|
|
|
The nurse is assessing pain in a client with appendicitis. Which initial statement or question by the nurse will be most effective in eliciting information?
|
"Tell me how you feel."
|
|
|
The nurse is providing preoperative care to a client scheduled for an appendectomy. Which statement regarding pain control is most appropriate?
|
"Take your pain medication before your pain becomes intense."
|
|
|
The nurse is admitting a client with tuberculosis who is coughing. To minimize the transmission of tuberculosis, which nursing measure is most appropriate?
|
Wearing an N95 disposable respirator mask when entering the client's room
|
|
|
The nurse is caring for a client with tuberculosis. The client's wife has a positive reaction to purified protein derivative (PPD) skin testing but doesn't have active tuberculosis. What treatment would the nurse expect to administer?
|
Isoniazid (INH) for six months
|
|
|
The nurse is caring for a client on a regimen of four medications to treat tuberculosis. The nurse discovers that the client isn't taking all of his medications. Which is appropriate for the nurse to say to the client?
|
"Taking many medications can be difficult. Tell me about the difficulties you're having."
|
|
|
The nurse is performing a dressing change for a client with a red, granulating foot ulcer. Which of the following actions is part of this procedure?
|
Cleaning the wound with normal saline solution
|
|
|
The nurse is caring for a client with diabetes mellitus. When teaching the client about foot care, which instruction should the nurse provide?
|
Avoid hot water bottles and heating pads.
|
|
|
The nurse is assessing a client with hyperthyroidism (Grave's disease). What findings should the nurse expect?
|
Weight loss, nervousness, tachycardia
|
|
|
The nurse is assessing a client after a thyroidectomy. The assessment reveals muscle twitching and tingling, along with numbness in the fingers, toes, and mouth area. The nurse should suspect what complication?
|
Tetany
|
|
|
The nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice?
|
Clay-colored stools
|
|
|
The nurse is caring for a client receiving spironolactone (Aldactone) to treat hypertension. Which instruction should the nurse give the client?
|
Avoid salt substitutes.
|
|
|
The nurse is caring for a client undergoing a cystoscopy to diagnose bladder cancer. Following the test, the client returns to his room. Which signs should alert the nurse to a potential complication?
|
Chills and tachycardia
|
|
|
The nurse is collecting data on an adult client's stage of psychosocial development. The nurse should consider:
|
the client's previous problem-solving strategies.
|
|
|
Which nursing action takes priority when admitting a client with right lower lobe pneumonia?
|
Elevate the head of the bed 45 to 90 degrees.
|
|
|
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|
The fluid level in the water-seal chamber fluctuates.
|
|
|
The nurse is assessing a client for signs of hypoxemia. Which of the following should the nurse interpret as a late sign of hypoxemia?
|
Diaphoresis
|
|
|
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|
"Increase fiber and fluids in your diet."
|
|
|
A male client who has had spinal anesthesia is under the physician's orders to lie flat postoperatively. When the client asks to go to the bathroom, the nurse encourages him to comply with the order. By complying, the client can avoid which complication?
|
Headache
|
|
|
The nurse is participating in a cancer-screening program for colorectal cancer. Which of the following clients presents the fewest risk factors for colon cancer?
|
A 60-year-old man who follows a diet low in fat and high in fiber
|
|
|
A client has severe pruritus from hepatitis B. Which of the following nursing measures would best enhance the client's comfort?
|
Providing sponge baths using tepid water.
|
|
|
A 46-year-old male client is admitted to the hospital with a suspected diagnosis of hepatitis B. He's jaundiced and complaining of weakness. Which of the following should the nurse include in the client's care plan?
|
Rest periods after small, frequent meals
|
|
|
A client receiving hemodialysis treatments has had surgery to form an arteriovenous fistula. Which of the following is most important for the nurse to be aware of when providing care for the client?
|
Taking a blood pressure reading on the affected arm can cause clotting of the fistula.
|
|
|
A 30-year-old teacher performs self-breast examinations monthly. Which of the following findings should she report promptly?
|
A hard, nontender mass in the upper outer quadrant of the left breast
|
|
|
A 42-year-old male complains of extreme fatigue and weakness after his first week of radiation therapy. Which of the following responses by the nurse would best reassure him?
|
"These symptoms usually diminish after therapy ends."
|
|
|
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|
The client requests that her family bring her makeup and a wig.
|
|
|
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|
Encouraging her to express her feelings and fears about her son's injury
|
|
|
A client is in the first postoperative day after a total laryngectomy and radical neck dissection. Which of the following is a priority goal?
|
Maintaining a patent airway
|
|
|
###############################################################################################################################################################################################################################################################
|
Check the pharynx with a penlight for bleeding, and notify the physician.
|
|
|
The nurse is teaching a female client with osteoporosis about her prescribed diet. Which of the following foods is the best source of calcium?
|
1 cup of low-fat yogurt
|
|
|
An 83-year-old female client arrives at the emergency department after falling on the ice outside her senior citizens' housing facility. The admitting diagnosis is right hip fracture. Which of the following would be most important for the nurse to assess?
|
Neurovascular compromise
|
|
|
During afternoon rounds, the nurse finds a male client using a pencil to scratch inside his knee-to-toe cast. The client is complaining of severe itching in the ankle area. Which action should the nurse take?
|
Encourage him to avoid scratching, and notify the physician if severe itching persists.
|
|
|
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|
A head injury is suspected and she's being evaluated further.
|
|
|
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|
Establish unresponsiveness.
|
|
|
A client with heart failure develops pink frothy sputum, coarse crackles, and restlessness. Which of the following actions should the nurse take first?
|
Place the client in high Fowler's position.
|
|
|
A 74-year-old man with a history of heart failure is admitted to the telemetry unit. Which of the following parameters should the nurse closely monitor in assessing the client's response to a bolus dose of I.V. furosemide (Lasix)?
|
Hourly urine output
|
|
|
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|
Begin electrocardiogram (ECG) monitoring.
|
|
|
A 56-year-old male has a blood pressure of 146/96 mm Hg. Upon hearing the reading, he exclaims, "My pressure has never been this high. Will I need to take medication to reduce it?" Which of the following is the best response by the nurse?
|
"You'll need to have your blood pressure rechecked several times before making a diagnosis."
|
|
|
The nurse must plan care for a 28-year-old female admitted with a diagnosis of myasthenia gravis. Which of the following times would be most appropriate for procedures and care to be completed?
|
In the morning, with frequent rest periods
|
|
|
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|
Blurred vision, intention tremor, and urinary hesitancy
|
|
|
A client is being discharged after successful same-day cataract surgery. The nurse instructs the client about permitted activities and those to avoid. Which of the following activities is permitted?
|
Cooking
|
|
|
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|
Call the physician to report the vital signs.
|
|
|
A client with a neurogenic bladder is beginning bladder training. Which of the following nursing actions is most important?
|
Set up specific times for the client to empty his bladder.
|
|
|
A 58-year-old male is admitted for a wedge resection of the left lower lung lobe after a chest X-ray revealed a lesion. The client is anxious and asks if he can smoke. Which of the following statements by the nurse would be most therapeutic?
|
"You're anxious about the surgery. Do you see smoking as helping?"
|
|
|
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|
Notify the physician of the symptoms and request to draw a serum potassium level.
|
|
|
A male client with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, he complains of severe pain in the surgical wound. Which action should the nurse take?
|
Assess the surgical site and affected extremity.
|
|
|
A client sustains a C5 spinal cord injury that results in quadriplegia. Several days after being moved out of the intensive care unit, he complains of a severe throbbing headache. What should the nurse do next?
|
Check the client's indwelling urinary catheter for kinks to ensure patency.
|
|
|
The nurse knows that a client has mastered the technique needed to correctly use an incentive spirometer when the client:
|
inhales slowly and deeply through the mouthpiece.
|
|
|
A client is receiving oxygen by way of a nasal cannula at a rate of 2 L/minute. How should the oxygen flow meter be set?
|
The line marked "2" should cut the ball in half.
|
|
|
An elderly client with pneumonia has a nursing diagnosis of <i>Ineffective airway clearance.</i> Which intervention would be most appropriate?
|
Monitor the need for suctioning every hour.
|
|
|
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|
The student has made little or no change in behaviors.
|
|
|
A client with pancreatitis has been receiving total parenteral nutrition (TPN) for the past week. Which nursing intervention helps determine if TPN is providing adequate nutrition?
|
Monitoring the client's weight every day
|
|
|
Which behavior during dinner suggests a therapeutic response to pyridostigmine (Regonol) in a client with myasthenia gravis?
|
The client swallows food without difficulty.
|
|
|
A client who underwent abdominal surgery complains of abdominal pain that makes him feel "full and uncomfortable." Which assessment should the nurse perform first?
|
Assess patency of the nasogastric (NG) tube.
|
|
|
The nursing instructor evaluates a nursing student who's assisting a client on crutches. Which nursing behavior demonstrates safe practice for a client who's learning to walk with crutches?
|
Placing a walking belt around the client's waist
|
|
|
When caring for a geriatric client, the nurse should expect to find which normal age-related change?
|
Slowed reaction time
|
|
|
A client with Alzheimer's disease has a nursing diagnosis of <i>Risk for injury related to memory loss, wandering, and disorientation.</i> Which nursing intervention should appear in this client's care plan to prevent injury?
|
Remove hazards from the environment.
|
|
|
For a client who has had a stroke, which nursing intervention can help prevent contractures in his lower legs?
|
Attaching braces or splints to each foot and leg
|
|
|
A client who's paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety with the nurse. Which behavior indicates that the client accurately understands safety measures related to paralysis?
|
The client uses a mirror to inspect his skin.
|
|
|
###############################################################################################################################################################################################################################################################
|
"It isn't a problem to rescind your DNR order. I'll let your physician know your wishes right away."
|
|
|
To treat cervical cancer, a client has had an applicator of radioactive material placed in her vagina. Which observation by the nurse indicates a radiation hazard?
|
The client receives a complete bed bath each morning.
|
|
|
A client with chronic renal failure (CRF) is admitted to the urology unit. Which diagnostic test results are consistent with CRF?
|
Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/dl
|
|
|
A client with nephritis is taking the diuretic furosemide (Lasix), as prescribed. Which client statement indicates an accurate understanding of client teaching about furosemide?
|
"I'll eat such foods as apricots, dates, and citrus fruits."
|
|
|
When a client's ventilation is impaired, the body retains which substance?
|
Carbon dioxide
|
|
|
The nurse is caring for a client with a chest tube. If the chest drainage system accidentally is disconnected, what should the nurse plan to do?
|
Place the end of the chest tube in a container of sterile saline.
|
|
|
A client with emphysema will be discharged in a few days. During a discharge teaching session, the nurse should instruct the client to avoid which possible exacerbation of the disorder?
|
Fumes
|
|
|
The nurse is caring for a 25-year-old client with end-stage testicular cancer who has been referred to hospice care. Which criterion excludes the client from hospice care?
|
The client entered a clinical trial through the National Cancer Institute.
|
|
|
Which medication should the nurse use to prevent infection in a client who has been burned?
|
Mafenide acetate (Sulfamylon)
|
|
|
Which nursing intervention helps prevent contractures in a client with burns on his legs?
|
Applying knee splints
|
|
|
The nurse is assisting with developing a care plan for a client with type A hepatitis. What is the main route of transmission of this hepatitis virus?
|
Feces
|
|
|
What data should the nurse collect to minimize the complications of myasthenia gravis?
|
Respiratory status
|
|
|
What should the nurse advise a young client to do to help prevent osteoporosis?
|
Consume at least 800 mg of calcium daily.
|
|
|
A client with a seizure disorder should be instructed to avoid which activity until the seizures are controlled by medication?
|
Swimming
|
|
|
The nurse is caring for a client with thrombocytopenia. What's the best way to protect this client?
|
Use the smallest needle possible for injections.
|
|
|
The nurse is using the Glasgow Coma Scale to help assess a client's level of consciousness (LOC). Which score on the Glasgow Coma Scale indicates a deep coma?
|
3
|
|
|
A 26-year-old client is diagnosed with a brain tumor. As the nurse assists him from the bed to the chair, the client begins having a generalized seizure. Which action should the nurse take first?
|
Assist the client to floor, place him in a side-lying position, and protect him with linens.
|
|
|
The nurse and a client have just discussed the client's recent diagnosis of hypothyroidism and its causes and effects. Which statement indicates that teaching was effective?
|
"Now I see. My clumsiness is caused by a hormone problem."
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|
Antacids
|
|
|
The nurse is collecting data on a client who comes to the clinic complaining of having a fever and chills for the past 2 days. Which findings suggest bacterial pneumonia?
|
Dyspnea and wheezing
|
|
|
The nurse is caring for a client who has just undergone a right nephrectomy. While evaluating the client for response to the surgery, the nurse should stay alert for which signs and symptoms of hemorrhage?
|
Weak, irregular pulse; cool, moist skin; and hypotension
|
|
|
A client with a spontaneous pneumothorax has a chest tube connected to a Pleur-evac drainage system and suction. Which of the following could cause a problem in the chest tube drainage system?
|
Blood clots in the drainage tubing
|
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|
A client is recovering from a stroke and will be discharged in a few days. When helping to develop this client's discharge plan, the nurse should include which intervention?
|
Discuss home care needs with the client before the day of discharge.
|
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|
Data collection
|
|
|
A client with bladder cancer has had his bladder removed and an ileal conduit created for urine diversion. While changing this client's pouch, the nurse observes that the area around the stoma is red, weeping, and painful. What should the nurse conclude?
|
The pouch faceplate doesn't fit the stoma.
|
|
|
The nurse is collecting data on a client who sustained a head injury. Which findings suggest increased intracranial pressure (ICP)?
|
Restlessness, disorientation, pupil dilation, and projectile vomiting
|
|
|
Which laboratory test value is elevated in clients who smoke and therefore can't be used as a general indicator of cancer?
|
Carcinoembryonic antigen level
|
|
|
After having transurethral resection of the prostate (TURP), a client returns to the unit with a three-way indwelling urinary catheter and continuous closed bladder irrigation. Which finding suggests that the client's catheter is occluded?
|
The client reports bladder spasms and the urge to void.
|
|
|
An alcoholic client is hospitalized with cirrhosis of the liver. In this client, which data collection findings may be early signs of alcohol withdrawal?
|
Hand tremor, irritability, and anxiety
|
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|
Report these findings to the physician.
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|
The client keeps the drainage bag below the bladder at all times.
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|
The nurse is planning postoperative care for a client who has received general anesthesia. During the immediate postoperative period, which nursing activity takes the highest priority?
|
Maintaining a patent airway
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|
During rounds, a client admitted with gross hematuria asks the nurse about his diagnosis. To facilitate effective communication, what should the nurse do?
|
Provide privacy for the conversation.
|
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|
The physician has ordered a condom catheter for a male client. While cleaning the client's perineal area, the nurse observes irritation, excoriation, and swelling of the penis. What should the nurse do next?
|
Inform the charge nurse of these findings.
|
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|
A client comes into the clinic with pain and warmth in his big toe and reduced urine output. The physician suspects gouty arthritis. The nurse can expect the physician to confirm this diagnosis by ordering which diagnostic tests?
|
Synovial fluid analysis and serum uric acid level
|
|
|
Before administering morphine to reduce a client's pain, the nurse collects data on several parameters, including heart rate, blood pressure, and respiratory rate. Which assessment should the nurse perform 15 to 30 minutes after she administers the drug?
|
Pain level
|
|
|
The nurse is teaching a client how to use transcutaneous electrical nerve stimulation (TENS) to manage pain. Which client statement indicates an accurate understanding of its use?
|
"If I have a headache, nausea, or unpleasant sensations, I'll use my troubleshooting techniques."
|
|
|
A few days ago, a client underwent a urinary diversion procedure and now has a continent ileal reservoir (Kock pouch). Which action indicates that the client is coping with his altered body image?
|
The client combs his hair and puts on street clothes.
|
|
|
When collecting data on a client with primary stage syphilis, the nurse should expect to discover which finding?
|
Painless chancre
|
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|
While a client is being prepared for discharge, his nasogastric (NG) tube becomes clogged. To remedy this problem and teach the client's family how to deal with it at home, what should the nurse do?
|
Irrigate the tube with cola.
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|
The nurse is planning care for a client with burns on his upper torso. Which nursing diagnosis should take the highest priority?
|
Ineffective airway clearance related to edema of the respiratory passages
|
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|
The nurse needs to administer medication as prescribed to a client with heart failure. What's the best way to verify the client's identity?
|
Check the client's medical record number and name on his identification bracelet.
|
|
|
A client has been taking a decongestant for allergic rhinitis. During a follow-up visit, which of the following suggests that the decongestant has been effective?
|
Less sneezing
|
|
|
During the acute phase of a burn, the nurse should collect data on which topic?
|
Circulatory status
|
|
|
A client with advanced cancer is about to begin hospice care at home. Which statement shows that the client understands the primary focus of hospice care?
|
"It will enhance the quality of my life."
|
|
|
The nurse is assigned to a client with infectious tuberculosis (TB). When assisting with creating a care plan for this client, how should the nurse plan to prevent disease transmission to other staff members?
|
Teach about safe disposal of tissues after coughing or sneezing.
|
|
|
A home health nurse is visiting a home care client with advanced lung cancer. While collecting data on the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition?
|
Hypoxia
|
|
|
The anesthesiologist orders atropine for a client who will undergo cholecystectomy. Why is this drug administered preoperatively?
|
To reduce respiratory secretions
|
|
|
The nurse is caring for a client with deep vein thrombosis. She is monitoring for complications such as pulmonary embolism. Which findings suggest pulmonary embolism?
|
Chest pain and dyspnea
|
|
|
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|
Poultry, red meat, and turnips
|
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|
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|
Close the bed curtains and give the other nurse a sheet or bath blanket to cover the client.
|
|
|
What should the nurse do to prevent infection transmission when caring for a client with hepatitis A?
|
Put on gloves to empty the emesis basin.
|
|
|
For a client with diverticulosis, the nurse asks the dietitian for a list of foods that should be avoided to prevent complications. Which foods are likely to be on the list?
|
Cucumbers and fresh tomatoes
|
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|
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|
Respiratory depression
|
|
|
At 8 a.m., the nurse collects data on a client who's scheduled for surgery at 10 a.m. During the data collection, the nurse detects dyspnea, a nonproductive cough, and back pain. What should the nurse do next?
|
Notify the physician immediately of these findings.
|
|
|
The physician has ordered an enema of soap solution for an adult client. Which technique should the nurse use?
|
Hold the solution container no higher than 12<font face="LWWSYM">"</font> (30 cm) above the rectum.
|
|
|
When helping to plan nursing care to maintain skin integrity for an adult client, the nurse should remember which general guideline?
|
Keep skin clean and dry to prevent breakdown.
|
|
|
The nurse is administering morphine, as prescribed, to a client before surgery. Why is this medication given preoperatively?
|
To relieve anxiety
|
|
|
The nurse is conducting a preoperative teaching session with a client who's expressing concerns about a breast mass. In this session, the nurse should use which nonverbal technique?
|
Facing the client squarely
|
|
|
The nurse is teaching a client with diabetes mellitus about dietary restrictions. This client should be instructed to avoid which foods?
|
Pecan pie and vanilla ice cream
|
|
|
Before preparing a client for surgery, the nurse assists in developing a teaching plan. What's the primary purpose of preoperative teaching?
|
To reduce the risk of postoperative complications
|
|
|
The physician has told a client to check his pulse each morning before taking digoxin (Lanoxin). After the nurse teaches the client how to take a radial pulse, what client behavior indicates an accurate understanding of the technique?
|
The client uses his middle three fingertips to palpate the radial artery.
|
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|
###############################################################################################################################################################################################################################################################
|
Repeat the radial pulse assessment and obtain an apical pulse.
|
|
|
A client who has had a pacemaker inserted is ready for discharge. What information should the nurse include in her discharge instructions to the client?
|
Avoid exposure to magnetic resonance imaging (MRI) equipment.
|
|
|
The nurse is assigned to care for an elderly client diagnosed with labyrinthitis (inflammation of the inner ear). Which of the following should the nurse expect to occur in the client?
|
Sudden onset of incapacitating vertigo, usually accompanied by nausea and vomiting
|
|
|
The nurse is assigned to care for a client experiencing acute pain. Which change in vital signs should the nurse expect to find?
|
Tachycardia
|
|
|
The nurse is caring for an elderly client about to undergo paracentesis. What intervention should the nurse perform to prepare the client for the procedure?
|
Have the client void before the procedure.
|
|
|
The nurse is assigned to care for a client in the immediate postoperative recovery phase. Although all are important, which criteria take priority during monitoring?
|
Airway, respiratory rate and depth, other vital signs, and skin color
|
|
|
###############################################################################################################################################################################################################################################################
|
Raise the bed to semi-Fowler's position.
|
|
|
A client with a history of duodenal ulcers tells the admitting nurse that he takes antacids once in a while to relieve the pain. Which statement by the client should be reported immediately?
|
"My bowel movements have been sticky and black."
|
|
|
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|
Constipation
|
|
|
The nurse is caring for a client who has just had a liver biopsy. Which nursing intervention is most applicable after the biopsy?
|
Keep the client on bed rest, lying on his right side.
|
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|
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|
"It helps reduce swelling in the rectal area, which helps relieve the discomfort."
|
|
|
The nurse is assisting with the placement of a Levin's nasogastric (NG) tube in a 56-year-old client with alcoholic cirrhosis. What is the best way to determine whether the NG tube is in his stomach?
|
Apply suction to the tube with a bulb syringe and observe for the return of gastric contents.
|
|
|
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|
maintain drainage of bile from the common bile duct.
|
|
|
A client with advanced cancer of the mouth has a tongue that's swollen, necrotic, and seeping. Which nursing diagnosis should be a priority in planning care?
|
Ineffective airway clearance
|
|
|
A client has a colostomy in the descending colon after surgical removal of a tumor. Which of the following should the nurse anticipate when the client resumes a regular diet?
|
Formed, soft stools
|
|
|
The physician inserts a Miller-Abbott tube in a client with a suspected small-bowel obstruction who has been vomiting fecal-like material. Which intervention would the nurse expect to perform after insertion of the tube?
|
Ambulate the client and turn him from side to side every 2 hours.
|
|
|
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|
Assist the client in standing and using the urinal or toilet.
|
|
|
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|
Withhold the client's insulin, bring her a glass of orange juice, and report her findings to the head nurse.
|
|
|
A 21-year-old client recently has been diagnosed with type 1 diabetes. The client's receiving 5 units of regular insulin and 15 units of NPH insulin every morning before breakfast at 7 a.m. Which statement is correct?
|
The NPH insulin will begin to act in 1 to 1<font face="LWWSYM">r</font> hours and will peak in 4 to 12 hours (by mid-afternoon)
|
|
|
###############################################################################################################################################################################################################################################################
|
Flushed cheeks, dry mouth, and acetone breath odor
|
|
|
A client with diabetes who had a stroke has right-sided paralysis and incontinence and is in the rehabilitation center. Which action should be the nurse's priority in caring for this client?
|
Wash the client's skin with soap and water, gently patting it dry.
|
|
|
A 55-year-old client with type 2 diabetes is obese and hasn't been successful at controlling his condition by diet alone. The physician has prescribed glipizide (Glucotrol). The nurse knows that glipizide is commonly used for type 2 diabetes because it:
|
stimulates the pancreas to secrete more insulin.
|
|
|
The nurse knows that dietary management is part of the treatment regimen for clients with diabetes. Which information should the nurse include in client-teaching sessions with clients who have diabetes?
|
Meals should be eaten at consistent times each day.
|
|
|
A female client has been diagnosed with hyperthyroidism. In planning her care, the nurse should give priority to which goal?
|
Providing adequate rest and sleep
|
|
|
A 35-year-old client is returned to his room after a thyroidectomy. Which nursing measure is most important on the evening of surgery?
|
Asking the client to say a few words to check his voice for tone and hoarseness
|
|
|
###############################################################################################################################################################################################################################################################
|
Thin, easily damaged skin
|
|
|
During a shift report, the nurse is told that a postoperative client with diabetes is on a "sliding scale." What does the "sliding scale" indicate?
|
Administration of regular insulin is based on periodic blood glucose readings.
|
|
|
A 70-year-old client is admitted to the hospital after an episode of right-sided weakness, difficulty speaking, and blurred vision. The physician diagnoses a stroke in evolution. Why does the nurse ask the client to squeeze her hand?
|
To assess the client's ability to follow simple commands
|
|
|
A client has lost his ability to express words. The nurse should plan to:
|
provide opportunities for the client to repeat words and point to objects.
|
|
|
A 22-year-old client has a history of seizures. While the client's transported to the medical imaging laboratory for a brain scan, he cries out, his muscles become rigid, and he falls to the floor. What should the nurse do first?
|
Move furniture away from the client.
|
|
|
After a client experiences a generalized tonic-clonic seizure, what's the priority nursing action?
|
Check the client's vital signs and remove restrictive clothing.
|
|
|
The physician prescribes levodopa-carbidopa (Sinemet) for a client with Parkinson's disease to control symptoms. Which information should the nurse include while teaching the client about this drug?
|
Antiembolism stockings are useful to prevent orthostatic hypotension, which is an adverse effect of this medication.
|
|
|
###############################################################################################################################################################################################################################################################
|
Turn the client on her right side and elevate the head of the bed 15 degrees.
|
|
|
The nurse is assisting the physician with a lumbar puncture. The client appears worried and anxious. After the procedure, which statement is most appropriate for the nurse to make?
|
"I want you to lie flat for awhile. I'll close the curtain, and perhaps you can rest. I'll be quiet when I check on you in a few minutes."
|
|
|
An 86-year-old female client with generalized arthritis arrives at the clinic for her regular checkup. The client takes aspirin several times per day. Because of the client's heavy use of aspirin, the nurse should gather information about:
|
easy bruising and reports of unusual bleeding.
|
|
|
A female client who fell while washing her windows has a fractured right ankle, requiring a cast. After assisting with the cast application, what instructions should the nurse give the client?
|
"Move the toes on your right foot for several minutes every hour."
|
|
|
A client with advanced cancer has been receiving chemotherapy and is experiencing stomatitis. To promote comfort and nutrition while the client's mouth is sore, the nurse should plan to speak with the client's family about:
|
rinsing the client's mouth with diluted hydrogen peroxide every 2 hours.
|
|
|
###############################################################################################################################################################################################################################################################
|
"I can't give out information about a client without consent from the client or the client's legal guardian.
|
|
|
A client reports urinary frequency and burning. The physician diagnoses cystitis and prescribes co-trimoxazole (Bactrim DS). What should the nurse tell the client?
|
"Take the medication with 6 to 8 oz (177 to 237 ml) of water."
|
|
|
An 86-year-old female client has a fractured left hip. Her left leg is in Buck's traction while she's being prepared for a hip pinning. The nurse who's planning to insert an indwelling urinary catheter would:
|
instruct the client to deep-breathe during catheterization.
|
|
|
A client who is at risk for blood clots after bone surgery is to receive subcutaneous heparin. A multidose vial of heparin contains 20,000 units in 5 ml. How many milliliters should the nurse administer for an ordered dose of 5,000 units?
|
1.25 ml
|
|
|
A client has been admitted to the hospital with heart failure. On entering the room, the nurse notices that the client is having difficulty breathing. Which position would be the most appropriate to help the client's breathing?
|
Place the client in high Fowler's position.
|
|
|
A client is on the surgical unit after orthopedic surgery. The physician has ordered 8 mg of morphine I.M. for pain. The Tubex reads "MS gr 1/6 <font face="LWWSYM">=</font> 1 cc." How much should the nurse inject?
|
0.8 ml
|
|
|
The nurse knows that client teaching about hypertension has been effective when the client states:
|
"I shouldn't adjust my medication without my physician's advice."
|
|
|
A male client has arteriosclerosis with intermittent claudication. The nurse has worked with him to develop a walking program. Which client statement indicates that he understands the program?
|
"I should walk until pain occurs, then rest."
|
|
|
A client with pneumonia has a nursing diagnosis of <i>Ineffective airway clearance related to increased secretions and ineffective cough.</i> Which intervention would facilitate effective coughing?
|
Sipping water, hot tea, or coffee
|
|
|
The nurse is teaching a client how to perform deep-breathing and coughing exercises. Which technique is correct?
|
Take a deep breath and cough until the lungs are empty of air.
|
|
|
An elderly client becomes extremely agitated and attempts to remove his endotracheal tube. The physician orders physical restraints. Which action indicates that a nurse has correctly applied the restraints?
|
A quick-release knot is used to tie the restraint.
|
|
|
###############################################################################################################################################################################################################################################################
|
Verify the dose against the physician's order in the client's medical record.
|
|
|
###############################################################################################################################################################################################################################################################
|
Inform the pharmacy that the medication is unavailable, ask them to prepare it, and tell them that someone will pick it up immediately.
|
|
|
A client is prescribed digoxin (Lanoxin), 0.125 mg by mouth stat. The pharmacy dispenses digoxin 0.25 mg. The nurse promptly administers the medication and then realizes she administered the wrong dose. How should the nurse proceed?
|
Obtain vital signs and notify the physician and nursing supervisor immediately of the error.
|
|
|
###############################################################################################################################################################################################################################################################
|
Inform the physician and request a social services consult.
|
|
|
The nurse is caring for a client who sustained a chemical burn in his right eye. She's preparing to irrigate the eye with sterile normal saline solution. Which steps are appropriate when performing the procedure? Select all that apply:
|
Place absorbent pads on the client's shoulder area.
|
|
|
The nurse is caring for a client who sustained a chemical burn in his right eye. She's preparing to irrigate the eye with sterile normal saline solution. Which steps are appropriate when performing the procedure? Select all that apply:
|
Wash hands and put on gloves.
|
|
|
The nurse is caring for a client who sustained a chemical burn in his right eye. She's preparing to irrigate the eye with sterile normal saline solution. Which steps are appropriate when performing the procedure? Select all that apply:
|
Direct the solution onto the exposed conjunctival sac from the inner to outer canthus.
|
|
|
A hospitalized client asks the nurse for "something for pain." Which information is most important for the nurse to gather before administering the medication? Select all that apply:
|
Administration time of the last dose
|
|
|
A hospitalized client asks the nurse for "something for pain." Which information is most important for the nurse to gather before administering the medication? Select all that apply:
|
Client's pain level on a scale of 1 to 10
|
|
|
A hospitalized client asks the nurse for "something for pain." Which information is most important for the nurse to gather before administering the medication? Select all that apply:
|
Type of medication the client has been taking
|
|
|
A hospitalized client asks the nurse for "something for pain." Which information is most important for the nurse to gather before administering the medication? Select all that apply:
|
Effectiveness of previous dose of medication
|
|
|
###############################################################################################################################################################################################################################################################
|
|
|
|
A client is ordered to receive a sodium phosphate enema for relief of constipation. Proper administration of the enema includes which steps? Select all that apply:
|
Assist the client into Sims' position.
|
|
|
A client is ordered to receive a sodium phosphate enema for relief of constipation. Proper administration of the enema includes which steps? Select all that apply:
|
Wash hands and put on gloves.
|
|
|
A client is ordered to receive a sodium phosphate enema for relief of constipation. Proper administration of the enema includes which steps? Select all that apply:
|
Encourage the client to retain the solution for 5 to 15 minutes.
|
|
|
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|
Notify the client's primary physician.
|
|
|
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|
Cover the wound with saline-soaked sterile gauze.
|
|
|
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|
Assess and document the behavior that requires continued use of restraints.
|
|
|
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|
Tie the restraints in quick-release knots.
|
|
|
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|
Ask the client if he needs to go to the bathroom and provide range-of-motion (ROM) exercises every 2 hours.
|
|
|
###############################################################################################################################################################################################################################################################
|
"Let's talk about your mother's illness and how it will progress."
|
|
|
###############################################################################################################################################################################################################################################################
|
"You sound like you have some questions about your mother dying. Let's talk about that."
|
|
|
###############################################################################################################################################################################################################################################################
|
"Tell me how you're feeling about your mother dying."
|
|
|
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|
Document the client's statement and the location, and type of injuries.
|
|
|
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|
Assist the client in developing a safety plan for times of increased violence.
|
|
|
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|
Provide the client with telephone numbers of local shelters and safe houses.
|
|
|
###############################################################################################################################################################################################################################################################
|
Take a seat next to the client and sit quietly.
|
|
|
###############################################################################################################################################################################################################################################################
|
Say to the client, "You're feeling upset about the news you received about the transplant."
|
|
|
The nurse is collecting data on a newly admitted client. When filling out the family assessment, who should the nurse consider to be a part of the client's family? Select all that apply:
|
All people the client views as family
|
|
|
The nurse is collecting data on a newly admitted client. When filling out the family assessment, who should the nurse consider to be a part of the client's family? Select all that apply:
|
People who provide for the physical and emotional needs of the client
|
|
|
A nurse is caring for a client whose cultural background is different from her own. Which actions are appropriate? Select all that apply:
|
Consider that nonverbal cues may have different meanings in different cultures.
|
|
|
A nurse is caring for a client whose cultural background is different from her own. Which actions are appropriate? Select all that apply:
|
Respect the client's cultural beliefs.
|
|
|
A nurse is caring for a client whose cultural background is different from her own. Which actions are appropriate? Select all that apply:
|
Ask the client if he has cultural requirements that should be considered during his care.
|
|
|
The nurse is caring for a 45-year-old married woman who has undergone hemicolectomy for colon cancer. The woman has two children. Which concepts about families should the nurse keep in mind when providing care for this client? Select all that apply:
|
Illness in one family member can affect all members.
|
|
|
The nurse is caring for a 45-year-old married woman who has undergone hemicolectomy for colon cancer. The woman has two children. Which concepts about families should the nurse keep in mind when providing care for this client? Select all that apply:
|
A family member may have more than one role in a family.
|
|
|
The nurse is caring for a 45-year-old married woman who has undergone hemicolectomy for colon cancer. The woman has two children. Which concepts about families should the nurse keep in mind when providing care for this client? Select all that apply:
|
The effects of an illness on a family depend on the stage of the family's life cycle.
|
|
|
The nurse is caring for a 45-year-old married woman who has undergone hemicolectomy for colon cancer. The woman has two children. Which concepts about families should the nurse keep in mind when providing care for this client? Select all that apply:
|
Changes in sleeping and eating patterns may be signs of stress in a family.
|
|
|
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|
Recommending community resources for adult day care and respite care
|
|
|
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|
Encouraging the spouse to talk about the difficulties of caregiving
|
|
|
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|
Asking whether friends can help with errands or provide short periods of relief
|
|
|
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|
|
|
|
###############################################################################################################################################################################################################################################################
|
|
|
|
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|
Assess the client for allergies to penicillin.
|
|
|
###############################################################################################################################################################################################################################################################
|
Administer the medication because the amount is within the dosing recommendations.
|
|
|
###############################################################################################################################################################################################################################################################
|
Obtain a sputum culture before administering the medication.
|
|
|
The nurse is using the Z-track method of I.M. injection to administer iron dextran to a client with iron deficiency anemia. Which actions should the nurse take to give this injection? Select all that apply:
|
Confirm the client's identity before administering the iron dextran.
|
|
|
The nurse is using the Z-track method of I.M. injection to administer iron dextran to a client with iron deficiency anemia. Which actions should the nurse take to give this injection? Select all that apply:
|
Change the needle after drawing up the iron dextran.
|
|
|
The nurse is using the Z-track method of I.M. injection to administer iron dextran to a client with iron deficiency anemia. Which actions should the nurse take to give this injection? Select all that apply:
|
Before inserting the needle, displace the skin laterally by pulling it away from the injection site.
|
|
|
The nurse is using the Z-track method of I.M. injection to administer iron dextran to a client with iron deficiency anemia. Which actions should the nurse take to give this injection? Select all that apply:
|
Inject the iron dextran after aspirating for blood return.
|
|
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The nurse is preparing to administer 4 units of regular insulin to a client with type 1 diabetes mellitus. Which supplies does the nurse need to perform the injection? Select all that apply:
|
Medication administration record
|
|
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The nurse is preparing to administer 4 units of regular insulin to a client with type 1 diabetes mellitus. Which supplies does the nurse need to perform the injection? Select all that apply:
|
27-gauge, <font face="LWWSYM">r</font><font face="LWWSYM">"</font> needle
|
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|
A 40-year-old client is admitted with a diagnosis of new-onset atrial fibrillation. To obtain an accurate pulse count, the nurse counts the apical heart rate. Identify the area where the nurse should place the stethoscope to best hear the apical rate.
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|
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A client is experiencing problems with balance and fine and gross motor function. Identify that area of the client's brain that's malfunctioning.
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|
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|
Have the parents stay with the child and participate in his care.
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A 13-year-old visits the school nurse because he's experiencing back pain, fatigue, and dyspnea. The nurse suspects that the child may have scoliosis. The nurse should first:
|
inspect the child for uneven shoulder height or uneven hip height.
|
|
|
The nurse is caring for a child who has just been immunized. When teaching the child's parents about potential adverse effects, the nurse should instruct the parents to immediately report:
|
generalized urticaria.
|
|
|
A child who had bacterial meningitis is scheduled to have his hearing tested before discharge. The mother asks the nurse why this test is necessary. Which response by the nurse is appropriate?
|
"Some children with bacterial meningitis suffer damage to the nerve responsible for hearing."
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|
The nurse is caring for a child who was involved in a motor vehicle accident. The child has a chest tube in place. If the chest tube is accidentally removed, the nurse should immediately:
|
cover the opening with petroleum gauze.
|
|
|
The nurse is providing cardiopulmonary resuscitation (CPR) to a 4-year-old child. The nurse should:
|
use the heel of one hand for sternal compressions.
|
|
|
A mist tent contains a nebulizer that creates a cool, moist environment for a child with an upper respiratory tract infection. The cool humidity helps the child breathe by:
|
decreasing respiratory tract edema.
|
|
|
An otherwise-healthy adolescent has meningitis and is receiving I.V. and oral fluids. The nurse should monitor this client's fluid intake because fluid overload may cause:
|
cerebral edema.
|
|
|
The nurse is caring for a 16-year-old female client who isn't sexually active. The client asks if she needs a Papanicolaou (Pap) test. The nurse should reply:
|
"No, because you aren't sexually active."
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|
|
A teenage mother brings her 1-year-old child to the pediatrician's office for a well-baby checkup. She says that her baby can't sit alone or roll over. An appropriate response by the nurse would be:
|
"Let's see about further developmental testing."
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|
An emergency department nurse suspects neglect in a 3-year-old boy admitted for failure to thrive. Signs of neglect in the child would include:
|
poor hygiene and weight loss.
|
|
|
A boy, age 3, develops a fever and rash and is diagnosed with rubella. His mother has just given birth to a baby girl. Which statement by the mother best indicates that she understands the implications of rubella?
|
"I'll call my neighbor who's 2 months pregnant and tell her not to have contact with my son."
|
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|
The nurse is preparing to give a 9-year-old client a preoperative I.M. injection. Which size needle should the nurse use?
|
22G, 1<font face="LWWSYM">"</font>
|
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|
The nurse is caring for an adolescent client who underwent surgery for a perforated appendix. When caring for this client, the nurse should keep in mind that the main life-stage task for an adolescent is to:
|
develop an identity and independence.
|
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|
What's the best advice for a nurse to give to the parents of a 2-year-old client who frequently throws temper tantrums?
|
Ignore the behavior when it happens.
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|
A mother tells the nurse that she wants to begin toilet training her 22-month-old child. The most important factor regarding toilet training that the nurse should stress to her is:
|
developmental readiness of the child.
|
|
|
A mother complains to the nurse that her 4-year-old son often lies. What's the nurse's best response?
|
Acknowledge him by saying, "That's a pretend story."
|
|
|
A mother is playing with her infant, who's sitting securely alone on the floor of the clinic. The mother hides a toy behind her back and the infant looks for it. What age would the nurse estimate the infant to be?
|
10 months
|
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|
The nurse is collecting data on whether the client has received all recommended immunizations for his age. Which immunizations should he have received between ages 4 and 6?
|
Pneumococcal polysaccharide vaccine (PPV) and influenza vaccine
|
|
|
The mother of a 4-year-old child tells the nurse that her child is a poor eater. What's the nurse's best recommendation for helping her increase her child's nutritional intake?
|
Allow the child to feed herself.
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|
The nurse is teaching the mother of an ill child about childhood immunizations. The nurse should tell the mother that live virus vaccines shouldn't be administered to children with:
|
leukemia.
|
|
|
A 7-year-old boy is hospitalized with cystic fibrosis. To help him manage secretions and avoid respiratory distress, the nurse should:
|
perform chest physiotherapy every 4 hours.
|
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Give a tepid sponge bath.
|
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|
The nurse is interviewing a 16-year-old female at a clinic. It's her first visit and she says that she has been exposed to herpes by her boyfriend. Initially, with primary genital or type 2 herpes simplex, the nurse would expect the client to have:
|
burning or tingling on vulva, perineum, or vagina.
|
|
|
A 2-year-old child is brought to the emergency department with a history of upper airway infection that has worsened over the last 2 days. The nurse suspects the child has croup. Signs of croup include a hoarse voice, inspiratory stridor, and:
|
a barking cough.
|
|
|
A 2-year-old child is brought to the emergency department with suspected croup. The child appears frightened and cries as the nurse approaches him. The nurse needs to assess the child's breath sounds. The best way to approach the child is to:
|
allow the child to handle the stethoscope before listening to his lungs.
|
|
|
A 2-year-old child is brought to the emergency department with suspected croup. Which of the following data collection findings reflect increasing respiratory distress?
|
Intercostal retractions
|
|
|
The nurse is collecting data on an 8-month-old child for signs of neurologic deficit and increased intracranial pressure (ICP). These signs would include:
|
an altered level of consciousness.
|
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|
A mother, who's visibly upset, carries her 2-month-old infant into the crowded emergency department. The child appears limp and lifeless. The mother screams to the nurse for help. The nurse should:
|
take the infant and mother back to a treatment room.
|
|
|
While checking a 2-month-old child's airway, the nurse finds that the child isn't breathing. After two unsuccessful attempts to establish an airway, the nurse should:
|
administer five back blows.
|
|
|
While making her rounds on the pediatric floor, the nurse finds an infant in his crib unresponsive and without respirations. Which action should the nurse take?
|
Call for assistance.
|
|
|
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|
It occurs more commonly in infants who sleep in the prone position.
|
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|
The nurse is providing care for a mother whose infant has died. The mother tells the nurse that she's angry at God for taking away her child. She has vowed never again to go to church or pray. Which nursing diagnosis is most appropriate?
|
<i>Spiritual distress</i>
|
|
|
A nurse on the pediatric floor is caring for a toddler. The nurse should keep in mind that toddlers:
|
express negativism.
|
|
|
A 3-year-old child with Down syndrome is admitted to the pediatric unit with asthma. The child doesn't enunciate words well and holds onto furniture when he walks. The nurse should ask the mother:
|
how the child's condition today differs from his normal condition.
|
|
|
The nurse is caring for a toddler with Down syndrome. To help the toddler cope with painful procedures, the nurse can:
|
hold and rock him and give him a security object.
|
|
|
The nurse is preparing to teach a 13-year-old client with asthma to administer his own breathing treatments. Which principle should the nurse keep in mind when planning the teaching session?
|
Adolescents are worried about appearing different from their peers.
|
|
|
A child, age 3, is brought to the emergency department in respiratory distress caused by acute epiglottiditis. Which clinical manifestations should the nurse expect to assess?
|
Severe sore throat, drooling, leaning forward to breathe
|
|
|
When caring for a child with epiglottiditis, the nurse should first:
|
prepare him for tracheotomy.
|
|
|
The nurse is taking a history from the parents of a child admitted with Reye's syndrome. Which illness would the nurse expect the parents to report their child having the previous week?
|
Chickenpox
|
|
|
A 4-year-old child is having a sickle cell crisis. The initial nursing intervention should be to:
|
provide oral and I.V. fluids.
|
|
|
A 14-year-old female client in skeletal traction for treatment of a fractured femur is expected to be hospitalized for several weeks. When planning care, the nurse should take into account the client's need to achieve what developmental milestone?
|
Identity
|
|
|
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|
"Tell me more about how you feel."
|
|
|
The nurse is teaching a parent how to administer antibiotics at home to a child with acute otitis media. Which statement by the parent indicates that teaching has been successful?
|
"I'll give the antibiotics for the full 10-day course of treatment."
|
|
|
When planning care for a 7-year-old boy with Down syndrome, the nurse should:
|
assess the child's current developmental level and plan care accordingly.
|
|
|
A baby boy has just had surgery to repair his cleft lip. Which nursing intervention is the most important during the immediate postoperative period?
|
Clean the suture line carefully with a sterile solution after every feeding.
|
|
|
Several children in a kindergarten class have been treated for pinworm. To prevent the spread of pinworm, the school nurse meets with the parents and explains that they should:
|
tell the children not to bite their fingernails.
|
|
|
A 4-year-old male is scheduled for a nephrectomy to remove a Wilms' tumor. Which intervention should be included in the nursing care plan?
|
Provide preoperative teaching to the child and his parents.
|
|
|
A baby undergoes surgery to correct an esophageal atresia and tracheoesophageal fistula. Which nursing diagnosis has the highest priority during the first 24 hours postoperatively?
|
Ineffective airway clearance
|
|
|
A local elementary school has requested scoliosis screening for its students from the hospital's community outreach program. The school should be informed that:
|
this is an appropriate request and arrangements will be made as soon as possible.
|
|
|
At what age should boys be taught how to do a monthly testicular self-examination?
|
Age 12
|
|
|
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|
Immediately bring her daughter into the emergency department.
|
|
|
A child is sent to the school nurse because, according to his teacher, he's constantly scratching his head. When the nurse assesses his hair and scalp, she finds evidence of lice. What did the nurse see?
|
Small white spots that adhere to the hair shaft, close to the scalp
|
|
|
The nurse is calculating the proper dosage of medication for a child. Which parameter provides the most accurate dosage?
|
Body surface area in relation to weight
|
|
|
The nurse is conducting a well-baby examination of a 3-month-old infant. During the examination, the nurse shouldn't be able to elicit which reflex?
|
Stepping
|
|
|
The mother of a hospitalized 3-year-old girl expresses concern because her daughter is wetting the bed. What should the nurse tell her?
|
It's common for a child to exhibit regressive behavior when anxious or stressed.
|
|
|
A 15-year-old girl visits the neighborhood clinic seeking information on how to keep from getting pregnant. What should the nurse say in response to her request?
|
Can you tell me about the precautions you're taking now?
|
|
|
A 10-year-old girl visits the clinic for a check-up before entering school. The child's mother questions the nurse about what to expect of her daughter's growth and development at this stage. Which response is most appropriate?
|
Friends will be very important to her, and she'll develop an interest in the opposite sex.
|
|
|
A 10-year-old boy falls, injures his left shoulder, and is taken to the emergency department. While the client waits to be seen by the physician, what intervention should the nurse perform first?
|
Keep him in a comfortable position and apply ice to the injured shoulder.
|
|
|
A 14-year-old client reports right lower quadrant pain, nausea, vomiting, and a low-grade fever for the last 12 hours. A physical examination reveals rebound tenderness and a positive psoas sign. Based on these findings, what would the nurse suspect?
|
Appendicitis
|
|
|
The nurse is giving instructions to parents of a child diagnosed with sickle cell disease. The instructions should include which of the following?
|
Avoid areas of low oxygen concentration such as high altitudes.
|
|
|
The nurse is teaching accident prevention to the parents of a toddler. Which of the following is appropriate for the nurse to tell the parents?
|
Place locks on cabinets containing toxic substances.
|
|
|
The family of a child dying from leukemia asks the nurse about organ donation. Who must give consent for the child's organs to be donated?
|
Parents
|
|
|
The nurse is teaching the parents of a 5-year-old child how to respond in case of poisoning. If poisoning occurs, what should the parents' first response be?
|
Call the poison control center.
|
|
|
The nurse is collecting data on a 3-year-old child who has ingested toilet bowl cleaner. What finding should the nurse expect?
|
Edematous lips
|
|
|
A child ingests a caustic toilet bowl cleaner during a visit to a friend's house. The child's mother tells the nurse she feels guilty. What should the nurse say to the mother?
|
Tell me about your guilty feelings.
|
|
|
The nurse administers an I.M. injection to a 6-year-old. Afterward, the nurse should:
|
discard the uncapped needle in a puncture-proof container.
|
|
|
The nurse is teaching about proper nutrition to the parents of a child with cystic fibrosis. Which of the following instructions should the nurse include?
|
Encourage a high-calorie, high-protein diet.
|
|
|
A mother asks the nurse why her 12-month-old baby gets otitis media more frequently than her 10-year-old son. What should the nurse tell her?
|
The baby's eustachian tubes are shorter and lie more horizontally.
|
|
|
The nurse is developing a plan to teach a mother how to reduce her baby's risk of developing otitis media. Which of the following directions should the nurse include in the teaching plan?
|
Place the baby in an upright position when giving a bottle.
|
|
|
The nurse is caring for a 10-year-old child with rheumatic fever. While obtaining the child's health history from the mother, the nurse should ask if the child recently had which illness?
|
Strep throat
|
|
|
A child with rheumatic fever complains of painful joints. What nonpharmacologic measures should the nurse use to reduce the child's pain?
|
Using a bed cradle to keep linens off the joints
|
|
|
The nurse is preparing to discharge a child who has rheumatic fever. Which class of medications is prescribed to prevent recurrence of rheumatic fever?
|
Antibiotics
|
|
|
An 18-month-old male child is admitted to the pediatric unit with a diagnosis of celiac disease. What finding would the nurse expect in this child?
|
A protuberant abdomen
|
|
|
The nurse is giving nutritional counseling to the mother of a child with celiac disease. Which statement by the mother would indicate understanding?
|
My son can't eat wheat, rye, oats, or barley.
|
|
|
The nurse is caring for a child with celiac disease. How should the nurse evaluate the effectiveness of nutritional therapy?
|
Monitor the appearance, size, and number of stools.
|
|
|
The nurse teaches a mother how to provide adequate nutrition for her toddler, who has cerebral palsy. Which of the following observations indicates that teaching has been effective?
|
The child eats finger foods by himself.
|
|
|
The school nurse is examining a student at an elementary school. Which of the following findings would lead the nurse to suspect impetigo?
|
Vesicular lesions that ooze, forming crusts on the face and extremities
|
|
|
The nurse is teaching parents how to reduce the spread of impetigo. The nurse should encourage parents to:
|
teach children the importance of proper hand washing.
|
|
|
A 2-month-old infant hasn't received any immunizations. Which immunizations should the nurse prepare to administer?
|
Hib; DTaP; HepB; and IPV
|
|
|
The school nurse is planning a program for a group of teenagers on skin cancer prevention. Which of the following instructions should the nurse emphasize in her talk?
|
Examine skin once per month, looking for suspicious lesions or changes in moles.
|
|
|
The nurse observes a 2<font face="LWWSYM">r</font>-year-old client who is playing with another child of the same age in the play room on the pediatric unit. What type of play should the nurse expect the client to engage in?
|
Parallel play
|
|
|
The nurse is interviewing the mother of a 7-year-old child. Which of the following symptoms reported by the mother would most lead the nurse to suspect that the child has type 1 diabetes?
|
Recent bed wetting
|
|
|
The nurse is preparing a continuous insulin infusion for a child with diabetic ketoacidosis and a blood glucose of 800 mg/dl. Which solution is the most appropriate at the beginning of therapy?
|
100 units of regular insulin in normal saline solution
|
|
|
The nurse is caring for a neonate who has hypospadias. His parents are planning to have the baby circumcised before discharge. When teaching the parents about their child's condition, the nurse should tell them:
|
the foreskin will be needed at the time of surgical correction.
|
|
|
The nurse is approached by the mother of a child with hypospadias. She says to the nurse, "Why did this have to happen to my baby? Why couldn't he be perfect? How could this have happened?" What should the nurse say in response?
|
"You seem upset. Tell me about it."
|
|
|
The nurse is caring for an infant with congenital clubfoot. After the final cast has been removed, which member of the health care team will most likely help the infant with leg and ankle exercises and provide his parents with a home exercise regimen?
|
Physical therapist
|
|
|
The nurse in a well-child clinic is collecting data on children for scoliosis. Which of the following children is most at risk for scoliosis?
|
10-year-old girl
|
|
|
The nurse is teaching parents about accident prevention for a toddler. Which of the following guidelines is most appropriate?
|
Make sure all medications are kept in containers with childproof safety caps.
|
|
|
The nurse is using drawing, puppetry, and other forms of play therapy while treating a terminally ill, school-age child. The purpose of these techniques is to help the child:
|
express feelings that he can't articulate.
|
|
|
###############################################################################################################################################################################################################################################################
|
Herniating the brain stem
|
|
|
A 6-year-old girl has been hospitalized with rheumatic fever for 4 weeks. Her symptoms have gradually subsided, and she's now ready for discharge. Which of the following plans for her health care is most important for her future well-being?
|
Arrange for the administration of prophylactic antibiotics to prevent a recurrence of rheumatic fever.
|
|
|
###############################################################################################################################################################################################################################################################
|
He'll have a temporary colostomy; "pull-through" surgery will be done in the future.
|
|
|
An obese 14-year-old girl states that she wants to lose weight. In addition to her dietary intake and physical activity, what data would be the most important to collect?
|
How food is used in her home
|
|
|
A 9-year-old client with weakness in his legs and a history of influenza is admitted to the facility. He's diagnosed with Guillian-Barr<font face="LWWSYM">e</font> syndrome. The nurse must notify the physician immediately of which finding?
|
Increased hoarseness
|
|
|
A 2-year-old male is admitted for possible bacterial meningitis. Which of the following nursing actions should the nurse take first?
|
Assess the client's neurologic status.
|
|
|
A 10-year-old girl with sickle cell anemia has been admitted for vaso-occlusive crisis. Which of the following would be the best activity for the client?
|
Reading
|
|
|
An infant is diagnosed with patent ductus arteriosus. Which drug may be administered to achieve closure of the defect?
|
Indomethacin (Indocin)
|
|
|
Which of the following would be a priority nursing diagnosis for a child with iron deficiency anemia?
|
Activity intolerance related to reduced oxygen-carrying capacity of blood
|
|
|
Which of the following would be most important to include when teaching home management of a child with hemophilia?
|
Toothbrushes should be held under warm water before use.
|
|
|
###############################################################################################################################################################################################################################################################
|
A description of the child's stools
|
|
|
An 18-month-old female comes in for a well-baby checkup. Her mother reports that she drinks five 8-oz bottles of whole milk a day. Which of the following should the nurse tell the mother to include in the child's diet to improve iron intake?
|
Peanut butter, green vegetables, and raisins
|
|
|
A 10-year-old male with sickle cell anemia continues to wet the bed at night. He feels frustrated about this and is too embarrassed to sleep over at a friend's house. Which of the following responses by the nurse is most appropriate?
|
"We can try a bladder training program."
|
|
|
###############################################################################################################################################################################################################################################################
|
She drinks 40 to 48 oz of pasteurized cow's milk daily.
|
|
|
A 4-year-old girl is admitted to the hospital to rule out a diagnosis of leukemia. Which of the following would be the best room assignment?
|
Alone in a private room
|
|
|
A 2-year-old girl is being discharged from the hospital after treatment for croup. Her father asks, "What should we do if she gets croup again?" What's the best nursing response?
|
"If she gets another cold, watch for croup. Keep a cool-mist humidifier running in her room, and give her lots of clear liquids."
|
|
|
A neonate with a tracheoesophageal fistula is to undergo a repair. Postoperatively, which of the following nursing measures should be implemented first?
|
Change the client's position every 2 hours from the back to either side, keeping the head slightly elevated.
|
|
|
A 2-year-old client returns from surgery after a bowel resection as a result of Hirschsprung's disease. A temporary colostomy is in place. Which immediate postoperative nursing intervention would have priority?
|
Auscultate lung sounds.
|
|
|
A 2-week-old client returned 6 hours ago from surgery to correct pyloric stenosis. Which postoperative nursing care would be most important?
|
Feed small amounts frequently, assess the amount of emesis, and encourage parental involvement in care.
|
|
|
A mother brings her 12-month-old infant to the pediatrician's office for a check-up. Which finding suggests that the infant has cystic fibrosis?
|
Presence of fat in the stool
|
|
|
###############################################################################################################################################################################################################################################################
|
Compare his growth trends with those of his parents and siblings.
|
|
|
A 15-month-old male is brought to the ambulatory care clinic for well-child care by his mother. He's crying and pulling at his left ear, which appears erythematous. Which of the following actions should the nurse take first?
|
Examine the affected ear last in order to minimize distress early in the exam.
|
|
|
A healthy 6-year-old boy has never been immunized. His mother brings him to the clinic today to "get his shots for school." Which immunizations should the client receive before entering school?
|
DTaP, IPV, hepatitis B, varicella, and MMR
|
|
|
A 2-year-old male is brought to the ambulatory care clinic by his father for a routine well-child visit. He has a runny nose and a cough. The nurse examines his musculoskeletal system. Which physical finding would indicate further investigation?
|
Asymmetric or unilateral bowleg
|
|
|
Which of the following is the most significant finding in a history related to congenital hip dislocation?
|
Breech presentation at birth
|
|
|
Immediately after a 1-year-old client returns from a cardiac catheterization, the nurse notes that the pulse distal to the catheter insertion site is weaker. The nurse should take which of the following actions?
|
Record the data on the nursing notes.
|
|
|
A 12-month-old female client is at the clinic for a well-baby checkup. During the oral examination, the nurse discovers that her teeth are full of caries and that the client still uses a bottle. Which action should the nurse take first?
|
Ask the client's mother about the client's bedtime routine.
|
|
|
###############################################################################################################################################################################################################################################################
|
Restrain the client's elbows.
|
|
|
A 5-month-old female is brought to the pediatric clinic by her mother. The child has had recurrent middle-ear infections since she was 3 months old. Which of the following data are most important to collect at today's visit?
|
Whether the client received all of her prescribed antibiotic at the time of the last infection
|
|
|
Which of the following is the most desirable position for a neonate with a congenital dislocated hip?
|
Prone position with hips abducted
|
|
|
###############################################################################################################################################################################################################################################################
|
With meals and snacks
|
|
|
A 1-year-old male is diagnosed with a congenital cardiac defect after cardiac catheterization. His parents have expressed concern about activities at home. Which is the best response by the nurse when teaching these parents?
|
"Allow him to play and be active as long as he doesn't get fatigued."
|
|
|
###############################################################################################################################################################################################################################################################
|
Rock and cuddle him often.
|
|
|
###############################################################################################################################################################################################################################################################
|
Elevate the scrotal sac.
|
|
|
The nurse is caring for a 15-year-old girl who is receiving total parenteral nutrition (TPN). The nurse understands that this solution is given:
|
directly into the superior vena cava.
|
|
|
When attempting to dislodge a foreign object from an infant's airway, the rescuer should initiate five back blows followed by:
|
five chest thrusts.
|
|
|
The physician prescribes penicillin G, 300,000 units I.M., for a child who is 18 months old. What is the best site for the nurse to administer this injection?
|
Vastus lateralis muscle
|
|
|
The nurse is collecting data on a school-age child who has just had a tonsillectomy. Which finding suggests postoperative hemorrhage?
|
Frequent swallowing
|
|
|
A toddler is immobilized with traction to his legs. Which play activity would be appropriate for this child?
|
Pounding board
|
|
|
###############################################################################################################################################################################################################################################################
|
Eat a snack before swimming.
|
|
|
A school-age child with fever and joint pain has just received a diagnosis of rheumatic fever. The child's parents ask the nurse if anything could have been done to prevent this disorder. Which intervention is most effective in preventing rheumatic fever?
|
Early detection and treatment of streptococcal infections
|
|
|
A toddler with bacterial meningitis is being admitted to the inpatient unit. Which infection control measure should the nurse be prepared to use?
|
Respiratory isolation
|
|
|
A preschooler is admitted to the hospital the day before scheduled surgery. This is the child's first hospitalization. What can the nurse do to help reduce this child's anxiety about surgery?
|
Give the child dolls and medical equipment to play out the experience.
|
|
|
Parents bring their infant to the clinic, seeking treatment for vomiting and diarrhea that has lasted for 2 days. When collecting data, the nurse detects dry mucous membranes and lethargy. What other finding suggests deficient fluid volume?
|
A sunken fontanel
|
|
|
###############################################################################################################################################################################################################################################################
|
The client will change positions with minimal discomfort.
|
|
|
A parent brings a 19-month-old toddler to the clinic for a regular checkup. When palpating the toddler's fontanels, what should the nurse expect to find?
|
Closed anterior and posterior fontanels
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A toddler is admitted to the hospital with nephrotic syndrome. The nurse carefully monitors the toddler's fluid intake and output and checks urine specimens regularly with a reagent strip. Which finding is the nurse most likely to report?
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Proteinuria
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For a preschooler who weighs 33 lb (115 kg), the physician prescribes meperidine (Demerol), 15 mg I.M. at 7 a.m. as a preoperative medication. To administer this medication, the nurse should use which approach?
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Let the preschooler choose which leg to use for the injection.
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Encourage the parent to stand next to the crib and stay with the child.
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After an infant undergoes surgical repair of a cleft lip, the physician orders elbow restraints. For this infant, the postoperative care plan should include which nursing action?
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Removing the restraints every 2 hours
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The physician prescribes meperidine (Demerol), 30 mg I.M., as preoperative medication for a school-age child who weighs 66 lb (30 kg). Meperidine is supplied as 50 mg/ml. How much meperidine should the nurse administer?
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0.6 ml
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The nurse is instructing parents about the nutritional needs of their full-term infant, age 2 months, who is breast-feeding. Which response shows that the parents understand their infant's dietary needs?
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"We won't start any solid foods now."
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Reye's syndrome
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The nurse is collecting data concerning the sexual development of a preteen girl. What's the first sign of sexual maturation in females?
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Breast bud development
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Fatty stools
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A nanny is taught to administer digoxin (Lanoxin) to a 6-month-old infant at home. Which statement by the nanny indicates that teaching was successful?
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"I'll measure the dose carefully."
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An infant who has been in foster care since birth requires a blood transfusion. Who's authorized to give written informed consent for the procedure?
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The foster mother
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Treat the parents professionally and answer their questions appropriately.
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The parents of a 6-month-old infant diagnosed with a terminal brain tumor have chosen palliative care for their son. Which interventions will be provided for this infant?
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Pain management, comfort measures, and support for the parents will be offered.
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A nurse in a pediatrician's office is teaching the mother of a 2-year-old child about car seat safety. The mother asks if her son, who weighs 35 lb (15.9 kg), requires a car seat. Which response by the nurse is best?
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"He should ride in the car seat until he's 4 years old and weighs at least 40 lb."
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Security
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The charge nurse on a pediatric unit informs a staff nurse that four of her clients require attention. Which client should the nurse see first?
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A 10-year-old client with asthma whose oxygen saturation levels are dropping
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A 15-year-old client comes to the clinic requesting a test for human immunodeficiency virus (HIV) exposure. The adolescent is concerned that her parents might be notified of her test results. Which response by the nurse is best?
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"HIV testing is confidential; after we get the test results, we will discuss your options."
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A 14-year-old client with type 1 diabetes is admitted with ketoacidosis for the second time in 3 months. The mother explains, "I don't know why this keeps happening." Which response by the nurse is best?
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"Adolescents sometimes become overwhelmed by adhering to dietary restrictions and taking medications."
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The nurse observes a gun under the jacket of a man who's visiting a 17-year-old client. Which action should the nurse take first?
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Notify security immediately.
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Meeting with the pain management team to devise a more effective pain control plan
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A 14-year-old client diagnosed with acne vulgaris asks what causes it. Which factors should the nurse identify for this client? Select all that apply:
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Increased hormone levels
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A 14-year-old client diagnosed with acne vulgaris asks what causes it. Which factors should the nurse identify for this client? Select all that apply:
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Growth of anaerobic bacteria
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A 14-year-old client diagnosed with acne vulgaris asks what causes it. Which factors should the nurse identify for this client? Select all that apply:
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Heredity
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The nurse is caring for a client in the first 4 weeks of pregnancy. The nurse should expect which data collection findings?
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Breast sensitivity
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The nurse is caring for a client with mild active bleeding from placenta previa. Which assessment factor indicates that an emergency cesarean delivery may be necessary?
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Fetal heart rate of 80 beats/minute
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Data collection findings of a pregnant client reveal that she feels very anxious because of a lack of knowledge about giving birth. The client is in her second trimester. Which intervention by the nurse is most appropriate for this client?
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Provide her with the information and teach her the skills she'll need to understand and cope during birth.
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The nurse is collecting data on a pregnant woman in the clinic. In the course of collecting data, the nurse learns that this woman smokes one pack of cigarettes a day. The first step the nurse should take to help the woman stop smoking is to:
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assess the client's readiness to stop.
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The assessment of an Apgar score for a neonate includes:
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heart rate, respiratory effort, reflex irritability, and color.
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The nurse is teaching the mother of an infant about the importance of immunizations. The nurse should teach her that active immunity:
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results from exposure of an antigen through immunization or disease contact.
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When evaluating a client's knowledge of symptoms to report during her pregnancy, which statement would indicate to the nurse that the client understands the information given to her?
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"If I have blurred or double vision, I should call the clinic immediately."
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The nurse has a client at 30 weeks' gestation who has tested positive for the human immunodeficiency virus (HIV). What should the nurse tell the client when she says that she wants to breast-feed her baby?
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Discourage breast-feeding because HIV can be transmitted through breast milk.
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The neonate of a client with type 1 diabetes mellitus is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate is:
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lethargy.
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The nurse is collecting data on a neonate. When maternal estrogen has been transferred to the fetus, which sign will the nurse see in the neonate?
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Enlarged breast tissue
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A 20-year-old female's pregnancy is confirmed at a clinic. She says her husband will be excited, but is concerned because she herself isn't excited. She fears this feeling may mean she'll be a bad mother. The nurse should respond by:
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telling the client such feelings are normal in the beginning of pregnancy.
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A woman who is 10 weeks pregnant tells the nurse that she's worried about her fatigue and frequent urination. The nurse should:
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recognize these as normal early pregnancy signs and symptoms.
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should be referred to community resources available for pregnant women.
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The nurse is providing care for a pregnant client. The client asks the nurse how she can best deal with her fatigue. The nurse should instruct her to:
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try to get more rest by going to bed earlier.
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The nurse is providing care for a pregnant 16-year-old client. The client says that she's concerned she may gain too much weight and wants to start dieting. The nurse should respond by saying:
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"Nutrition is important because depriving your baby of nutrients can cause developmental and growth problems."
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The nurse is providing care for a pregnant client in her second trimester. Glucose tolerance test results show a blood glucose level of 160 mg/dl. The nurse should anticipate that the client will need to:
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be taught about diet.
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The nurse is providing care for a pregnant client with gestational diabetes. The client asks the nurse if her gestational diabetes will affect her delivery. The nurse should explain that:
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the delivery may need to be induced early.
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A newly pregnant client tells the nurse that she hasn't been taking her prenatal vitamins because they nauseate her. In addition to telling the client how important taking the vitamins are, the nurse should advise her to:
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take the vitamin on a full stomach.
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A baby born 2 hours ago has just arrived in the neonate nursery. Which nursing measure will prevent the neonate from losing heat due to evaporation?
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Drying him thoroughly after a bath
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The nurse is caring for a neonate with a myelomeningocele. The priority nursing care of a neonate with a myelomeningocele is primarily directed toward:
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preventing infection.
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The nurse is conducting a neonatal assessment of a baby boy, born 3 hours earlier. Which assessment would make the nurse suspect a congenital hip dislocation?
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Unequal gluteal folds
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The nurse has been teaching a new mother how to feed her infant son who was born with a cleft lip and palate. Which action by the mother would indicate that the teaching has been successful?
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Burping the baby frequently
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A client who's 34 weeks pregnant is experiencing bleeding caused by placenta previa. The fetal heart sounds are normal and the client isn't in labor. Which nursing intervention should the nurse perform?
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Monitor the amount of vaginal blood loss.
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Which findings are consistent with mild preeclampsia?
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Hypertension, edema, proteinuria
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The physician prescribes phototherapy for a neonate with jaundice. The nurse should monitor the neonate for which common adverse effect of phototherapy?
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Watery stools
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A client gave birth to a healthy full-term baby girl 2 hours ago by cesarean delivery. When assessing this client, which finding requires immediate nursing action?
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Tachycardia and hypotension
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Monitor partial pressure of oxygen (Pa<font size="-2">O</font><font face="LWWSUB">2</font>) levels.
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"I need to use insulin each day."
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A client's gestational diabetes is poorly controlled throughout her pregnancy. She goes into labor at 38 weeks and delivers a baby boy. Which priority intervention should be included in the care plan for the neonate during his first 24 hours?
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Provide frequent early feedings with formula.
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A 28-year-old client gave birth 1 hour ago to a full-term baby boy. Which finding should the nurse expect when palpating the client's fundus?
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Firm, at the level of the umbilicus
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Which finding is considered normal in the neonate during the first few days after birth?
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Weight loss then return to birth weight
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The mother of a neonate expresses concern about how she'll continue to breast-feed when she returns to work in 6 weeks. What's the best response by the nurse?
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"You can continue breast-feeding after you go back to work. You can pump your breasts and put the milk in a bottle."
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Early detection of an ectopic pregnancy is paramount in preventing a life-threatening rupture. Which signs and symptoms should alert the nurse to the possibility of an ectopic pregnancy?
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Abdominal pain, vaginal bleeding, and a positive pregnancy test
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The client has just given birth to her first child, a healthy, full-term baby girl. The client is Rh<font face="LWWSUB">o</font>(D)-negative and her baby is Rh-positive. What intervention will be performed to reduce the risk of Rh incompatibility?
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Administration of Rh<font face="LWWSUB">o</font> immune globulin I.M. to the mother within 72 hours
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Use a warm, moist compress over the painful area.
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The nurse teaches a postpartum client about breast-feeding. Which statement best indicates that the client knows how to prevent breast engorgement?
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"I'll breast-feed every 1<font face="LWWSYM">r</font> to 3 hours."
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The nurse is collecting data on a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus?
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One fingerbreadth below the umbilicus
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The nurse is helping to prepare a client for discharge following childbirth. During a teaching session, the nurse instructs the client to do Kegel exercises. What's the purpose of these exercises?
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To strengthen the perineal muscles
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The nurse is using Doppler ultrasound to assess a pregnant client. When should the nurse expect to hear fetal heart tones?
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11 weeks
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The nurse is planning care for a 16-year-old client in the prenatal clinic. Adolescents are prone to which complication during pregnancy?
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Iron deficiency anemia
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The nurse is caring for a 16-year-old pregnant client. The client is taking an iron supplement. What should this client drink to increase the absorption of iron?
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A glass of orange juice
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The nurse is caring for a client in her 34th week of pregnancy who wears an external monitor. Which statement by the client would indicate an understanding of the nurse's teaching?
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"I can lie in any comfortable position, but I should stay off my back."
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The nurse is developing a care plan for a client in her 34th week of gestation who's experiencing premature labor. What nonpharmacological interventions should the plan include to halt premature labor?
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Promoting adequate hydration
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The nurse is caring for a client in labor. Which data collection finding indicates fetal distress?
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Fetal blood pH less than 7.20
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Shallow chest breathing
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The nurse is caring for a client receiving a lumbar epidural anesthetic block to control labor pain. What should the nurse do to prevent hypotension?
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Ensure adequate hydration before the anesthetic is administered.
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Applying gentle pressure to the neonate's head as it's delivered
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The nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain from her episiotomy. What should the nurse instruct the client to do?
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Apply an ice pack to her perineum.
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Two days after having a cesarean delivery, a client is diagnosed with deep vein thrombosis. The nurse should monitor this client for which complication?
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Pulmonary embolism
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The nurse is collecting data on a client who believes she's pregnant. Which sign or symptom indicates a hydatidiform mole?
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Abnormally high human chorionic gonadotropin (hCG) levels
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The nurse is caring for a client after evacuation of a hydatidiform mole. The nurse should tell the client to:
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use birth control for at least 1 year.
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A client in the 13th week of pregnancy develops hyperemesis gravidarum. Which laboratory finding indicates the need for intervention?
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Ketones in urine
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A client with hyperemesis gravidarum is on a clear liquid diet. The nurse should serve this client:
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tea and gelatin dessert.
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The nurse is collecting data on a neonate. Health history findings indicate that the mother drank 3 ounces or more of alcohol per day throughout pregnancy. Which characteristic should the nurse expect to find?
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Upturned nose
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The nurse is caring for a client on her second postpartum day. The nurse should expect the client's lochia to be:
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red and moderate.
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The nurse is assessing a neonate. How should she assess the rooting reflex?
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Stroke the neonate's cheek.
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The nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first?
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Change the client's position.
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The nurse is teaching a client how to perform perineal care to reduce the risk of puerperal infection. Which activity indicates that the client understands proper perineal care?
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Using a peri-bottle to cleanse the perineum after each voiding or bowel movement
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The nurse gives a neonate an initial feeding of plain sterile water. The mother asks why this was given. What's the nurse's best response?
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"Plain sterile water will cause less irritation to the respiratory tract if the baby accidentally breathes some in."
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A 7-lb, 4-oz baby boy is born by spontaneous vaginal delivery. During the initial assessment at 1 hour postpartum, the nurse notices lanugo, acrocyanosis, mongolian spots, and hemangiomas. Which of these is an abnormal finding in a neonate?
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Hemangiomas
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Deficient knowledge about the need for cesarean birth
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The nurse is planning a teaching session for new parents. What's the best way to teach new parents about the care of their neonate?
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Focus on the behavior of their own neonate.
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This condition may be related to the neonate's temperature instability.
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Provide the client with a glass of skim milk.
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A woman in her 8th month of pregnancy is having dinner with her husband at their favorite restaurant. The woman suddenly chokes on a piece of chicken and appears to lose consciousness. What would be the best action by a nurse sitting at the next table?
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Apply chest thrust.
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One English muffin, <font face="LWWSYM">r</font> cup cooked grits, 1 egg, <font face="LWWSYM">r</font> banana, 1 cup skim milk, and 2 tsp margarine
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A primigravida client with acquired immunodeficiency syndrome (AIDS) is in labor at term. In preparing her nursing care plan, the nurse should include which of the following nursing diagnoses?
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Risk for infection related to suppressed immune status
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"I know I need to walk with a friend or family member."
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A 23-year-old primigravida client delivers a healthy 6-lb, 13-oz boy by vaginal delivery. The next day, the nurse is examining lower extremities for signs and symptoms of thrombophlebitis. Which of the following is the best sign to assess?
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Homans' sign
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"This is an adverse effect of magnesium sulfate therapy; the feeling will go away when the medication is discontinued."
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"Heparin doesn't cross the placenta, so it can't get into the baby's blood system."
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A pregnant client is receiving heparin. Which of the following should be a part of nursing assessment on every shift?
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Any signs of preterm labor and bleeding from an orifice
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A 15-year-old primigravida gave birth 2 days ago. She tells her primary nurse that having her own little baby will be wonderful. Which nursing response would best evaluate the accuracy of the client's expectations?
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"Tell me what your day will be like after you take your baby home."
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A client notices that her neonate's eyes appear to be crossed. She anxiously points this out to the nurse. What's the nurse's best response?
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"This is a temporary condition caused by immature neuromuscular control of the eye muscles."
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The nurse assesses a neonate's respiratory rate at 46 breaths/minute after 6 hours of life. Respirations are shallow, with periods of apnea lasting up to 5 seconds. Which action should the nurse take next?
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Continue routine monitoring.
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A pregnant client who is older than age 35 is at increased risk for which pregnancy-associated complication?
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Placenta previa
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A 19-year-old primigravida is being treated for her second case of simple vaginitis during pregnancy. Which of the following instructions is most important for the nurse to focus on during client teaching?
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Maintain cleanliness and avoid contamination after elimination.
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A client in her 36th week of pregnancy is admitted to the hospital with vaginal bleeding. After undergoing an ultrasonic scan, she's diagnosed with placenta previa. Which finding would best confirm this diagnosis?
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A soft, nontender uterus
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A primigravida client is 16 weeks pregnant. Which client-teaching instruction would be most important to prevent toxoplasmosis?
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Cook meats thoroughly.
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The client is experiencing normal ambivalence about being pregnant.
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A client is 22 weeks pregnant with her first baby. Her weight gain is normal, but she complains of constipation. What's the most effective recommendation the nurse can make?
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Increase intake of fluids and high-fiber foods.
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A client in her seventh month of pregnancy has been complaining of back pain and wants to know what can be done to relieve it. Which of the following responses by the nurse is most effective?
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"Avoid lifting heavy loads, and try using the pelvic tilt exercise."
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A nurse instructs a pregnant client about the importance of doing Kegel exercises frequently. Kegel exercises are effective for which of the following?
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To help maintain good perineal muscle tone by tightening the pubococcygeus muscle
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Respiratory complications
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As part of a prenatal nutritional teaching program for a 17-year-old client who's concerned about weight gain, which of the following statements by the nurse would be most appropriate?
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"During pregnancy you need to gain weight to help make sure your baby is healthy."
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A 34-year-old client at 32 weeks' gestation tells the nurse that her baby will be sick because she saw a dead dog on the road yesterday. What's the best response by the nurse?
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"I can see that you're concerned. Let's talk about what's bothering you."
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Which of the following complications of pregnancy are most common among adolescents?
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Pregnancy-induced hypertension (PIH) and iron deficiency anemia
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The human embryo grows at a very rapid rate. At what gestational age does a single-chambered heart begin to beat and pump its own blood cells through main blood vessels?
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Approximately 24 days
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A 22-year-old client presents to the maternity clinic for her first prenatal visit. She's gravida 1; approximate gestational age is 10 weeks. What's the simplest and most cost-effective means of determining nutritional status?
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Anthropometric measures and 24-hour recall
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A client with a history of heart failure becomes pregnant. When will the risk to her and her fetus become greatest?
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Weeks 28 to 32
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A client in the first trimester complains of nausea every morning and asks about medicine to prevent it. What's the nurse's most helpful response?
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"Let me tell you about some methods to control nausea without medication."
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"Smoking affects the baby's size and development."
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While evaluating the needs of a client during the second trimester, the nurse can anticipate which of the following?
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Increasing introspection but a general sense of well-being
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A primipara client in her 10th week of pregnancy calls the nurse to say that she's experiencing slight vaginal bleeding. What's the nurse's best response?
|
"Save any perineal pads, clots, and tissue and come to the clinic right away."
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A pregnant client is taking folic acid. During prenatal teaching, which of the following foods would the nurse recommend as high in folic acid?
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Egg yolks
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Supine hypotension
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The nurse would look for which positive sign when assessing a client for pregnancy?
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Fetal movement felt by the examiner
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A 35-year-old client is in the eighth month of her first pregnancy. Her physician orders a biophysical profile to be conducted the next day. What equipment would the nurse assemble to conduct this test?
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Ultrasound machine and fetal monitor
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A 23-year-old primigravida client has a normal vaginal delivery. The next day, the nurse monitors the client's lochia for color, amount, and the presence of clots. Which of the following best describes lochia on the first postpartum day?
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Dark red (lochia rubra), moderate amount, with a few small clots
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A baby born at 34 weeks' gestation has a surfactant deficit. Which of the following conditions would the nurse most likely find while collecting data on a neonate?
|
Sternal retractions
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A multigravida in her 34th week of gestation comes to the emergency department complaining of vaginal bleeding. Which of the following should be the nurse's first action?
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Assess fetal heart rate (FHR) and maternal blood pressure.
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Blood pressure of 146/90 mm Hg
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During labor, meconium in the amniotic fluid is a normal finding in which of the following situations?
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Breech presentation
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Which of the following indicates fetal distress?
|
Fetal scalp pH of 7.14
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A primipara at 32 weeks' gestation comes to the hospital complaining of vaginal bleeding. She has soaked one peripad. She has no pain or cramps. What may be a possible cause of the vaginal bleeding?
|
Placenta previa
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After an Rh-negative woman experiences a spontaneous abortion, the nurse should expect to administer which medication?
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Rh<font face="LWWSUB">o</font> (D) immune globulin (RhoGAM)
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Move the precipitant delivery cart to the labor room, and notify the neonatologist on call.
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"You may feel a fluttering or tight sensation in your chest."
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A client delivers a 9-lb, 10-oz neonate vaginally, with a midline episiotomy. Shortly after delivery, the client complains of not feeling well. In assessing for possible uterine hemorrhage, the nurse should note which of the following?
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Cool, clammy, pale skin and anxiety
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Lateral
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A client is in labor with her first baby. Which of the following would indicate that the client has moved into the second stage of labor?
|
The client has an uncontrollable urge to bear down.
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Identify factors that may affect the client's learning.
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A nurse is reviewing prenatal care with a client. Which of the following statements by the client best expresses an adequate understanding of the nutritional needs during pregnancy?
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"I'll need to eat more so that I'll gain about 25 pounds, but I want to make sure I don't fill up with junk food."
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Have the client lie on her left side, and ask the family to take turns being with the client one at a time.
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Promotion of self-esteem
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A client with diabetes gives birth to a 6-lb baby at 36 weeks' gestation. The neonate is placed in the neonatal intensive care unit. The mother is grieving over the early delivery. What action by the nurse would be most helpful to the client?
|
Seek involvement of external support systems to provide emotional comfort and material resources for the client.
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A neonate weighed 3,350 grams at birth. On discharge (postpartum day 3), his weight had decreased to 3,100 grams. His mother is upset and asks whether the baby was fed in the nursery. Which of these responses would be most helpful?
|
"I can see that you're worried. His weight loss is an expected one. He'll probably start to gain weight now."
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A new mother is discharged 16 hours after delivery. Which of the following symptoms would require the new mother to contact her health care provider?
|
Bright red lochia with an increased flow rate
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The client is grieving the loss of her anticipated childbirth experience.
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Lower uterine segment transverse incision
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During her first prenatal visit to the obstetrician's office, a client complains of increased vaginal drainage. Which of the following responses by the nurse is most appropriate?
|
"This is normal during pregnancy. Just be sure to wash daily with soap and water."
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Determine the source of her anxiety and institute interventions to help her relax.
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|
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A first-time mother-to-be is in the labor room, her husband at her bedside. The client states that her contractions began 6 hours ago. Which of the following assessment findings would confirm that the client is in true labor?
|
Cervix that's 100% effaced and 2 cm dilated
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|
|
A pregnant client develops a chlamydia infection. Which drug is considered the most appropriate treatment for pregnant clients infected with chlamydia?
|
Azithromycin (Zithromax)
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|
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|
Palpate her abdomen to determine the intensity of labor contractions as they're taking place.
|
|
|
A client is in the second trimester of her first pregnancy. Which of the following findings should the nurse bring to the attention of the obstetrician or nurse-midwife?
|
No ballottement
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|
Put the client in a knee-chest position.
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|
Help the client urinate.
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|
A baby girl is delivered at 38 weeks' gestation. She weighs 5 lb, 2 oz and is having difficulty maintaining body temperature. Which nursing activity would best prevent cold stress in a term neonate?
|
Dry the neonate thoroughly, place her in a radiant heater, and monitor her temperature closely.
|
|
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|
The client fears rejection by her family because of her unplanned pregnancy.
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|
|
The nurse should anticipate which psychological reactions during the second trimester of pregnancy?
|
Self-centeredness and concentration on the behavior and appearance of children
|
|
|
When caring for a neonate, what's the most important step the nurse can take to prevent and control infection?
|
Practice meticulous hand washing.
|
|
|
The nurse is about to give a full-term neonate his first bath. How should the nurse proceed?
|
Bathe the neonate only after his body temperature has stabilized.
|
|
|
During an examination, a client who is 32 weeks pregnant becomes dizzy, light-headed, and pale while supine. What should the nurse do first?
|
Turn the client on her left side.
|
|
|
The nurse has just taught a client about the signs of true and false labor. Which client statement indicates an accurate understanding of this information?
|
"False labor contractions usually occur in the abdomen."
|
|
|
After an amniotomy, which client goal should take the highest priority?
|
The fetus will maintain adequate tissue perfusion.
|
|
|
When participating in planning care for a client in labor, the nurse expects to monitor the blood pressure frequently. Why?
|
Alterations in cardiovascular function affect the fetus.
|
|
|
In the first stage of labor, a client with a full-term pregnancy has an electronic fetal monitoring (EFM) device in place. Which EFM pattern suggests adequate uteroplacental-fetal perfusion?
|
Average variability
|
|
|
On the seventh day after giving birth, a client tearfully tells the nurse, "I should be happy, but I'm not. What's wrong with me?" At this point, what's the nurse's best response?
|
"It isn't unusual to have these feelings after delivery."
|
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|
The nurse is preparing to assess a client who gave birth 6 hours ago. Which statement best explains the use of gloves during the postpartum assessment?
|
Gloves are an essential part of standard precautions.
|
|
|
A client in the fourth stage of labor asks to use the bathroom for the first time since delivery. The client has oxytocin (Pitocin) infusing. Which response by the nurse is best?
|
"You may use the bathroom with my assistance."
|
|
|
A client has just been admitted to the postpartum unit after an uncomplicated vaginal birth of a healthy neonate. Which factor is the best predictor that this client will experience afterpains?
|
The client has given birth five times.
|
|
|
While the nurse helps prepare a postpartum client for discharge with her healthy neonate, the client complains of perineal discomfort. Which instruction should the nurse provide to ease the client's perineal discomfort when seated?
|
"Contract your buttocks before sitting or rising."
|
|
|
A postpartum client is scheduled for discharge tomorrow. During discharge teaching, the nurse should advise her to report which of the following to her health care provider?
|
Redness, warmth, and pain in a breast
|
|
|
Which factor is most likely to promote attachment between parents and their neonate?
|
Sustained contact immediately after childbirth
|
|
|
The nurse is reviewing a postpartum client's care plan before discharge. Which factor is the most likely to interfere with this client's parental attachment?
|
Recent loss of a parent
|
|
|
A postpartum client is being discharged tomorrow. Which goal is most appropriate in relation to the client's childbirth experience?
|
The client will discuss and integrate the experience, enabling progress to maternal role attainment.
|
|
|
At 36 weeks' gestation, the client delivered a neonate who died shortly after birth. Which nursing intervention is appropriate for this client?
|
Encourage her to see, touch, and hold the neonate.
|
|
|
A client undergoing prenatal blood testing tests positive for human immunodeficiency virus (HIV). What should the nurse do with this information?
|
Follow facility policy for documenting and communicating HIV status.
|
|
|
An adolescent who's 14 weeks pregnant comes to the clinic for a prenatal examination. During the examination, the client says to the nurse, "I'm still not sure whether I want to keep my baby." Which response by the nurse is best?
|
"Have you and the physician discussed your options?"
|
|
|
The nurse observes many cuts and bruises on the back, arms, and legs of a pregnant client. The client tells the nurse, "I was cleaning and a box of supplies fell on me." Which response by the nurse is most appropriate?
|
"It's our responsibility to maintain client confidentiality and to make sure our clients are safe."
|
|
|
A client in labor, who attended natural childbirth classes, is asking for something to relieve the pain. What should the nurse do?
|
Contact the physician and support the client until something can be ordered for the pain.
|
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|
Obtain a set of vital signs and check the client's fundus and compare them to baseline data.
|
|
|
While preparing a client for a postpartum tubal ligation, the nurse overhears the client tell her husband that they can always have reversal surgery if they decide they want more children in the future. Which intervention by the nurse is best?
|
Discuss the client's understanding of the procedure in private.
|
|
|
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|
The client will demonstrate ability to bottle-feed the neonate.
|
|
|
The nurse understands that measures are necessary to contain health care costs. Which intervention demonstrates effective resource management?
|
Assigning the nursing assistant to deliver meal trays and stock rooms and assigning the licensed practical nurse to collect assessment data
|
|
|
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|
Observe standard precautions and place the neonate of the infected mother in a warmer inside the mother's room.
|
|
|
A licensed practical nurse (LPN) is delegating responsibilities to a certified nursing assistant (CNA) on a busy postpartum unit. Which task can be delegated to the CNA?
|
Bottle-feeding a 24-hour-old neonate
|
|
|
Which nutritional instructions should the nurse provide to a 32-year-old primigravida client? Select all that apply:
|
Caloric intake should be increased by 300 cal/day.
|
|
|
Which nutritional instructions should the nurse provide to a 32-year-old primigravida client? Select all that apply:
|
Protein intake should be increased by 30 g/day.
|
|
|
Which nutritional instructions should the nurse provide to a 32-year-old primigravida client? Select all that apply:
|
Intake of all minerals, especially iron, should be increased.
|
|
|
During a prenatal screening of a client with diabetes, the nurse should keep in mind that the client is at increased risk for which complications? Select all that apply:
|
Still birth
|
|
|
During a prenatal screening of a client with diabetes, the nurse should keep in mind that the client is at increased risk for which complications? Select all that apply:
|
Pregnancy-induced hypertension
|
|
|
During a prenatal screening of a client with diabetes, the nurse should keep in mind that the client is at increased risk for which complications? Select all that apply:
|
Spontaneous abortion
|
|
|
A client is scheduled for amniocentesis. What should the nurse do to prepare the client for the procedure? Select all that apply:
|
Ask the client to void.
|
|
|
A client is scheduled for amniocentesis. What should the nurse do to prepare the client for the procedure? Select all that apply:
|
Assess fetal heart rate.
|
|
|
A client is scheduled for amniocentesis. What should the nurse do to prepare the client for the procedure? Select all that apply:
|
Monitor maternal vital signs.
|
|
|
A client with hyperemesis gravidarum is on a clear liquid diet. Which foods would be appropriate for the nurse to serve? Select all that apply:
|
Tea and gelatin
|
|
|
A client with hyperemesis gravidarum is on a clear liquid diet. Which foods would be appropriate for the nurse to serve? Select all that apply:
|
Ginger ale and apple juice
|
|
|
A client with hyperemesis gravidarum is on a clear liquid diet. Which foods would be appropriate for the nurse to serve? Select all that apply:
|
Cranberry juice and chicken broth
|
|
|
The nurse is palpating the uterus of a client who is 20 weeks pregnant in order to measure fundal height. Identify the area on the abdomen where the nurse should expect to feel the uterine fundus.
|
|
|
|
A client has approached the nurse asking for advice on how to deal with his alcohol addiction. The nurse should tell the client that the only effective treatment for alcoholism is:
|
total abstinence.
|
|
|
The nurse is providing care for a client undergoing opiate withdrawal. Opiate withdrawal causes severe physical discomfort and can be life-threatening. To minimize these effects, opiate users are commonly detoxified with:
|
methadone.
|
|
|
The nurse is caring for a client who experiences false sensory perceptions with no basis in reality. These perceptions are known as:
|
hallucinations.
|
|
|
The nurse is caring for a client who is suicidal. When accompanying the client to the bathroom, the nurse should:
|
observe him.
|
|
|
The nurse is assisting with developing a care plan for a client with anorexia nervosa. Which action should the nurse include in the plan?
|
Set up a strict eating plan for the client.
|
|
|
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|
"How do you think you would kill yourself?"
|
|
|
The nurse is caring for a client suspected of abusing opiates. Data collection findings in a client abusing opiates would include:
|
euphoria and constricted pupils.
|
|
|
The nurse is caring for a client experiencing an anxiety attack. Appropriate nursing interventions include:
|
staying with the client and speaking in short sentences.
|
|
|
The nurse is teaching a new group of mental health aides. The nurse should teach the aides that setting limits is most important for:
|
a manic client.
|
|
|
A client is admitted with a diagnosis of delusions of grandeur. This diagnosis reflects a belief that one is:
|
highly important or famous.
|
|
|
The nurse is caring for a client, a Vietnam veteran, who exhibits signs and symptoms of posttraumatic stress disorder. Signs and symptoms of posttraumatic stress disorder include:
|
hyperalertness and sleep disturbances.
|
|
|
The nurse is caring for a client with manic depression. The care plan for a client in a manic state would include:
|
listening attentively with a neutral attitude and avoiding power struggles.
|
|
|
A client is a Vietnam War veteran with a diagnosis of posttraumatic stress disorder. He has a history of nightmares, depression, hopelessness, and alcohol abuse. Which option offers the client the most lasting relief of his symptoms?
|
The opportunity to verbalize memories of trauma to a sympathetic listener
|
|
|
A client is admitted for detoxification after a cocaine overdose. The client tells the nurse that he frequently uses cocaine but that he can control his use if he chooses. Which coping mechanism is he using?
|
Denial
|
|
|
A 22-year-old client is diagnosed with dependent personality disorder. Which behavior is most likely to be evidence of ineffective coping?
|
Inability to make choices and decisions without advice
|
|
|
The major goal of therapy in crisis intervention is to:
|
resolve the immediate problem.
|
|
|
A 38-year-old client is admitted for alcohol withdrawal. The most common early sign or symptom that this client is likely to experience is:
|
perceptual disorders.
|
|
|
A client is admitted with a diagnosis of schizotypal personality disorder. Which signs would this client exhibit during social situations?
|
Paranoid thoughts
|
|
|
The nurse is caring for a client in an acute manic state. What's the most effective nursing action for this client?
|
Reducing his stimulation
|
|
|
The nurse is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to:
|
identify anxiety-causing situations.
|
|
|
The nurse is caring for a 40-year-old client. Which behavior by the client indicates adult cognitive development?
|
Generates new levels of awareness
|
|
|
The nurse is collecting data on a client suffering from stress and anxiety. A common physiological response to stress and anxiety is:
|
diarrhea.
|
|
|
The nurse is collecting data on a client for lifestyle factors that might affect normal coping. Which factor would the nurse most likely consider?
|
Inadequate diet
|
|
|
Which statement about somatoform pain disorder is accurate?
|
The pain is real to the client, even though there may not be an organic etiology for the pain.
|
|
|
A client is admitted for an overdose of amphetamines. When collecting data on this client, the nurse should expect to see:
|
tension and irritability.
|
|
|
During a shift report, the nurse learns that she will be providing care for a client who's vulnerable to panic attack. Treatment for panic attacks includes behavioral therapy, supportive psychotherapy, and medication such as:
|
antianxiety drugs.
|
|
|
A client comes to the emergency department while experiencing a panic attack. The nurse can best respond to a client having a panic attack by:
|
staying with the client until the attack subsides.
|
|
|
A 24-year-old client is experiencing an acute schizophrenic episode. He has vivid hallucinations that are making him agitated. The nurse's best response at this time would be to:
|
explore the content of the hallucinations.
|
|
|
A client with paranoid type schizophrenia becomes angry and tells the nurse to leave him alone. The nurse should:
|
tell him that she'll leave for now but will return soon.
|
|
|
The nurse is providing care to a client with catatonic type of schizophrenia who exhibits extreme negativism. To help the client meet his basic needs, the nurse should:
|
tell the client specifically and concisely what needs to be done.
|
|
|
A client with manic episodes is taking lithium. Which electrolyte level should the nurse check before administering this medication?
|
Sodium
|
|
|
A client is admitted to the inpatient unit of the mental health center with a diagnosis of paranoid schizophrenia. He's shouting that the government of France is trying to assassinate him. Which of the following responses is most appropriate?
|
"I find it hard to believe that a foreign government or anyone else is trying to hurt you. You must feel frightened by this."
|
|
|
A client has been receiving chlorpromazine (Thorazine), an antipsychotic, to treat his psychosis. Which finding should alert the nurse that the client is experiencing pseudoparkinsonism?
|
Tremors, shuffling gait, masklike face
|
|
|
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|
Continue suicide precautions.
|
|
|
A 26-year-old male reports losing his sight in both eyes. He's diagnosed as having a conversion disorder and is admitted to the psychiatric unit. Which nursing intervention would be most appropriate for this client?
|
Not focusing on his blindness
|
|
|
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|
Rotate the nurses who are assigned to the client.
|
|
|
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|
begin anytime within the next 1 to 2 days.
|
|
|
The nurse in the substance abuse unit is trying to encourage a client to attend Alcoholics Anonymous meetings. When the client asks the nurse what he must do to become a member, the nurse should respond:
|
"Admit you're powerless over alcohol and that you need help."
|
|
|
The nurse is collecting data on a 15-year-old female who is being admitted for treatment of anorexia nervosa. Which clinical manifestation is the nurse most likely to find?
|
Hypotension
|
|
|
The nurse is caring for a client with antisocial personality disorder. Which of the following statements is most appropriate for the nurse to make when explaining unit rules and expectations to the client?
|
"You'll be expected to attend group therapy each day."
|
|
|
Which of the following factors would have the most influence on the outcome of a crisis situation?
|
Previous coping skills
|
|
|
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|
Removing items that the client could use in a suicide attempt
|
|
|
The nurse is caring for an adolescent female who reports amenorrhea, weight loss, and depression. Which additional data collection finding would suggest that the client has an eating disorder?
|
Excessive and ritualized exercise
|
|
|
The nurse is caring for a client diagnosed with antisocial personality disorder. The client has a history of fighting, cruelty to animals, and stealing. Which of the following traits would the nurse be most likely to uncover during data collection?
|
A low tolerance for frustration
|
|
|
The nurse is working with a client who abuses alcohol. Which of the following facts should the nurse communicate to the client?
|
Abstinence is the basis for successful treatment.
|
|
|
What herbal medication for depression, widely used in Europe, is now being taken by clients in the United States?
|
St. John's wort
|
|
|
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|
"I just can't seem to get down to the weight I want to be. I'm so fat compared to other girls."
|
|
|
A client diagnosed with depression tells the nurse that she won't allow herself to cry, because it upsets the whole family when she cries. This is an example of:
|
rationalization.
|
|
|
A client diagnosed with major depression has started taking amitriptyline hydrochloride (Elavil), a tricyclic antidepressant. What's a common adverse effect of this drug?
|
Dry mouth
|
|
|
A client has received treatment for depression for 3 weeks. Which behavior suggests that the client is recovering from depression?
|
The client talks about the difficulties of returning to college after discharge.
|
|
|
A client in the manic phase of bipolar disorder constantly belittles other clients and demands special favors from the nurses. Which nursing intervention would be most appropriate for this client?
|
Set limits with consequences for belittling or demanding behavior.
|
|
|
The nurse is caring for a client with hypochondriasis. Which behavior would the nurse be most likely to encounter?
|
Expression of fear of colorectal cancer following 3 days of constipation
|
|
|
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|
Report the complaint of chest pain to the physician.
|
|
|
The nurse is talking with a client who recently attempted suicide. The client asks her not to tell anyone one about their conversation. How should the nurse respond?
|
"I'll need to share information with the rest of your health care team if it's important to your care."
|
|
|
The nurse is administering atropine sulfate to a client about to undergo electroconvulsive therapy. Which data collection finding indicates that the medication is effective?
|
The client states that his mouth is dry.
|
|
|
The nurse is documenting a care plan for a client who has undergone electroconvulsive therapy. The nurse should include which intervention?
|
Reorienting the client to time and place
|
|
|
The nurse is caring for a client in the manic phase of bipolar disorder who's ready for discharge from the psychiatric unit. As the nurse begins to terminate the nurse-client relationship, which client response is most appropriate?
|
Expressing feelings of anxiety
|
|
|
A client with a borderline personality disorder has been playing one staff member against another. In formulating a care plan for this client, the nursing staff should include which intervention?
|
Rotating staff members who work with the client
|
|
|
A client is admitted to the substance abuse unit for alcohol detoxification. Which of the following medications is the nurse most likely to administer to reduce the symptoms of alcohol withdrawal?
|
Chlordiazepoxide (Librium)
|
|
|
The client tells the nurse he was involved in a car accident while he was intoxicated. What would be the most therapeutic response from the nurse?
|
"Tell me how you feel about the accident."
|
|
|
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|
inspect the client's personal belongings for potentially dangerous objects.
|
|
|
The nurse is caring for a client diagnosed with panic disorder. The client begins to hyperventilate. How should the nurse respond initially?
|
Stay with the client during the panic attack.
|
|
|
The nurse is caring for a client with panic disorder who has difficulty sleeping. Which nursing intervention would best help the client achieve healthy long-term sleeping habits?
|
Encouraging the use of relaxation exercises
|
|
|
A teenager was driving a car that slipped off an icy road, killing two of his friends. He repeatedly tells the nurse that he should be dead instead of his friends. The client's behavior is an example of:
|
survivor's guilt.
|
|
|
The nurse is caring for a client with schizophrenia. Which of the following outcomes is the least desirable?
|
The client spends more time by himself.
|
|
|
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|
Acknowledge that the client is hearing voices, but make it clear that the nurse doesn't hear these voices.
|
|
|
The nurse is caring for a client being treated for alcoholism. Before initiating therapy with disulfiram (Antabuse), the nurse teaches the client that he must read labels carefully on which of the following products?
|
Aftershave lotion
|
|
|
A client reports to the nurse that she feels like she's losing her mind. This fear is most commonly associated with which disorder?
|
Panic disorder
|
|
|
A family member is caring for a client diagnosed with Alzheimer's disease. Which of the following is most likely to cause the caregiver depression and role strain?
|
The caregiver feels unable to control the client and unable to cope with caregiving.
|
|
|
A client with schizophrenia who began taking haloperidol (Haldol) 1 week ago now exhibits jerking movements of the neck and mouth. These findings are associated with which adverse reaction to the drug?
|
Dystonia
|
|
|
Which nursing assessment has priority while a client's extremities are restrained?
|
Checking circulation in extremities
|
|
|
A psychiatric client who was voluntarily admitted now wishes to be discharged from the hospital, against medical advice. What's the most important assessment the nurse should make of the client?
|
Degree of danger to self and others
|
|
|
The nurse should determine that restraints are no longer needed when the client does which of the following?
|
Is calm verbally and nonverbally
|
|
|
A client on an inpatient psychiatric unit at a community mental health center is pacing up and down the hallway. The client has a history of aggression. Which of the following is the nurse's best response when approaching the client?
|
"You're pacing. Let's walk together and talk about it."
|
|
|
A 37-year-old male with a history of schizophrenia is having auditory hallucinations. The physician orders 200 mg of haloperidol (Haldol) orally or I.M. every 4 hours as needed. What's the nurse's best action?
|
Call the physician to clarify the order because the dosage is too high.
|
|
|
An inpatient psychiatric client suddenly becomes loud and visibly anxious. What's the best action for the nurse to take?
|
Say, "Let's go talk in your room."
|
|
|
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|
Ask, "Who are you talking to?"
|
|
|
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|
Deficient knowledge related to lack of motivation
|
|
|
A 35-year-old voluntary client suddenly begins yelling, throws a chair, and exhibits extreme agitation. Which of the following would be most important for the nurse to consider when planning an intervention?
|
Restraint should be used as a last resort.
|
|
|
Before forcing a client to take a medication, the nurse should give priority to which of the following?
|
The client's danger to self or others
|
|
|
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|
"You sound concerned."
|
|
|
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|
Adequate time has elapsed between discontinuing the first medication and beginning the second.
|
|
|
A client who has been hospitalized with depression is being discharged with a prescription of phenelzine (Nardil). In planning for discharge, the nurse should have a teaching plan that emphasizes which of the following?
|
Avoid red wine.
|
|
|
The physician prescribes a monoamine oxidase (MAO) inhibitor for a client. Which nursing diagnosis would be most appropriate to focus on during client teaching?
|
Risk for injury
|
|
|
A nurse is teaching clients in an outpatient clinic about monoamine oxidase (MAO) inhibitors. The nurse would best evaluate the clients' understanding of how their medications work by noting which of the following?
|
Food selections
|
|
|
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|
It's important not to force the person to face the phobic object or situation.
|
|
|
A 76-year-old widowed mother of six is admitted to a long-term care facility with a diagnosis of organic mental disorder. Which of the following approaches would be most helpful for the nurse in meeting the client's needs?
|
Simplify the environment as much as possible.
|
|
|
Which of the following snacks would be best for a client with anorexia nervosa who requires a high-protein, high-calorie diet?
|
Egg salad and peanuts
|
|
|
Which is the most appropriate nursing diagnosis for a client exhibiting obsessive-compulsive behavior?
|
Ineffective coping
|
|
|
###############################################################################################################################################################################################################################################################
|
Conversion
|
|
|
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|
Redirect the client to her room, and help her put on her more customary clothing.
|
|
|
What's the most effective intervention for handling a client with an antisocial personality?
|
Set limits with the client.
|
|
|
A client on the nursing unit, charged with child abuse, doesn't speak to the staff when approached. What's the nurse's best response to this client?
|
"Admission to a psychiatric unit can be very difficult."
|
|
|
A client is admitted for a suspected eating disorder. Which of the following statements would indicate that the client may be suffering from anorexia nervosa?
|
"I'm a perfectionist, and I work hard to get A's."
|
|
|
A client with a personality disorder exhibits manipulative behavior. Care planning for this client should include which of the following?
|
Verbal reinforcement when the client functions within established limits
|
|
|
A 24-year-old secretary is transferred to the psychiatric unit. Her husband says that she has been overeating and that she vomits soon after she eats. Her weight stays about the same, at 96 lb (43.5 kg). This behavior may indicate which medical diagnosis?
|
Bulimia
|
|
|
For a client with bulimia, which assessment is least important in the care plan?
|
Note changes in respiratory rate.
|
|
|
A client with personality disorder gets along poorly with his immediate family. The client's manipulative behavior most likely shows a failure to develop which of the following?
|
Trust
|
|
|
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|
Erratic and unpredictable behavior if challenged
|
|
|
###############################################################################################################################################################################################################################################################
|
"You're very hard on yourself."
|
|
|
###############################################################################################################################################################################################################################################################
|
Imbalanced nutrition: Less than body requirements
|
|
|
A client with antisocial personality disorder refuses to take a shower for 3 days. What's the nurse's best response?
|
"It's time for your shower. I'll help you with it."
|
|
|
A client with major depression states, "Everything is my fault, and I would be better off dead." What's the priority nursing intervention?
|
Assess the seriousness of the client's comment.
|
|
|
The nurse is interviewing a client who has been raped. Which strategy is most effective?
|
Using open-ended questions and listening intently
|
|
|
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|
Monitor her dental care, and set limits on the amount of daily brushing.
|
|
|
A client with a diagnosis of organic mental disorder becomes verbally and physically abusive when the nurse enters the client's room to assist with daily care. Which of the following interventions should the nurse engage in first?
|
Set firm limits verbally.
|
|
|
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|
Quiet and passive about pain
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A bulimic client admitted to the psychiatric unit suddenly shouts, "I want to leave right now. I'm not crazy and don't belong here." Which response should the nurse make?
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"You seem upset; I'll stay with you."
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"No, you can't. The rules apply equally to everyone, and you're asking to break them."
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A client with anorexia nervosa who's on bed rest stares at her dinner tray. She has made little effort to eat. Which statement by the nurse would be most therapeutic?
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"I'll stay with you while you eat and help you fill out tomorrow's menu."
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A client is hospitalized after experiencing sudden-onset paralysis. Diagnostic tests reveal no positive physical findings. What's a likely cause?
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An involuntary attempt to solve a conflict
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What should the nurse teach the parents of a child who's receiving methylphenidate (Ritalin)?
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Monitor the child's growth closely because the drug may interfere with growth and development.
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A client with major depression begins to improve and participates in treatment programs on the unit. The nurse should recognize that the client is ready for discharge when the client does which of the following?
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Discusses plans to return home and continue outpatient treatment
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Which of the following concepts about anorexia nervosa should the nurse consider in understanding a client's cry for help?
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Rejection of food as a way to obtain love and care from parents
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Encourage the client to perform as much self-care as possible.
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A 37-year-old man with a history of schizophrenia is having hallucinations. He shouts to the nurse, "You're stepping on spiders! Move aside. Don't you see them?" What's the nurse's best response?
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"No, I don't see them, but I believe that you do see them."
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Teaching for a client taking antipsychotic medication should include which of the following instructions?
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Avoid abrupt withdrawal of the medication.
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A client on an inpatient psychiatric unit at a community mental health center is pacing the hallway and appears agitated. When the nurse approaches him, he says loudly, "Leave me alone." What's the nurse's best approach?
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Say, "You sound upset. I'd like to help."
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Increased appetite
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Which of the following instructions is most important for a client taking lithium carbonate (Eskalith)?
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Maintain a high fluid intake.
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Advise the client that it isn't unusual for grieving and loss to continue for quite some time.
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"I can see how upsetting this is for you. It must be very difficult to be unable to function independently."
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"I'm so sorry that your pet had to be put to sleep. I know how important your cat was to you."
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"I can see how upset you are. Let's sit in the office so that we can talk about how you're feeling."
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"You've been through a very difficult experience. Let's move into the office so that we can talk."
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"You're pretty upset right now. Studying for finals can be very stressful. Let's work on a plan that might be helpful."
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The nurse is caring for an elderly client who exhibits signs of dementia. The most common cause of dementia in an elderly client is:
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Alzheimer's disease.
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The caregiver distinguishes obligations she must fulfill from those that can be controlled or limited.
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A 78-year-old Alzheimer's client is being treated for malnutrition and dehydration. The nurse decides to place him closer to the nurses' station because of his tendency to:
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wander.
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An 89-year-old client is suffering from dementia of the Alzheimer's type. Which intervention would be most useful in managing his dementia?
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Provide a safe environment.
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The nurse plans to include the parents of a client with anorexia nervosa in therapy sessions along with the client. What fact should the nurse remember about the parents of clients with anorexia?
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They tend to overprotect their children.
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The lithium level should be measured before the client receives the next lithium dose.
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The nurse is collecting data on a client who has been admitted to the emergency department. Which signs would suggest an overdose with an antianxiety agent?
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Emotional lability, euphoria, and impaired memory
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The nurse is assigned to care for a recently admitted client who has attempted suicide. What should the nurse be sure to do?
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Search the client's belongings and room carefully for items that could be used to attempt suicide.
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A client has been taking imipramine (Tofranil), 125 mg P.O. daily, for 1 week. The client wants to stop taking the medication because he still feels depressed. At this time, what's the nurse's best response?
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"Because imipramine must build up to a therapeutic level, it may take 3 to 4 weeks to reduce depression."
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Relate the client's concern for her health and the desire to help her make decisions to keep her healthy.
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"Many people who've been in your situation experience similar emotions and behaviors."
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Since admission 4 days ago, a client has refused to take a shower, stating, "There are poison crystals hidden in the shower head. They'll kill me if I take a shower." Which nursing action is most appropriate?
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Accept these fears and allow the client to take a sponge bath.
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A client is ready to be discharged with a prescription for the antipsychotic agent haloperidol (Haldol), 10 mg P.O. b.i.d. During a discharge teaching session, the nurse should provide which instruction to the client?
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Apply a sunscreen before being exposed to the sun.
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When teaching the family of a client with schizophrenia, the nurse should provide which information?
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Support is available to help family members meet their own needs.
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A client who cares for a parent with Alzheimer's disease at home reports feeling guilty because, at times, the client wishes the parent would die. What is the nurse's best response?
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"Being responsible for your parent's care must be difficult."
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For a client with anorexia nervosa, which goal takes the highest priority?
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The client will establish adequate daily nutritional intake.
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After learning that a roommate has tested positive for the human immunodeficiency virus, a client asks the nurse about moving to another room on the psychiatric unit because the client doesn't feel "safe" now. What should the nurse do first?
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Ask the client to describe his fears.
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A parent brings a preschooler to the emergency department for treatment of a dislocated shoulder. The parent states the injury occurred when the child fell down the stairs. Which behavior should make the nurse suspect that the child was abused?
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The child doesn't cry when the shoulder is examined.
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The client keeps a journal and discusses it with the nurse.
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A client becomes angry and belligerent toward the nurse after speaking on the phone with his mother. The nurse recognizes this as what coping mechanism?
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Displacement
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A client on the behavioral health unit spends several hours per day organizing and reorganizing his closet. He repeatedly checks to see if his clothing is arranged in the proper order. What term is commonly used to describe this behavior?
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Compulsion
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A client on the behavioral health unit is being evaluated for depression. Which statement by the client leads the nurse to suspect depression?
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"I just know my daughter doesn't love me anymore."
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Opioids
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A nurse is caring for a female client who's taking 1 mg of alprazolam (Xanax) twice per day for panic attacks. The nurse knows that the client understands teaching about the drug when the client states:
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"I'll discuss my plans for pregnancy with my physician."
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The nurse is explaining the Bill of Rights for psychiatric patients to a client who has voluntarily sought admission to an inpatient psychiatric facility. Which rights should the nurse include in the discussion? Select all that apply:
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Right to refuse treatment
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The nurse is explaining the Bill of Rights for psychiatric patients to a client who has voluntarily sought admission to an inpatient psychiatric facility. Which rights should the nurse include in the discussion? Select all that apply:
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Right to a written treatment plan
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The nurse is explaining the Bill of Rights for psychiatric patients to a client who has voluntarily sought admission to an inpatient psychiatric facility. Which rights should the nurse include in the discussion? Select all that apply:
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Right to confidentiality
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The nurse is explaining the Bill of Rights for psychiatric patients to a client who has voluntarily sought admission to an inpatient psychiatric facility. Which rights should the nurse include in the discussion? Select all that apply:
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Right to personal mail
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"You may leave the hospital at any time unless you are suicidal."
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"Let's talk more after the health team has assessed you."
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"Because you could hurt yourself, you must be safe before being discharged."
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The nurse is caring for a client with renal failure who requires peritoneal dialysis. The nurse doesn't feel comfortable performing the procedure. What would be the most appropriate action for the nurse to take?
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Ask the nursing supervisor for assistance in using the equipment.
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A nurse suspects that another nurse has been drinking. She smells alcohol on the nurse's breath and notes slurred speech. What's the best course of action for the nurse to take?
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Immediately notify the nursing supervisor.
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the gender of the physician.
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Which of the following clients would be a priority for the nurse to evaluate when assuming responsibility for their care at the beginning of the day shift?
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The client who had a total laryngectomy the previous day
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The nurse receives a report on the assigned clients at the beginning of the evening shift. On which of the following clients should the nurse plan to collect data first?
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An elderly client with pneumonia who has periods of confusion
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They can be charged with slander.
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Perform the procedure with the LPN.
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Report the incident to the proper authorities.
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The nurse is caring for a client who is Mormon. Which nursing action meets the spiritual needs of this client?
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Offering to contact a clergy member
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Document the problem in writing for the manager.
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The nurse is assigned to care for eight clients. Two nonprofessionals are assigned to work with the nurse. Which statement is valid in this situation?
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The nurse is responsible to supervise assistive personnel.
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Standard precautions were designed for the care of all clients in hospitals, regardless of their diagnosis or infection status. Guidelines for standard precautions include:
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disposing of sharp instruments into an impervious container.
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Which of the following statements is true?
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Standard precautions should be used whenever contact with blood or other body fluids is likely.
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Which of the following measures should a nurse take when following standard precautions?
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Wash hands immediately after removing gloves.
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The nurse caring for an 8-month-old infant diagnosed with respiratory syncytial virus is unable to read a medication dosage written in the infant's medical record. What is the ethical solution for the nurse?
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Call the physician and ask for a verbal order to clarify the dosage.
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In the course of providing care, the nurse discovers a possible error in the physician's order. How should the nurse respond?
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Confer with the physician and then decide whether or not to carry out the order.
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The nurse on the adolescent unit delegates a task to the nursing assistant. After delegating the task, the nurse should do which of the following?
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Allow adequate time for the task to be completed, then follow-up with the nursing assistant.
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A client is to undergo a hysterectomy without oophorectomy. The nurse is witnessing the client's signature on a consent form. Which comment would best indicate informed consent on the part of the client?
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"The physician is going to remove my uterus and told me about the risk of hemorrhage."
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The nurse is caring for a client admitted to the emergency department after a motor vehicle accident. Under the law, the nurse must obtain informed consent before treatment unless:
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the client is in an emergency situation.
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a risk-management incident.
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Breach of confidentiality
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A nurse accidentally administers 40 mg of propranolol (Inderal) to a client instead of 10 mg. Although the client exhibits no adverse reactions to the larger dose, the nurse should:
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complete an incident or unusual occurrence report.
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nurse practice acts.
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A client is dissatisfied with his hospitalization. He decides to leave against medical advice and refuses to sign the paperwork. The nurse's next course of action is to:
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let him leave.
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A nurse needs assistance transferring an elderly, confused client to bed. The nurse leaves the client to find someone to assist her with the transfer. While the nurse is gone, the client falls and hurts herself. The nurse is at fault because she didn't:
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arrange for continual care of the client.
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An adolescent girl arrives in the emergency department after a physical assault. A male health care provider is assigned to examine the client. Which action would best protect the client's rights during the physical examination?
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Keeping the suspected attacker from the examination room
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A client became seriously ill after a nurse gave him the wrong medication. After his recovery, he files a lawsuit. Who's most likely to be held liable?
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The nurse and the hospital
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A client with end-stage liver cancer tells the nurse he doesn't want extraordinary measures used to prolong his life. He asks what he must do to make these wishes known and legally binding. How should the nurse respond to the client?
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Discuss documenting his wishes in an advance directive.
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While admitting a client with pneumonia, the nurse notes multiple bruises in various stages of healing. The client has Alzheimer's disease and a history of multiple fractures. Legally, the most important action for the nurse to take is to:
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inform appropriate local authorities.
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Provide emotional support and pain relief.
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A 69-year-old male client is diagnosed with prostate cancer. Which nursing action constitutes an invasion of the client's privacy?
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Telling the family that the client has cancer without the client's knowledge
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Referring the client to a social worker for discharge
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The nurse is following a critical pathway to help a client who underwent hip replacement surgery meet specific objectives. What is a critical pathway?
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A clinical management tool that organizes the major interventions for a multidisciplinary health care team
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The nurse works in a managed-care environment. The nurse is expected to be oriented to which of the following criteria?
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Quality of care and cost-containment
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A client asks to be discharged from the health care facility against medical advice (AMA). What should the nurse do?
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Notify the physician.
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When documenting care in a client's medical record, the nurse should:
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record the time and date for all entries.
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Genetic counselor
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Parents whose first child has celiac disease ask the nurse if all of their children will have the disease. To whom should the nurse refer them?
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Genetic counselor
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The nurse is caring for a school-age child with cerebral palsy. The child has difficulty eating using regular utensils and requires a lot of assistance. Which of the following referrals is most appropriate?
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Occupational therapist
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"The community health nurse will check me and my baby and talk with my physician."
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The nurse is caring for a client with hyperemesis gravidarum who will need close monitoring at home. When should the nurse begin discharge planning?
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On admission to the hospital
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The parents or legal guardians of a child aren't available to give consent for treatment of a life-threatening situation. Which of the following statements is most accurate?
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Consent may not be needed in a life-threatening situation.
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The parents of a 5-year-old child call the clinic to tell the nurse that they think their child has been abused by her day-care provider. What should the nurse advise them to do?
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Schedule an immediate appointment with their health care provider.
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The charge nurse on a pediatric unit informs a licensed practical nurse that four of her clients require attention. Which client should the nurse see first?
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A 10-year-old with asthma whose oxygen saturation levels are dropping
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"I can't confirm whether your employee is a client here."
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Based on multiple referrals, the nurse determines that childhood injuries are increasing in the community in which she practices. The first step needed in developing an educational program is:
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assessing the strengths and needs of the community while identifying barriers to learning.
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Report to the CCU and identify tasks that she feels she can safely perform.
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Two family members are arguing in a child's room. They start to hit each other and the child is crying. Which is the most appropriate nursing action?
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Remove the child from the room.
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Speak to the manager and document in writing all concerns related to the assignment.
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Which task can a licensed practical nurse (LPN) appropriately delegate to a nursing assistant?
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Encouraging a client to drink fluids
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A 70-year-old client who's alert and oriented refuses to take his regularly scheduled medications. Which action should the licensed practical nurse (LPN) take?
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Inform the physician, document in the client's medication administration record that the medications weren't given, and document in the medical record why the client refused to take them.
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The nurse notes that a client frequently coughs while eating. Which health team member should be notified of this finding?
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Speech therapist
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A licensed practical nurse is admitting a client to the medical-surgical floor. She asks the client if he has an advance directive. The client responds saying, "I don't know what you mean." How should the nurse respond?
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"An advance directive is a document that states your wishes about health care."
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Many clients are brought to the emergency department after sustaining injuries in a building explosion. Using disaster management principles, which client should be triaged first?
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A 62-year-old client with tachypnea
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