DAVID'S Q&A FOR THE NCLEX-RN EXAMINATION TEST # 3

778.A nurse working in a hospital is assigned to care for a client who has a visual deficit. The nurse should plan to promote effective communication by: 1. announcing being present in the room and informing the client of the nurse’s name. 2. standing directly in front of the client while speaking with the client. 3. using a loud, clear voice when talking with the client. 4. touching the client to get the client’s attention before beginning to perform an assessment.

779.A client is seen in a primary care clinic because of a painful eye. The client is diagnosed with a hordeolum of the left eye. The client’s treatment plan is likely to include: 1. wearing an eye patch on the left eye. 2. administering miotic eye drops twice daily. 3. applying warm compresses several times daily and applying antibiotic ointment. 4. avoiding reading and other close work.

780.A hospitalized client tells a nurse that he feels as if he has something in his eye under the upper eyelid. The client does not recall any incident involving his eye. He has no eye pain or difficulty seeing. The eye is not reddened, and the client is able to open and shut his eye. The nurse should: 1. notify the client’s primary care provider. 2. flush the eye with sterile saline. 3. don gloves, use a cotton-tipped applicator to evert the upper lid, and examine the eye and inner lid. 4. place a patch on the eye, taping the eye from the outside to the inside.

781.Which member of the interdisciplinary team should a nurse expect a consultation when planning the care of the client with Ménière’s disease?. 1. Rheumatologist. 2. Otolaryngologist. 3. Physiatrist. 4. Oncologist.

782.A client diagnosed with Ménière’s disease tells a nurse that medication treatment for vertigo has been prescribed and provides the nurse with a list of med ications recently received. Which medication is most likely prescribed for treating the vertigo?. 1. Meclizine (Antivert®). 2. Megestrol (Megace®). 3. Meropenem (Merrem®). 4. Metoprolol (Lopressor®).

783. To reduce the risk of recurrent otitis media, which vaccine should a nurse recommend?. 1. Varicella vaccine (Varivax®). 2. Pneumococcal vaccine (Prevnar®). 3. Typhoid vaccine (Typhim Vi®). 4. Zoster vaccine (Zostavax®).

784.A client receives a prescription for sodium fluoride for otosclerosis and asks a nurse what the medication will do for his ears. Which response by the nurse is correct?. 1. “The medication prevents the breakdown of bone cells and hardens the bone in the ear.”. 2. “The medication causes the breakdown of bone cells and softens the bone in the ear.”. 3. “The medication blocks the effect of histamine and dries the fluid in the ear.”. 4. “The medication causes the production of histamine and increases the fluid in the ear.”.

785.A client recovering from stapedectomy surgery for otosclerosis reports dizziness after surgery. To de crease symptoms, which interventions should a nurse advise the client to implement? SELECT ALL THAT APPLY. 1. Refrain from sudden movements. 2. Minimize chewing on the affected side. 3. Avoid lifting objects. 4. Minimize bending over. 5. Restrict fluid intake. 6. Avoid watching television.

786.A client has a hearing loss from a suspected acoustic neuroma. Which diagnostic test should a nurse plan to prepare the client to confirm the presence of a tumor?. 1. Tympanometry. 2. Arteriogram of the cranial vessels. 3. Magnetic resonance imaging (MRI). 4. Auditory canal biopsy.

787.A nurse assesses a postoperative client after surgical removal of a right-sided acoustic neuroma by a translabyrinthine approach and notes that the client is complaining of pain and has new onset of right-sided facial drooping and numbness. Determine which action the nurse should take next, and place the following items in order of priority, with 1 as the first activity carried out by the nurse and 4 the item requiring consideration last?. _____ Close the right eye and place a patch over it. _____ Assess the operative incision site. _____ Contact the physician to report facial drooping. _____ Medicate the client for pain.

788. A client’s daughter tells a nurse of frustration while communicating with her elderly mother who wears hearing aides. A nurse suggests that the daugh ter should: 1. minimize oral communication to essential matters. 2. speak directly into the client’s better ear. 3. use exaggerated mouth expressions while speaking. 4. attract the client’s attention before speaking.

789. A resident of a long-term care facility tells the nurse that he is having increased difficulty hearing dur ing conversations and while watching television. A nurse should: 1. teach the client to eliminate background noises. 2. assess the client’s hearing and examine the client’s ears using an otoscope. 3. contact the primary care provider and schedule the client for bilateral ear irrigations. 4. teach the client to look directly at the speaker’s face in conversations or while watching a television program.

790. A client is admitted to a nursing care facility for rehabilitation after suffering a stroke. Observa tions by a nurse that should suggest the client has im paired hearing include: SELECT ALL THAT APPLY. 1. the client nods and agrees to all statements by the nurse. 2. the client asks for more information about the physical therapy schedule. 3. the client is slow to respond verbally but answers questions appropriately. 4. the client speaks in a loud tone of voice. 5. the client leans in toward the nurse when the nurse speaks. 6. the client asks the nurse to be careful before the nurse begins the otoscopic examination.

791.Which interventions should the nurse advise a client to implement for home treatment of acute sinusitis? SELECT ALL THAT APPLY. 1. Take over-the-counter antacids. 2. Apply warm compresses to the face. 3. Use saline nasal spray. 4. Take over-the-counter decongestants. 5. Drink plenty of fluids. 6. Spend time outdoors in the sunlight.

792.A nurse should teach a client, following a diagnostic arthroscopy, to: SELECT ALL THAT APPLY. 1. elevate the involved extremity for 24 to 48 hours. 2. apply ice continually for 24 hours. 3. report severe joint pain immediately to the physician. 4. resume usual activities to help reduce swelling. 5. treat pain with a mild analgesic such as acetaminophen (Tylenol®).

793. Which treatments should a nurse plan for a client being seen in the clinic for a second-degree an kle sprain?. 1. Rest, elevate the extremity, apply ice, and apply a compression bandage. 2. Perform range of motion to determine the extent of injury, apply heat, check circulation and sensation, and examine the ankle. 3. Reduce pain with moist heat, then apply ice to reduce swelling; check circulation, motion, and sensation; and elevate the ankle. 4. Refer the client immediately to an orthopedic surgeon, administer analgesics, control swelling with ice, and encourage rest and elevation.

794.A client involved in a work-related accident is sched uled for surgery to repair a comminuted femur frac ture. Three days following surgery, the client asks a nurse to describe what is meant by “a comminuted femur fracture.” In describing the fracture, which il lustration should the nurse show the client?. 1. Illustration A. 2. Illustration B. 3. Illustration C. 4. Illustration D.

795.A college student walking with a stiff left leg visits a campus health service reporting knee pain and a click when walking. He is concerned because sometimes his knee either “locks” or “gives way.” He thinks he twisted his knee wrong during a tennis match, but is not sure. A nurse suspects the client has: 1. an injury of the meniscus cartilage. 2. a fracture of the lateral tibial condyle. 3. a fractured patella. 4. a lateral collateral ligament injury.

796.A client is suspected of having a fat embolism fol lowing a pelvic fracture from a motor vehicle acci dent. A nurse should assess for which sign that is specific to a fat emboli?. 1. Dyspnea. 2. Chest pain. 3. Delirium. 4. Petechiae.

797.Which order written by a physician should be a prior ity for a nurse caring for a client who sustained an unstable pelvic fracture in a motor vehicle accident?. 1. Urinalysis. 2. Blood alcohol level. 3. Computed tomography (CT) scan of the pelvis. 4. Two units of cross-matched whole blood.

798.A licensed practical nurse is reporting observations and cares to a registered nurse (RN). Based on the re port, which client should the RN assess immediately?. 1. The client, 2 hours following a total knee replacement, who has 100 mL bloody drainage in the suction container of an autotransfusion drainage system. 2. The client with a crush injury to the arm who was given another analgesic and a skeletal muscle relaxant for throbbing, unrelenting pain. 3. The client in a new body cast who was turned every 2 hours and supported with waterproof pillows. 4. The client with an external fixator on the left leg, having serous drainage from the pin sites.

799.A clinic nurse has completed teaching for a client with a rotator cuff tear who is being treated conserva tively. Which client statement indicates that further teaching is needed?. 1.“I received a corticosteroid injection in my shoulder to reduce the inflammation.”. 2.“I will be doing progressive stretching and strengthening exercises now that the pain is controlled.”. 3.“I should continue taking ibuprofen (Advil®) with food for pain control.”. 4.“I will need an open acromioplasty surgery to repair the torn cuff after the swelling is reduced.”.

800.Which findings should a nurse expect when assessing a client diagnosed with a left femoral neck fracture? SELECT ALL THAT APPLY. 1.Left leg is abducted. 2.Left leg is externally rotated. 3.Left leg is shorter than right leg. 4.Pain in the lateral side of the left knee. 5.Pain in the groin area.

801.A client with a lower left leg fracture and a cast is us ing crutches. A nurse is evaluating whether the client is able to correctly get into a chair. Prioritize the ac tions that the client should be taking to correctly get into the chair. ______ Grasp the arm of the chair with the right hand. ______ Stand with the back of the unaffected leg centered against the chair. ______ Lean forward and flex the knees and hips. ______ Lower the body into the chair. ______ Brace the chair against the wall. ______ Transfer the crutches to the left hand,holding the crutches by the hand bars.

802.A 28-year-old client and his spouse were involved in a motorcycle accident in which his spouse was killed. The client, being treated in the progressive care unit for multiple rib fractures and a broken leg, asks the nurse in which room his wife is located. Which response is most appropriate?. 1. “Your wife is not in the hospital.”. 2. “I’m sorry, but your wife did not survive the accident.”. 3. “I need to get your family so that you can talk to them about your wife.”. 4. “The doctor will be talking to you about your wife and where she is located.”.

803.An elderly client with Alzheimer’s dementia is being admitted from a postanesthesia unit following a hip hemiarthroplasty to treat a hip fracture. Which inter vention should a nurse initially plan for the client’s pain control?. 1. Apply a fentanyl (Duragesic®) transdermal patch. 2. Initiate morphine sulfate per patient-controlled analgesia (PCA) with a basal rate. 3. Administer intravenous morphine sulfate based on the client’s report of pain. 4. Administer scheduled doses of morphine sulfate intravenously around the clock.

804.A diabetic client is admitted with a tentative diagno sis of osteomyelitis secondary to a wound on the an kle. The client’s ankle is painful, red, swollen, and warm, and the wound is persistently draining. The client’s temperature is 102.2°F (39°C). Based on the client’s status, which written physician’s order should a nurse plan to defer until later?. 1. Obtain wound culture. 2. Administer ceftriaxone (Rocephin®) 1 g IV (intravenously) q12 hours. 3. Apply splint to immobilize ankle. 4. Begin teaching on self-administration of home IV antibiotics.

805.A nurse is assessing an elderly client in Buck’s trac tion to temporally immobilize a fracture of the proxi mal femur prior to surgery. Which finding requires the nurse to intervene immediately?. 1. Reddened area on the sacrum. 2. Voiding concentrated urine, 50 mL/hr. 3. Capillary refill 3 seconds, dorsiflexion and sensation intact, pedal pulses palpable. 4. Lower leg secure in traction boot and ropes and pulleys and 5 lb weight hanging freely.

806.A nurse is providing instructions to a client who has a plaster cast to attain adequate molding following a fracture to the right wrist. Which statement, if made by the nurse, is incorrect?. 1. “Keep your cast uncovered while drying so that moisture can evaporate.”. 2. “Your cast will have a musty odor and dull gray appearance until it dries. But once fully dry, your cast should be odorless and shiny white.”. 3. “Your cast will feel sticky and very warm during the drying process, but it will dry very quickly in about 30 minutes.”. 4. “Support the cast by elevating it on pillows and avoid any sharp or hard surfaces, especially while your cast is drying, because it can cause denting and pressure areas.”.

807.A client has an external fixator for reduction of a tib ial fracture. A nurse is evaluating the client’s effec tiveness in ambulating with crutches. Place an X on the three areas where the client should be bearing weight when crutch walking.

808.A male client has been in a body cast for the past 2 days to treat numerous broken vertebrae from a fall. The client is reporting dyspnea, vomiting, epi gastric pain, and abdominal distention. Which ac tion demonstrates the best clinical judgment by a nurse?. 1. Immediately notifies the client’s physician of these findings. 2. Initiates oxygen at 2 liters per nasal cannula to relieve the dyspnea. 3. Places ice packs around the cast to reduce the abdominal distention. 4. Administers ondansetron (Zofran®), the prescribed antiemetic on the client’s MAR.

809. An experienced nurse observes a new nurse caring for a client in skeletal traction to stabilize a fracture of the proximal femur prior to surgery. Which observation by the experienced nurse indicates the new nurse needs additional orientation?. 1. Positions the client so the feet stay clear of the bottom of the bed. 2. Checks ropes so that they are positioned in the wheel groves of the pulleys. 3. Removes weights from the ropes until the weights hang freely off the bed frame. 4. Performs pin site care with chlorhexidine solution twice daily.

810. A client diagnosed with osteoarthritis, tells a clinic nurse about the inability to ambulate and staying on bedrest because of hip stiffness. In addition to teach ing the client measures to reduce joint stiffness, which referral for the client should the nurse plan to discuss with the health-care provider?. 1. Psychiatrist. 2. Social worker. 3. Physical therapist. 4. Arthritis Foundation.

811. A client is admitted for a total hip arthroplasty for chronic degenerative joint disease of the left hip. A nurse documents during the admission assess ment that the client uses alternative therapies for osteoarthritis treatment. The evidence for this docu mentation would include the client stating: SELECT ALL THAT APPLY. 1. taking ibuprofen (Advil®) every 4 to 6 hours for pain control. 2. wearing a copper bracelet continuously. 3. taking glucosamine sulfate 1,000 mg daily. 4. applying magnets to the hip joint and securing with an ace wrap. 5. sleeping on the unaffected hip with a pillow between the legs.

812. Which nursing action should be implemented on the second postoperative day for a client who received a right total hip replacement (THR) with a cemented prosthesis?. 1. Assisting the client to the bathroom, which has an elevated toilet seat, using a walker and partial weight bearing of the right leg. 2. Removing the Hodgkin’s splint, which maintained leg alignment during the night, and positioning pillows to adduct the client’s right leg. 3. Reinfusing the returns from a Stryker® wound autotransfusion drainage system, which has collected 400 mL in the past 24 hours. 4. Assisting the client to get out of bed on the left side so the client can stand to use the urinal.

813.To prevent dislocation of the hip prosthesis following total hip replacement, a nurse should plan to: SELECT ALL THAT APPLY. 1. place pillows or a wedge pillow between the client’s legs to keep them adducted. 2. use a fracture bedpan and instruct the client to flex the unaffected hip and use the trapeze to lift the pelvis while the nurse places the pan. 3. prevent hip flexion by not elevating the head of the bed more than 90 degrees. 4. place a pillow between the client’s knees when initially assisting the client out of bed. 5. elevate both of the client’s legs when sitting in the wheelchair to decrease swelling.

814. One month after discharge, a client who had a left total hip replacement calls a clinic reporting acute constant pain in the left groin and hip area and feel ing like the left leg is shorter than the right. A nurse advises the client to come to the clinic immediately suspecting: 1. wound infection. 2. deep vein thrombosis (DVT). 3. dislocation of the prosthesis. 4. aseptic loosening of the prosthesis.

815. To prevent circulatory complications after a right to tal knee replacement, a nurse should ensure that the client is: 1. flexing both feet and exercising uninvolved joints every hour while awake. 2. using the continuous passive motion device (CPM) every 2 hours for 30 minutes. 3. assisted up to a chair as soon as the effects of anesthesia have worn off. 4. using the trapeze to lift the buttocks off the bed and then rotating each leg intermittently.

816. A nurse assesses a client 4 hours after a left total knee replacement. The client has a knee immobi lizer in place with medial and lateral ice packs that have warmed. The surgical extremity’s neurovascu lar status is intact and vital signs stable. A Stryker® wound drain, an autotransfusion drainage system, has 350 mL drainage collected. The client reports pain at a level 3, which is tolerable, and denies nau sea. The client has not voided since before surgery. Which interventions should the nurse plan to imple ment at this time? SELECT ALL THAT APPLY. 1. Notify the client’s physician. 2. Reinfuse the salvaged blood loss. 3. Remove the immobilizer and place a pillow behind the client’s knee to create a 90-degree knee flexion. 4. Stand the client at the bedside to facilitate bladder emptying. 5. Place the affected extremity in a continuous passive motion device (CPM) to begin early motion. 6. Replace the ice packs in the knee immobilizer.

817. Which priority nursing diagnosis should a nurse doc ument in the plan of care for a client following a C5–C6 anterior cervical discectomy?. 1. Potential ineffective breathing pattern. 2. Potential impaired tissue perfusion. 3. Risk for infection. 4. Impaired skin integrity.

818. A nurse receives an order to administer cyclobenza prine (Flexeril®) 30 mg orally three times daily to a client hospitalized with acute cervical neck pain. The pharmacy has supplied 10-mg tablets. Which action by the nurse is best?. 1. Administer three 10-mg tablets with food. 2. Call the physician to question the order. 3. Observe the client for drowsiness after administration. 4. Administer morphine sulfate intravenously for immediate pain control.

819. A college student consults a clinic nurse and re ports acute lower back pain of sudden onset. In addi tion to taking the prescribed medications, which instructions should the nurse include? SELECT ALL THAT APPLY. 1. Continue routine activity within your pain tolerance while paying attention to correct posture. 2. Temporarily avoid specific activities known to increase mechanical stress on the spine, such as lifting. 3. When sleeping on your side, flex your hips and knees and place a pillow between your knees. 4. Maintain bedrest for 1 week in a contour position and then begin leg flexion and hyperextension exercises. 5. Stand intermittently when attending classes and sit with a soft support at the small of the back. 6. When sleeping on your back, elevate your head and chest with pillows 30 degrees, flex your knees slightly, and support your knees with a pillow.

820.A nurse assesses a client 6 hours postoperatively fol lowing a lumbar spinal fusion. The client is experi encing a headache rated at 8 out of 10 but denies nausea. The neurovascular status of the lower extrem ities is intact, and the vital signs are within the nor mal range. The client log rolls with assistance. The lungs have fine crackles in the left base. The back dressing has a dime-sized bloody spot surrounded by a moderate amount of clear yellowish drainage. Which nursing action demonstrates the nurse’s best clinical judgment?. 1. Administering morphine sulfate intravenously. 2. Encouraging coughing and deep breathing. 3. Reinforcing the incisional dressing. 4. Notifying the client’s physician.

821.Which action should a nurse plan in the care of the client who had a surgical repair of a right Dupuytren’s contracture?. 1. Elevating the right lower extremity above the level of the heart. 2. Assisting the client with bathing, dressing, grooming, and toileting. 2. Assisting the client with bathing, dressing, grooming, and toileting. 4. Frequent rewrapping of the elastic bandage on the right extremity to decrease edema.

822.A clinic nurse suspects that a client may have devel oped osteomyelitis 3 months following a left shoulder arthroplasty. Which findings on assessment prompted the nurse’s conclusion? SELECT ALL THAT APPLY. 1. Sudden onset of chills. 2. Temperature 103°F (39.4°C). 3. Bradycardia. 4. Report by the client of a pulsating pain in the area that intensifies with movement. 5. Painful, swollen area on the left shoulder.

823.To which client should a nurse plan to provide teach ing about genetic resources?. 1. Client who had an ankle fracture secondary to a boating accident. 2. Client who had a ganglion removed from the dorsum of the wrist. 3. Client who had a surgical repair of a fracture due to osteoporosis. 4. Client who had a total knee replacement due to degenerative joint disease.

824.When analyzing the serum laboratory report for a client diagnosed with lung cancer that has metasta sized to the pelvic bone, which finding should a nurse anticipate?. 1. Elevated calcium. 2. Decreased hemoglobin. 3. Elevated creatinine (Scr). 4. Elevated creatine kinase (CK).

825.A nurse reads the chart of a 25-year-old male and notes that he has been diagnosed with an osteosarcoma of the distal femur. Which statement indicates the nurse’s correct interpretation of the client’s diagnosis?. 1. The tumor originated elsewhere in the client’s body and metastasized to the bone. 2. Osteosarcoma is the most common and most often fatal primary malignant bone tumor. 3. The only treatment for osteosarcoma is a leg amputation well above the tumor growth. 4. Osteosarcoma is a nonmalignant growth that can be excised and the bone replaced with a bone graft.

826.A nurse reports to a physician that a 75-year-old client continues to experience phantom limb pain fol lowing an above-the-knee amputation (AKA) despite nursing interventions of distraction and administering the prescribed morphine sulfate. Which interventions to minimize the altered sensory perceptions should the nurse anticipate that the physician might pre scribe? SELECT ALL THAT APPLY. 1. Local anesthetic to the residual limb. 2. Transcutaneous electrical nerve stimulation (TENS). 3. A beta-blocker medication such as atenolol (Tenormin®). 4. An antiseizure medication such as oxcarbazepine (Trileptal®). 5. Reducing the client’s activity level until the sensations resolve. 6. A different analgesic, such as meperidine hydrochloride (Demerol®).

827.A client, with a lower leg amputation, is experiencing edema, so a nursing assistant (NA) elevates the client’s residual left limb on pillows. What is the most appropriate action by the nurse when observing that the client’s leg has been elevated?. 1. Thank the NA for being so observant and intervening appropriately. 2. Remove the pillows, raise the foot of the bed, and inform the NA that the limb should not be elevated on pillows because it could cause a flexion contracture. 3. Inform the NA that this was the correct action at this time in the client’s recovery, but once the client’s incision heals the leg should not be elevated. 4. Report the incident to the surgeon and tell the NA to complete a variance report because the client’s leg should not have been elevated.

827.A client, with a lower leg amputation, is experiencing edema, so a nursing assistant (NA) elevates the client’s residual left limb on pillows. What is the most appropriate action by the nurse when observing that the client’s leg has been elevated?. 1. Thank the NA for being so observant and intervening appropriately. 2. Remove the pillows, raise the foot of the bed, and inform the NA that the limb should not be elevated on pillows because it could cause a flexion contracture. 3. Inform the NA that this was the correct action at this time in the client’s recovery, but once the client’s incision heals the leg should not be elevated. 4. Report the incident to the surgeon and tell the NA to complete a variance report because the client’s leg should not have been elevated.

828.A client is scheduled for an outpatient electroen cephalogram (EEG). A nurse instructs the client to prepare for the test by: 1. removing all hair pins. 2. avoiding eating or drinking at least 6 hours prior to the test. 3. being prepared to have some of the scalp shaved. 4. having blood drawn for a glucose level 2 hours before the test.

829.A client is seen by a primary care provider because of difficulty walking. A neurological assessment is done. A nurse informs the client that which assess ment procedure was done to test the functioning of the cerebellum?. 1. Ask the client to shut the eyes and distinguish whether the touch is with a sharp or dull object (either end of a cotton-tipped applicator). 2. Ask the client to hold hands with palms up perpendicular to the body with eyes closed. 3. Ask the client to grasp and squeeze 2 fingers of each of the examiner’s hands. 4. Ask the client to alternate placing hands up and then hands down on thighs as fast as possible.

830.A nurse is admitting a client with a diagnosis of meningitis. Which of the nurse’s assessment findings support this diagnosis? SELECT ALL THAT APPLY. 1. Nuchal rigidity. 2. Severe headache. 3. Pill-rolling tremor. 4. Photophobia. 5. Fever. 6. Micrographia.

831.A client is hospitalized with a diagnosis of meningo coccal meningitis. The client is at risk for the compli cation of septic emboli. Which intervention by a nurse directly addresses this risk?. 1. Monitoring vital signs on an hourly basis. 2. Administering meningitis polysaccharide vaccine (Menoune®). 3. Assessing neurological function with the Glasgow coma scale every 2 hours. 4. Completing a vascular assessment of all extremities every 2 hours.

832.A client is admitted to an emergency department (ED). A nurse in the ED documents that the client is “postictal upon transfer” as evidenced by which observation?. 1. Yellowing of the skin. 2. Recently experienced a seizure and is in a drowsy or confused state. 3. Severe itching of the eyes. 4. Abnormal sensations including tingling of the skin.

833.A client being admitted for surgery has a vagus nerve stimulation (VNS) device that was implanted several months earlier for seizure management. The nurse de termines that the VNS is working properly when: 1. it stimulates the heart to beat when the client has bradycardia during a seizure. 2. the client activates the device to stop a seizure from occurring. 3. it defibrillates the client when the client experiences a lethal dysrhythmia during a seizure. 4. the client does not experience any airway obstruction from secretions during a seizure.

834. A client with a history of epilepsy has consecu tive seizures lasting more than 5 minutes and is in status epilepticus. Which interventions should be in cluded in this client’s immediate treatment? SELECT ALL THAT APPLY. 1. Administer dexamethasone (Decadron®) intravenously. 2. Administer oxygen and prepare for endotracheal intubation. 3. Prepare for immediate defibrillation. 4. Continue to protect the patient from injury. 5. Administer lorazepam (Ativan®) intravenously. 6. Transfer to a facility with expertise in treating status epilepticus.

835.A client has undergone a lumbar laminectomy with spinal fusion 12 hours earlier. Which assessment finding should indicate to a nurse that the client has a leakage of cerebrospinal fluid?. 1. Backache not relieved by analgesics. 2. 100 mL of serosanguineous fluid measured from the Jackson-Pratt® drain since surgery. 3. Clear fluid drainage noted on the surgical dressing. 4. Temperature of 101.3°F (38.5°C).

836.A client has had recurrent episodes of low back pain. Which statement indicates that the client has incorpo rated positive lifestyle changes to decrease the inci dence of future back problems?. 1. “I stoop and avoid twisting when I lift objects.”. 2. “I wear my old comfortable shoes whenever I go for a walk to avoid blisters.”. 3. “I walk 5 miles each day on the weekends.”. 4. “I sit as much as possible and elevate my legs.”.

837. A nurse in an emergency department assesses a client injured in a diving accident 2 hours earlier. A com puted tomography (CT) scan reveals a fracture of the C4 cervical vertebra. The client is breathing inde pendently but has no movement or muscle tone from below the area of injury. The nurse understands that the client: 1. has suffered a complete spinal cord injury (SCI). 2. is experiencing spinal shock. 3. has sustained an upper motor neuron injury. 4. will be a quadriplegic.

838.A nurse learns in report that a client admitted with a vertebral fracture has a halo external fixation device in place. Based on this information, for which inter vention should the nurse plan?. 1. Ensure the weight with the traction is hanging freely. 2. Remove the vest at bedtime. 3. Perform pin site care. 4. Progressively loosen the pins in the skull each day.

839. A nurse is caring for a client with a spinal cord injury at the level of the sixth cervical vertebra. The client is at risk for the complication of autonomic dysreflexia. For which associated symptoms should a nurse monitor the client? SELECT ALL THAT APPLY. 1.Sweating. 2.Headache. 3.Hypotension. 4.Blurred vision. 5.Anxiety. 6.Tachycardia.

840. A client with multiple sclerosis is seen in an of fice of a primary care provider. The client states that fatigue is the present concern. A nurse performs an assessment and reviews the client’s current medica tions and blood laboratory results. Which findings by the nurse are most likely to contribute to the client’s fatigue? SELECT ALL THAT APPLY. 1.Hemoglobin is 9.5 g/dL and hematocrit is 31.8%. 2.Taking baclofen (Lioresal®) 15 mg 3 times per day. 3.Working 4 to 8 hours per week in the family business. 4.Stopped taking amytriptyline (Elavil®) 8 weeks earlier. 5.Presence of a cardiac murmur at the fifth intercostal space to the left of the sternum. 6.Leans on cane and right leg weakness noted when walking in room.

841. A client develops muscle weakness and seeks med ical attention from a primary care provider. The client asks a nurse during the initial assessment if the symp toms suggest “Lou Gehrig’s” disease. Which is the most appropriate response to the client?. 1. “You may have been working too much and that is why you are tired. Let’s not think the worst.”. 2. “Tell me what has you thinking that you might have Lou Gehrig’s disease.”. 3. “Have you been having trouble remembering things along with this weakness?”. 4. “Well, you are in the right place to figure out what is going on.”.

842.A client with a diagnosis of Guillain-Barré syndrome is scheduled to receive plasmapheresis treatments. A nurse explains to the client’s spouse that the purpose of plasmapheresis is to: 1. remove excess fluid from the bloodstream. 2. restore protein levels in the blood. 3. remove circulating antibodies from the bloodstream. 4. infuse lipoproteins to restore the myelin sheath.

843.For which associated complication should a nurse monitor the client experiencing Guillain-Barré syndrome?. 1. Autonomic dysreflexia. 2. Septic emboli. 3. Increased intracranial pressure (ICP). 4. Respiratory failure.

844.A home health nurse evaluates the foot care of a client with peripheral neuropathy. Which client ac tions in providing foot care are appropriate? SELECT ALL THAT APPLY. 1. Visually inspects the feet on a daily basis including using a handled mirror to see the bottom of the foot. 2. Applies a lubricating lotion to the feet and legs daily, but not in between the toes. 3. Goes barefoot in the house to air out the feet. 4. States wearing warm socks and boots when outside in cold weather. 5. Tests bath water with a thermometer. 6. Trims toenails weekly to a rounded contour.

845.A nurse is performing hourly neurological assessment checks on a client who is admitted with changes in mental status. The nurse understands that frequent as sessments are used to determine if a client is develop ing increased intracranial pressure (ICP). Which op tion correctly describes the outcome if ICP is untreated and progresses?. 1. Displacement of brain tissue. 2. Increase in cerebral circulation and perfusion. 3. Increase in serum pH. 4. Improved brain tissue oxygenation.

845.A nurse is performing hourly neurological assessment checks on a client who is admitted with changes in mental status. The nurse understands that frequent as sessments are used to determine if a client is develop ing increased intracranial pressure (ICP). Which op tion correctly describes the outcome if ICP is untreated and progresses?. 1. Displacement of brain tissue. 2. Increase in cerebral circulation and perfusion. 3. Increase in serum pH. 4. Improved brain tissue oxygenation.

846. A client who receives a diagnosis of right-sided stroke should be assessed for risk factors of stroke during the initial hospitalization,and measures should be instituted to lessen the client’s risk. A nurse should address these risk factors as a priority and in stitute measures because:SELECT ALL THAT APPLY. 1.one of every four strokes occurs as a recurrent stroke. 2.the time period of greatest risk for a second stroke is the first 30 days after ischemic symptoms occur. 3.the potential for recovery continues for at least 6 months after the initial stroke event. 4.controlling modifiable risk factors is too difficult for persons who have already experienced a stroke. 5.the resultant deficit will cause the client to deny or minimize that there is a problem. 6.most stroke victims develop depression and less interest in learning preventive measures as the recovery process lengthens.

847.A client who has had a stroke stares at a nurse but does not attempt to verbally respond to the nurse’s questions. The client follows instructions without any problems. The nurse understands that the client is displaying symptoms consistent with: 1.receptive aphasia. 2.global aphasia. 3.expressive aphasia. 4.both receptive and expressive aphasia.

847.A client who has had a stroke stares at a nurse but does not attempt to verbally respond to the nurse’s questions. The client follows instructions without any problems. The nurse understands that the client is displaying symptoms consistent with: 1.receptive aphasia. 2.global aphasia. 3.expressive aphasia. 4.both receptive and expressive aphasia.

848. A client is admitted to the intensive care unit with a severe stroke. The client is receiving a con tinuous intravenous insulin infusion titrated accord ing to hourly blood glucose results to control hyper glycemia. The client’s spouse asks the nurse why the client is receiving insulin when the client is not diabetic. Which explanations to the client’s spouse should the nurse include? SELECT ALL THAT APPLY. 1. “The body reacts to stress by producing various hormones, which results in elevated glucose levels.”. 2. “The body has less effective utilization of glucose during serious illness.”. 3. “Insulin lessens the likelihood of brain tissue becoming swollen.”. 4. “Use of insulin will decrease the likelihood of the client becoming diabetic in the future.”. 5. ‘The stroke affected the part of the brain that controls the release of insulin.”. 6. “A side effect of the medications administered is the development of type 1 diabetes mellitus.”.

849. A client with a deteriorating mental status after suffering a stroke has a rectal temperature of 102.3°F (39.1°C). For which reason should a nurse initiate interventions to bring the temperature to a normal level?. 1. A normal temperature will strengthen the client’s immune system against infection. 2. Hyperthermia lowers the incidence of mortality. 3. A normal temperature will decrease the score on the Glasgow coma scale. 4. Hyperthermia increases the likelihood of a larger area of brain infarct.

850.A client is diagnosed with a stroke that affects the right hemisphere of the brain. A nurse, receiving re port prior to the care of this client, should expect the client to have which symptom?. 1. Right hemiparesis. 2. Expressive aphasia. 3. Poor impulse control. 4. Marked anxiety when learning new tasks.

851.A client seeks medical attention at an emergency de partment after experiencing left-sided weakness and slurred speech. The client receives a diagnosis with an ischemic stroke and is evaluated for treatment with thrombolytic therapy. A definite contraindication for thrombolytic therapy is: 1. a normal computed tomography (CT) scan of the brain. 2. a serious head injury 4 weeks earlier. 3. a history of diabetes mellitus. 4. the onset of neurological deficits 2 hours earlier.

852.A client is admitted to an intensive care unit because of a leaking cerebral aneurysm. A family member asks a nurse why the client is awakened and ques tioned about his orientation so frequently when he needs to rest. The nurse answers the family member based on the knowledge that the earliest sign of increased intracranial pressure (ICP) is: 1. pupillary changes. 2. drop in the blood pressure. 3. altered sensation. 4. changes in the level of consciousness.

853.A nurse is orienting a new nurse to a unit. The expe rienced nurse evaluates that the new nurse under stands information related to a stroke resulting from a subarachnoid hemorrhage when which points are addressed by the new nurse? SELECT ALL THAT APPLY. 1. Subarachnoid hemorrhage is often associated with a rupture of a cerebral aneurysm. 2. Subarachnoid hemorrhage usually occurs while the client is sleeping and is noticed when the client awakens. 3. Subarachnoid hemorrhage is accompanied by complaints of an extremely severe headache. 4. Subarachnoid hemorrhage may be treated with thrombolytic therapy if no contraindications exist. 5. Subarachnoid hemorrhage often results in bloody cerebrospinal fluid (CSF). 6. Subarachnoid hemorrhage causes nuchal rigidity. 6. Subarachnoid hemorrhage causes nuchal rigidity.

854. A nurse should plan for which measure to treat an elderly client with normal pressure hydrocephalus (NPH)?. 1. Carotid endarterectomy. 2. Ventriculoperitoneal shunt. 3. Lumbar drain. 4. Anticonvulsant medications.

855.Following an industrial accident in which a client sustained a severe craniocerebral trauma, the client develops the complication of diabetes insipidus (DI). A nurse suspects this complication is occurring when observing which symptom?. 1. Hyperglycemia. 2. Large amounts of urinary output. 3. Elevated urine specific gravity. 4. Decrease in level of consciousness.

856. A client hits her head in a minor motor vehicle accident and refuses medical attention at the time of the accident. The client makes an appointment with a primary care provider 6 weeks later because of headaches. The primary care provider diagnoses the client with mild traumatic brain injury (TBI). Which details noted by a nurse in the client’s history of the injury support this diagnosis? SELECT ALL THAT APPLY. 1.The client has had no episodes of vomiting after the accident. 2.The client remembers the events leading up to the accident and what occurred during the accident. 3.The client has experienced episodes of headache and dizziness on a daily basis since the accident. 4.The client has difficulty concentrating and focusing while at work. 5.The client reported a loss of consciousness for a few seconds at the time of the injury. 6.The client describes a funny taste in the mouth since the accident that is “disgusting.”.

857.An anxious client is seen in a clinic because the client suspects that he/she has a brain tumor. The client questions a nurse about treatment options if tests show the presence of a tumor. The nurse answers the client based on the knowledge that treatment of a brain tu mor depends on: SELECT ALL THAT APPLY. 1.rate of growth of the tumor. 2.whether the tumor is malignant or benign. 3.cell type from which the tumor originates. 4.location within the brain. 5.whether the tumor will reoccur. 6.the client’s age and type of insurance.

858.A nurse is caring for a group of clients on a medical unit in a rural hospital. Which client would the nurse be least likely to monitor for the potential complica tion of a brain abscess?. 1. Client with endocarditis. 2. Client with idiopathic epilepsy. 3. Client who has had a liver transplant. 4. Client with meningitis.

859.A client who had a craniotomy 2 days earlier is re ceiving mannitol (Osmitrol®) intravenously to de crease intracranial pressure. Which diagnostic labora tory value should be monitored while the client is receiving this medication?. 1. Serum osmolarity. 2. White blood cell (WBC) count. 3. Serum cholesterol. 4. Erythrocyte sedimentation rate (ESR).

860.A client with epilepsy is prescribed phenytoin sodium (Dilantin®) 100 mg 3 times per day orally as anticon vulsant therapy. The most precise method for a nurse to determine if this is the proper dose for the client is: 1. observation of the client for seizures. 2. observation of the client for adverse effects. 3. determining whether the client is able to participate in usual activities. 4. monitoring serum phenytoin levels.

861.An elderly client with Parkinson’s disease is pre scribed levodopa and carbidopa (Sinemet®). Which point should a nurse include in the teaching plan for the client and spouse?. 1. The client is at increased risk for falls due to dizziness and orthostatic hypotension. 2. The client should stop taking multiple vitamins. 3. The medication should not be taken with food. 4. The medication has very few adverse effects.

862.A home health nurse is making a home visit to a client with multiple sclerosis. The nurse reviews the home medications taken by the client. Which ques tion should the nurse ask to determine the effective ness of the client’s medication, baclofen (Lioresal®)?. 1. “How has your appetite been?”. 2. “Are you having any difficulty with having regular bowel movements?”. 3. “Are you having trouble with spasms?”. 4. “Does your urine look clear and not infected?”.

863.A nurse plans care for a client and notes that all of the following must be completed for a client being prepared for surgery. Which intervention should the nurse complete first?. 1. Complete the preoperative checklist. 2. Assess the client’s preoperative vital signs. 3. Remove the client’s rings, gold chain, and wristwatch. 4. Administer 10 mEq KCL IV for a serum potassium level of 3.0 mEq/L.

864.Which client statement made during a presurgical admission assessment needs the most immediate follow-up?. 1. “I haven’t eaten foods or had any fluids for the past 12 hours.”. 2. “I donated my own blood in case I need a transfusion; the last donation was 4 days ago.”. 3. “I took my usual dose of warfarin (Coumadin®) and other cardiac meds this morning with a sip of water.”. 4. “I brought a copy of my Health Care Directives so others will know my wishes should my heart stop during surgery.”.

865.A nurse is to witness the signature of a surgical con sent for multiple clients scheduled for surgery the fol lowing day. In evaluating the health history of each client, the nurse should plan to obtain a signature from the next of kin for: 1. a 75-year-old client who is blind. 2. a 60-year-old client who does not understand English. 3. a 50-year-old client who is forgetful, but fully oriented. 4. a 16-year-old educated client who fully understands the surgery.

866.A nurse receives the written laboratory results of a positive pregnancy test for a client scheduled for an emergency appendectomy. The nurse should first: 1. call the lab to verify the results of the test. 2. inform the client of the positive results. 3. report the results immediately to the surgeon. 4. notify the client’s primary physician of the results.

867. During a presurgical admission assessment, a client states, “I’ve told my surgeon that I am a Jehovah’s Witness and I won’t accept a blood transfusion.” Which statement by the nurse would be most appropriate?. 1. “Tell me about your fear of receiving a blood transfusion.”. 2. “Your request to not receive a transfusion would be honored. Your consent is needed to administer blood or blood products.”. 3. “You don’t need to worry about getting a blood transfusion. We have newer equipment that causes less blood loss during surgery.”. 4. “Are you sure you wouldn’t want a blood transfusion if one is needed during surgery? You can always change your mind after surgery.”.

868.A nurse is analyzing serum laboratory results for a 73-year-old female client scheduled for surgery in 2 hours. The nurse concludes that which result would warrant the most immediate notification of the physician?. 1. Hemoglobin 10 g/dL. 2. Creatinine 1.0 mg/dL. 3. Potassium 4.5 mEq/dL. 4. Prothrombin time 22 seconds.

869.A nurse is reviewing preoperative orders for a client who is to have surgery on the large intestine the next day. Which written orders should the nurse question? SELECT ALLTHATAPPLY. 1. NPO after midnight. 2. Erythromycin 500 mg bid. 3. Tap water enemas until hard stool passed. 4. Clear liquid diet the day before surgery. 5. Begin incentive spirometer (IS) use prior to surgery.

870.A physician writes an order to hold all medications the morning of surgery for a client with a history of type 1 diabetes mellitus and hypertension. A nurse should call the physician to clarify the hold order for what medication?. 1. Acetylsalicylic acid (aspirin). 2. Ducosate sodium (Colace®). 3. Regular and NPH insulin (Humulin®). 4. Clonidine (Catapres®).

871. Which client statement indicates that a client who is scheduled for a 3-hour surgery under general anesthesia needs further teaching?. 1. “A breathing tube will be placed when I am in the operating room.”. 2. “I should shave the skin in the surgical area the evening prior to surgery.”. 3. “I should splint my incision with a pillow when coughing and deep breathing after surgery.”. 4. “I might need a urinary catheter inserted before surgery so my urine output can be monitored.”.

872. Which nursing action would be best when a pre operative client verbalizes fear of postoperative pain?. 1. Providing diversional activities when client reports fear of pain. 2. Encouraging the client to verbalize concerns regarding the fear of pain. 3. Informing the client of experiences and the likelihood of pain pre- and postoperatively. 4. Explaining the medications ordered for pain control, availability, and treatment goals.

873.Which statement by a nurse is most effective when collecting data about a preoperative client’s recre ational drug use?. 1. “Describe the drugs you use and the frequency that you use these drugs.”. 2. “Do you use any over-the-counter medications or illegal substances?”. 3. “Tell me about all medications and substances you take because complications can occur if you are taking something we do not know about.”. 4. “Because herbs, medications, and recreational drugs such as marijuana and cocaine affect the type and amount of anesthesia you need, list any of these you take and how often you use them.”.

874. A nurse evaluates that a preoperative client can prop erly use a volume incentive spirometer when which client action is noted?. 1. Sits upright, inserts the mouthpiece, and blows until the lungs are emptied of air. 2. Sits upright, exhales, seals lips around the mouthpiece, inhales, and holds breath for 5 seconds. 3. Sits at the edge of the bed, coughs, inserts the mouthpiece, and blows slowly for 10 seconds. 4. Sits at the edge of the bed, breathes deeply five times, inserts the mouthpiece, and inhales quickly.

875. A nurse is teaching a client prior to surgery about the device illustrated. The nurse teaches the client that the primary purpose of the device illustrated is to: 1. improve circulation prior to surgery. 2. prevent intra- and postoperative deep vein thrombosis. 3. assist in keeping the client warm during surgery. 4. promote dehiscence and wound healing postoperatively.

876. A client in an operating room holding area, who is to receive general anesthesia, reports having a dry mouth because food and fluids have been withheld for 8 hours. Which action by a nurse is most appropriate?. 1. Teach the client that the primary reason food and fluids have been withheld is to prevent vomiting and potential complications. 2. Clarify that food and fluids should have been withheld only for 4 hours and offer a small sip of water. 3. Explain to the client that a full stomach puts pressure on the diaphragm and prevents full lung expansion during surgery. 4. Tell the client that the general anesthetic will soon make the client sleepy and unaware of the mouth dryness.

877. A nurse is caring for a client who received conscious sedation during a surgical procedure. Which assess ment of this client is most important for a nurse to make postoperatively?. 1. Lung sounds. 2. Amount of urine output. 3. Ability to swallow liquids. 4. Rate and depth of breathing.

878.Upon arrival to an operating room holding area, a client who is scheduled for abdominal surgery is noted to have replaced a tongue ring that was re moved when the operative checklist was completed. Which is the most appropriate initial action by a nurse?. 1. Document the findings on the client’s medical record. 2. Request that the client once again remove the tongue ring. 3. Complete a variance report, noting that the client has replaced the tongue ring. 4. Notify the surgeon and the anesthesiologist of the replacement of the tongue ring.

879. A nurse is orienting a new nurse to a postanes thesia care unit (PACU). Which statement by the new nurse indicates further orientation is needed?. 1. “Lactated Ringer’s (LR) and 5% dextrose with LR are typical IV solutions administered in the PACU.”. 2. “If a client has an opioid overdose, I should expect to administer naloxone hydrochloride (Narcan®).”. 3. “I should monitor vital signs and perform a pain assessment every 15 minutes or more often if necessary.”. 4. “Once a client responds verbally after a spinal anesthetic, the client can be transferred to the nursing unit.”.

880.Which information is most important for a postanes thesia care unit nurse to include in a report on a post operative client to a surgical unit nurse?. 1. Location of the relatives. 2. Review of the surgical consent. 3. Placement of client belongings. 4. Last dose and type of pain medication.

881.A nurse evaluates that a client has achieved an ex pected outcome for the second postoperative day fol lowing abdominal surgery under general anesthesia. Which finding supports the nurse’s conclusion?. 1. Passing flatus. 2. Urine output 680 mL in 24 hours. 3. Crackles in bilateral lung bases. 4. Rates incisional pain at 4 out of 10 on a 0 to 10 rating scale 60 minutes after analgesic given.

882.A nurse is planning the discharge of a client follow ing recovery from an exploratory laparotomy. The client has a history of chronic back pain and limited ability to ambulate. The nurse plans for further discharge teaching when the client states: 1. “I can leave my elastic antiembolic (TEDS®) stockings off once I get home.”. 2. “I should be eating a diet high in protein, calories, and vitamin C now and when I get home.”. 3. “An alternative method to control pain and reduce swelling is applying ice to my incision.”. 4. “I use my incentive spirometer every 2 hours so I can reach my volume goal before discharge.”.

883.A nurse is reviewing a plan of care for a postopera tive client with a history of sickle cell disease. Which nursing diagnosis, documented on the client’s care plan, should the nurse address first?. 1. Anxiety. 2. Impaired skin integrity. 3. Deficient fluid volume. 4. Ineffective airway clearance.

884.A nurse is caring for a postoperative client who re ports an inability to void. Which initial action by the nurse is most appropriate?. 1. Turning on running water. 2. Inserting a urinary catheter. 3. Palpating the client’s bladder. 4. Reviewing the client’s chart for the time of the last voiding.

885. A postoperative client who received a spinal anesthetic is experiencing a headache, photophobia, and double vision. A nurse’s initial intervention should be to: 1. immediately notify the surgeon. 2. position the client flat in bed. 3. limit the client’s fluid intake. 4. administer steroid medications.

886.A physician documents in a client’s postoperative progress notes that the client is experiencing a respi ratory infection with a shift to the left in the white blood cell (WBC) differential count. Which finding by a nurse reviewing the client’s laboratory report would support the physician’s documentation?. 1. Decreased WBC count. 2. Increased band cells. 3. Decreased hemoglobin. 4. Increased C-reactive protein.

887. In reviewing a physician’s orders for a postop erative client who underwent gynecological surgery, which order should a nurse determine is specifically written with the intent to prevent postoperative thrombophlebitis and pulmonary embolism?. 1. Have the client dangle the legs the evening of surgery. 2. Administer enoxaparin (Lovenox®) 40 mg subcutaneously daily. 3. Administer hydromorphone (Dilaudid®) 1 to 4 mg IV every 3 to 4 hours as needed (prn). 4. Encourage coughing and deep breathing (C&DB) every hour while awake.

888.A nurse assesses that a client on the second postoper ative day following abdominal surgery has dimin ished breath sounds in both lung bases, is taking shal low breaths, is able to achieve only 500 mL on an incentive spirometer, and has been smoking one pack of cigarettes per day prior to surgery. The nurse’s best interpretation of these findings is that the client is experiencing: 1. atelectasis. 2. pneumonia. 3. a normal postoperative course. 4. chronic obstructive pulmonary disease (COPD).

889.A nurse notes redness, swelling, and warmth of and around the incision when assessing a client’s leg inci sion 48 hours after femoral popliteal bypass surgery. The nurse’s best analysis should be that the incision is: 1. healing normally for the second postoperative day. 2. showing signs of rejection of the suture materials. 3. inflamed and could indicate the presence of an infection. 4. infected and showing signs of wound dehiscence.

890.Which outcome should indicate to a nurse that a post surgical client’s coughing and deep breathing (C&DB) is most effective?. 1. Respirations are 16 per minute and unlabored. 2. Lung sounds are audible and clear on auscultation. 3. Coughs include small amount of clear secretions. 4. Cough effort is strong and productive.

891.A client is to receive a second dose of oxycodone/ acetaminophen (Percocet®) for postoperative incisional pain. When a nurse brings the medication to the client, the client says, “Why bring this medication again? It makes me feel sick.” Which statement is the most appropriate initial nurse response?. 1. “I can call the doctor to see what else can be ordered for your pain.”. 2. “Describe what you feel when you say that the medication makes you feel sick.”. 3. “The doctor has ordered an antacid. I can give you this along with the medication.”. 4. “Many people say the same thing. The aspirin in the medication is hard on your stomach.”.

892.A nurse evaluates that the drainage from a client’s na sogastric (NG) tube, inserted for gastric decompres sion during emergency surgery, would be normal if it: 1. returns brown-liquid in color. 2. returns greenish-yellow in color. 3. has an alkalotic hydrogen level (pH). 4. measures less than 25 mL in volume.

893.A nurse notifies a physician after assessing a client 5 days after an exploratory laparotomy and noting a distended abdomen, abdominal pain, absence of flatus, and absent bowel sounds. Which typical complication of abdominal surgery should the nurse conclude may be occurring?. 1. Paralytic ileus. 2. Silent peritonitis. 3. Fluid volume excess. 4. Malabsorption syndrome.

894.Which statement should a nurse include when teach ing a client prior to discharge following abdominal surgery?. 1. “Return to work in about 4 weeks because working increases your physical activity gradually.”. 2. “The ordered iron and vitamins tablets will promote wound healing and red blood cell growth.”. 3. “Daily walking carrying 10-pound weights will help to strengthen your incision.”. 4. “Home-care nursing service is usually paid by insurance if you need help around the house.”.

895.A nurse is calculating nasogastric (NG) tube drainage for a postoperative client. At 0700 hours, the client’s drainage container was marked at 150 mL. At 1500 hours, there was 575 mL in the container. During the nursing shift, the nurse in stilled 30 mL of saline irrigation into the tube four times as prescribed by the physician. The nurse calculates that the actual NG tube drainage for the client from 0700 to 1500 hours is _____ mL.

896.A nurse assesses that two areas of a client’s postoper ative leg incision are not approximated. Place an X on the two areas in the illustration that correctly de pict the nurse’s wound assessment.

897.A nurse is interpreting the serum laboratory report il lustrated for a postoperative client. The nurse,notify ing a physician of the laboratory results,should ex pect the physician to order which stat order?. 1.Administer 1 unit packed red blood cells (RBCs). 2.Administer potassium chloride 10 mEq in 100 mL 0.9% NaCl via intravenous piggyback (IVPB). 3.Hold the ACE inhibitor enalapril (Vasotec®). 4.Administer calcium gluconate 10 mEq in 100 mL 0.9% NaCl via IVPB.

898.A nurse is planning care for a client who is scheduled for an intravenous pyelogram (IVP). Which interven tion should the nurse include in the care of this client?. 1. Teaching the client that a warm, flushing sensation may be experienced as the dye is injected. 2. Preparing the client for a bladder catheterization before the procedure. 3. Keeping the client NPO after the procedure until test results are obtained. 4. Ambulating the client in the hall to promote excretion of the dye.

899.A nurse assessing a client’s right groin puncture site after a renal angiogram finds a saturated, bloody dressing and blood pooling on the sheets. What should be the nurse’s first action?. 1. Remove the dressing to further assess the puncture site. 2. Reinforce the dressing with a compression dressing. 3. Apply firm pressure directly over the puncture site dressing with a gloved hand. 4. Have the client flex the right leg to help control the bleeding by constriction.

900.A nurse notes blood clots in a client’s urine after a cystoscopy. Which is the most appropriate initial action by the nurse?. 1. Perform bladder irrigation. 2. Notify the health-care provider (HCP). 3. Apply heat to the client’s bladder area. 4. Administer the prescribed antispasmodic agent.

901. Which nursing action should a nurse perform first for a client experiencing a suspected hospital-ac quired bladder infection?. 1. Obtain a clean-catch urine specimen for culture and sensitivity. 2. Start antibiotic medications. 3. Teach the client to wipe the perineum front to back after toileting. 4. Prepare the client for bladder catheterization.

902.After completing a health history for a female client experiencing recurrent urinary tract infections (UTI), a nurse determines that the client should be taught to reduce her risk for a UTI by: 1. eliminating caffeine and tea from her diet. 2. taking tub baths rather than showers. 3. wearing good quality synthetic underwear. 4. abstaining from sexual intercourse.

903.A home health client verbalizes concerns about pro ducing brown-colored urine after taking nitrofuran toin (Furadantin®) for a urinary tract infection. Which response by a nurse is most appropriate?. 1. “Your urine is too concentrated. Take only one-half the dose of your medication.”. 2. “Discontinue taking the medication and make an appointment for a urine culture.”. 3. “Continue taking the medication because nitrofurantoin (Furadantin®) discolors the urine.”. 4. “Drink 500 mL of fluid every 3 hours to lighten your urine color.”.

904. A client is admitted to a hospital with a diagno sis of acute pyelonephritis. Which symptom occurs most frequently and should be monitored by the nurse?. 1. Low-grade fever. 2. Bradycardia. 3. Flank pain on the affected side. 4. Rebound tenderness in left lower quadrant.

905.During a teaching session with a client, a nurse shows the client an illustration indicating the area of inflammation during a bout of pyelonephritis. Iden tify this area of inflammation with an X.

906.A nurse evaluates that a client, diagnosed with ob structing left ureterolithiasis, may have passed the calculi in the urine when which outcome has been achieved?. 1. Voiding clear amber urine greater than 30 mL per hour. 2. No hematemesis or urinary tract infection (UTI). 3. Absence of epigastric pain, nausea, and vomiting. 4. Absence of colicky pain in the left lateral flank and groin.

907. A nurse is completing an admission assessment for a client suspected of having an obstructing struvite cal culus of the right ureter. During the assessment, which is the best question for the nurse to ask the client?. 1. “Are you experiencing any left flank pain?”. 2. “Do you like to drink cranberry, prune, or tomato juice?”. 3. “Have you had a history of chronic urinary tract infections (UTIs)?”. 4. “How often do you eat organ meats, poultry, fish, and sardines?”.

908. A nurse is admitting a client with a diagnosis of renal calculi to a hospital nursing unit. Which nursing action should be performed first?. 1. Encourage the client to increase oral fluids. 2. Obtain supplies to measure and strain all urine. 3. Assess the severity and location of the client’s pain. 4. Obtain consent for an extracorporeal shock wave lithotripsy (ESWL).

909.Which nursing actions should a nurse plan in the care of a client immediately after extracorporeal shock wave lithotripsy (ESWL)? SELECT ALL THAT APPLY. 1. Measure and strain all urine. 2. Keep the client NPO for 24 hours. 3. Check for ecchymosis on the flank of the affected side. 4. Assess the incision to see if it is clean, dry, and intact. 5. Remove the stent if one has been placed before or during ESWL.

910. Which interventions should a nurse include when car ing for a female client experiencing new onset urge urinary incontinence? SELECT ALL THAT APPLY. 1. Take the client to the bathroom every 4 hours. 2. Administer diuretics at supper time so the bladder is empty at night. 3. Turn on the water or flush the toilet to assist the client to void. 4. Space fluids at regular intervals during the day and limit fluids after the dinner hour. 5. Instruct the client on insertion of vaginal weights which are to be worn throughout the day.

911. A nurse admits a client diagnosed with poly cystic kidney disease (PKD). The client is experienc ing dull flank pain, nocturia, and diluted urine with a low urine specific gravity. A nurse is reviewing orders written by a health-care provider. Which orders should the nurse question? SELECT ALL THAT APPLY. 1. Increase fluid intake to 2 L daily. 2. Restrict sodium intake to 500 mg daily. 3. Initiate referral for genetic counseling. 4. Lisinopril (Prinivil®) 2.5 mg daily for hypertension. 5. Metoprolol (Lopressor®) 12.5 mg (oral) bid.

912.When which assessment finding is noted, for a client with polycystic kidney disease (PKD), should a nurse suspect that a cyst has ruptured?. 1. Reports a decrease in pain. 2. Voids cola-colored urine. 3. Passes bloody stools. 4. Has decreased serum creatinine levels.

913.A client is diagnosed with renal cell carcinoma. Which specific symptoms should a nurse expect when completing an assessment of the client?. 1. Hematuria and nocturia. 2. Abdominal pain and dysuria. 3. Flank pain and hematuria. 4. Suprapubic pain and foul-smelling urine.

914. A client asks a nurse to clarify a health-care provider’s explanations about the client’s scheduled cystectomy with an ileal conduit for urinary diver sion. Regarding this procedure, a nurse should ex plain that: 1. no stoma is required with this surgery and the normal anatomic urinary flow is maintained. 2. a permanent external urinary collecting device will be required. 3. urinary continence is possible with muscle control and Kegel exercises. 4. bladder retraining will be taught later during the recovery.

915. Which intervention should a nurse include in the care of a client who had continent urinary diver sion surgery with creation of a Kock pouch?. 1. Insert a catheter at 4- to 6-hour intervals to drain the urine. 2. Cleanse the skin around the stoma with alcohol and water daily. 3. Instruct the client to sleep on the side of the stoma to promote urine drainage. 4. Apply the stoma pouch so that it fits snuggly around the stoma.

916. A nurse is reviewing the care plan for a client after a urinary diversion with an ileal conduit that includes all of the nursing diagnoses listed. Which nursing di agnosis should the nurse place as the lowest priority?. 1. Altered skin integrity. 2. Disturbed body image. 3. Deficient fluid volume. 4. Acute pain.

917. A nurse teaches a client with a noncontinent urostomy created during urinary diversion that the stoma should be: 1. flush with the skin. 2. constrained with clothing. 3. intermittently catheterized. 4. red, moist, and protruding.

918. A client has a nephrostomy tube in place after a par tial nephrectomy. When caring for a nephrostomy tube, a nurse should: SELECT ALL THAT APPLY. 1. clamp the tube periodically to allow the remaining nephrons to adapt. 2. irrigate only if ordered and then with less than 5 mL of sterile saline solution. 3. observe for signs of infection, such as cloudy foul smelling urine draining from the tube. 4. maintain patency of the closed drainage system by keeping it below the level of the kidney. 5. add the amount of output from the nephrostomy tube to the output from the urinary drainage tube to calculate the hourly urine output. 6. record the amount of output from each tube separately.

919. A nurse reviews the laboratory report of a client with acute renal failure (ARF) and notes that the serum potassium level is 6.8 mEq/L. Which medication should the nurse plan to administer specifically to protect the heart from the high potassium levels?. 1. Erythropoietin. 2. Regular insulin. 3. 50% dextrose. 4. Calcium gluconate.

920.A client with chronic renal failure receives a he modialysis treatment. The client’s weight before dialy sis was 83 kilograms and after dialysis 80 kilograms. A nurse estimates that the amount of fluid that the client lost was ____ liters.

921.A nurse evaluates that a client is in the recovery phase of acute renal failure (ARF). Achievement of which outcomes supports the nurse’s conclusion? SELECT ALL THAT APPLY. 1.Increased urine specific gravity. 2.Increased serum creatinine level. 3.Decreased serum potassium level. 4.Absence of nausea and vomiting. 5.Absence of muscle twitching.

922.A nurse is interpreting the serum laboratory report below for a client with a diagnosis of acute renal fail ure (ARF) secondary to cardiac catheterization. Based on the findings of the serum laboratory report, which action should the nurse establish as the priority?. 1.Administer intravenous (IV) calcium gluconate. 2.Administer IV furosemide. 3.Begin cardiac monitoring. 4.Restrict foods high in potassium.

923.After a diagnosis of chronic renal failure, a client was started on epoetin alfa (Epogen®). Which finding should a nurse expect when evaluating the desired therapeutic effectiveness of the medication?. 1. Decrease in serum creatinine levels (SCr). 2. Increase in white blood cells (WBCs). 3. Increase in serum hematocrit (Hct). 4. Decrease in blood pressure (BP).

924.A client hospitalized with a diagnosis of chronic re nal failure (CRF) is experiencing hypotension, cold and clammy skin, and dysrhythmias. An arterial blood gas (ABG) is drawn with orders to notify the physician if abnormal. Based on the following re sults, a nurse should notify the physician to report that the client is experiencing: 1. respiratory acidosis. 2. respiratory alkalosis. 3. metabolic acidosis. 4. metabolic alkalosis.

925. A client with a diagnosis of end-stage renal dis ease states to a nurse, “I don’t think I want to be on dialysis anymore; it’s just too painful for me.” What is the most appropriate response by the nurse?. 1. “Why do you think you will be unable to stay on dialysis?”. 2. “You feel that dialysis is painful for you. Tell me more about that.”. 3. “It really isn’t hard to stay on dialysis. Remember you can sleep during the dialysis run.”. 4. “You need to stay on dialysis to avoid getting worse. You could die if you don’t go to dialysis regularly.”.

926.Which notation should a nurse document as an appro priate outcome in the plan of care for a client with chronic renal failure?. 1. Consumption of three large meals daily without nausea. 2. Daily weight gain of no more than 3 pounds. 3. Reduced serum albumin levels within 1 week. 4. Absence of bleeding.

927. A nursing assistant reports to a nurse that a client di agnosed with chronic renal failure has “white crys tals” and dry, itchy skin. Based on this information, the nurse should instruct the nursing assistant to: 1. apply the prescribed antipruritic cream to the client’s skin. 2. offer the client a glass of warm milk to drink. 3. bathe the client in tepid water. 4. assess the client’s serum creatinine levels.

928. Which nursing assessment is most accurate in determining the patency of a client’s newly placed left forearm internal arteriovenous (AV) fistula for hemodialysis?. 1. Feeling for a bruit on the left forearm. 2. Palpating for a thrill over the fistula. 3. Aspirating blood from the fistula every 8 hours. 4. Checking the client’s distal pulses and circulation.

929.A nurse is initiating peritoneal dialysis for a client with renal failure. During the infusion of the dialysate, the client reports abdominal pain. Which intervention by the nurse is most appropriate?. 1. Stopping the dialysis. 2. Slowing the infusion. 3. Asking if the client is constipated. 4. Explaining that the pain will subside after a few exchanges.

930.The spouse of a client who has been on hemodialysis for the past 5 years, calls a clinic because the client has stopped eating, is taking long naps, and refuses to talk with the spouse. A nurse interprets that the client is most likely experiencing: 1. depression. 2. displacement. 3. noncompliance. 4. activity intolerance.

931. A nurse is concerned that a client receiving peritoneal dialysis may be experiencing peritonitis. Which find ing noted on the nurse’s assessment supported this concern?. 1. Abdominal numbness. 2. Cloudy dialysis output. 3. Radiating sternal pain. 4. Decreased white blood cells.

932.A nurse is admitting a client with possible renal trauma after a motor vehicle accident. When caring for this client, which actions should be taken by the nurse? Prioritize the nurse’s actions by numbering each action from the highest priority (1) to the lowest priority (5). ____ Teach the client signs of a urinary tract infection (UTI). ____ Palpate both flanks for asymmetry. ____ Assess for pain in the flank area. ____ Prepare the client for a CT scan. ____ Inspect the abdomen and the urethra for gross bleeding.

933. A nurse is preparing to conduct a women’s wellness seminar at a local civic center. What infor mation should the nurse plan to include about risk factors for development of breast cancer? SELECT ALL THAT APPLY. 1. Breast cancer occurs most frequently in women younger than 30 years. 2. The longer the interval between menarche and menopause, the more the risk increases. 3. Nulliparous women are at increased risk. 4. Risk is increased in postmenopausal women with body mass indexes below 20. 5. Women whose sisters or mothers have had breast cancer are at increased risk. 6. The risk increases for women with fibrocystic breast disease.

934.An oncologist tells a nurse that he has informed a client that her breast cancer is stage 1. After over hearing the client talking with her husband, the nurse determines that the client has not fully understood the diagnosis. Which statement was most likely made by the client to her husband?. 1. “I guess I won’t be here to see our daughter graduate this spring.”. 2. “I understand that I will need some type of chemotherapy.”. 3. “I will be starting radiation therapy soon.”. 4. “I think I have a good chance to be a 5-year survivor.”.

935. A client with newly diagnosed breast cancer asks a nurse to explain the advantages of a sentinel lymph node biopsy (SLNB). Which explanation should the nurse state to the client?. 1. “The sentinel node biopsy improves the potential that the total tumor will be removed.”. 2. “The sentinel node biopsy can decrease the number of axillary lymph nodes that must be removed during surgery.”. 3. “The sentinel node biopsy makes breast reconstruction easier to perform.”. 4. “The sentinel node biopsy, if performed, will make hormonal therapy unnecessary.”.

936. A nurse is conducting a breast cancer aware ness seminar at a local church. After the seminar, a 40-year-old female tells the nurse that she is at high risk for developing breast cancer and her health-care provider suggests that she begin taking tamoxifen (Soltamox®). She asks the nurse to explain how this drug will help her avoid developing breast cancer. The nurse’s response should be based on the knowledge that tamoxifen is: 1. a potent anti-inflammatory drug that prevents the body’s inflammatory response to the tumor growth. 2. a type of chemotherapy agent that has minimal side effects if taken prophylactically. 3. a drug that will decrease the risk of endometrial cancer, which is related to breast cancer development. 4. a drug that blocks estrogen receptors on tumor cells and causes tumor regression.

937. In preparation to provide care to a client after a TRAM (transrectus abdominis myocutaneous) flap breast reconstruction, which actions should a nurse anticipate including in the collaborative plan of care for the client?. 1. Initiating passive range of motion to the affected side immediately after surgery and continue every 4 hours. 2. Assessing capillary refill, color, and temperature of the flap every hour for 24 hours. 3. Maintaining a pressure dressing on the reconstructed breast for 48 hours. 4. Keeping the affected arm below the level of the reconstructed breast for 48 hours.

938. A client who is 5 days post–abdominal surgery is discussing her general health with a nurse. In the process of the discussion, the client tells the nurse that she has been experiencing breast pain for which she has had several diagnostic procedures, all of which have been negative. The client asks if the nurse has any advice on how this breast pain can be con trolled without using prescription medications. Which suggestions should the nurse make? SELECT ALL THAT APPLY. 1. Take evening primrose oil, 1,000 mg three times per day. 2. Go without a bra for at least 4 hours a day. 3. Reduce caffeine in the diet. 4. Supplement the diet with B complex vitamins. 5. Apply hot packs to the breast.

939. A nurse is conducting a health history interview with a 20-year-old college sophomore when the client starts crying and says, “I’m so worried. I found a lump in my breast last night and I’m scared I might have cancer!” Which fact should the nurse consider when formulating a response to the client?. 1. Young women are at increased risk to develop breast cancer. 2. A nondiscrete possible mass or thickening has a high index of suspicion for breast cancer. 3. Benign fibroadenomas are the most frequent cause of breast masses in women under 25 years. 4. College students often develop infectious breast disorders due to the close personal contact required in dormitory living.

940.At a 6-week postpartum visit, a client tells a nurse that she is considering breast reduction and wants to know if she could still breastfeed a baby after such a procedure. Which statement should be the basis for the nurse’s response?. 1. Breast reduction does not affect the ability to breastfeed. 2. If the nipples are left connected to breast tissue, lactation is possible. 3. Breast reduction makes lactation impossible due to the amount of breast tissue removed. 4. Breastfeeding is impossible due to the changes that take place in the nipple structure from the surgery.

941. While working in a urology clinic, a nurse receives a phone call from a concerned client diagnosed with known benign prostatic hyperplasia (BPH). The client says he developed a cold a few days ago and since then his urinary frequency and urgency have increased. The nurse should immediately ask the client if he has: 1. been drinking large amounts of water. 2. been exercising more than usual. 3. been taking any over-the-counter cold remedies. 4. increased the amount of dairy products in his diet.

942.A client is admitted to a surgical unit following a transurethral prostatectomy. The client has a continu ous bladder irrigation (CBI) running. A nurse as sesses the client’s urine and finds dark red urine con taining several small clots. In response to this finding, which action should the nurse take?. 1. Increase the flow of the bladder irrigation fluid. 2. Immediately turn off the bladder irrigation. 3. Irrigate the catheter manually. 4. Deflate the balloon on the catheter.

943.During the last 8 hours, a nurse cared for a client who had a transurethral prostatectomy. The client has con tinuous bladder irrigation (CBI) infusing. At the end of the 8 hours, a nurse determines that the client re ceived 3,050 mL of irrigation fluid and that 4,030 mL of fluid was emptied from the urinary drainage bag. The nurse calculates the actual urine output for 8 hours to be _______ mL.

944.A nurse is caring for a client who is 24-hours post–transurethral prostatectomy. The nurse suspects the client may be having bladder spasms when he de scribes abdominal pain rated as 5 on a 0 to 10 numeric scale. A nurse assesses the Foley catheter and finds it draining freely. Based on this information, what should be the most appropriate nursing intervention?. 1. Administer morphine sulfate intravenously, which is ordered as needed (prn). 2. Administer a belladonna and opium suppository, which is ordered prn. 3. Ambulate the client. 4. Apply cold compresses to the client’s abdomen.

945.While obtaining a hospital admission history for a 35-year-old client, which statement made by the client should prompt a nurse to consider that the client has chronic prostatitis?. 1. “I am having difficulty obtaining erection.”. 2. “When I ejaculate I have pain.”. 3. “I have been feeling pressure around my rectum.”. 4. “I don’t think I am totally emptying my bladder.”.

946.A nurse is reviewing hospital admission orders for a client diagnosed with acute prostatitis. Before initiat ing the orders, which order should the nurse question?. 1. Begin intravenous trimethoprim/sulfamethoxazole (Bactrim®) 1 gram every 6 hours. 2. Give ibuprofen (Motrin®) 600 mg orally every 6 hours prn (as needed). 3. Maintain bedrest with bathroom privileges. 4. Insert a Foley urinary drainage catheter.

947. A community health nurse is asked to prepare health education on testicular cancer. To obtain the maximal impact, the nurse should plan to present this education to which group?. 1. High school males. 2. Males over 30-years-old who have never fathered a child. 3. Males over 21-years-old who have fathered at least one child. 4. Males who are over the age of 50 years.

948.A client with testicular cancer is admitted to a hospi tal for treatment of the disease. A nurse reviews the client’s laboratory values. After this review, the nurse concludes that the: 1. client may have developed an infection. 2. client’s nutrient intake has been inadequate. 3. client’s liver has been activated in an attempt to fight the disease. 4. client’s disease may have metastasized.

949.A client is told that he will require a right orchiec tomy for treatment of testicular cancer. The client asks a nurse if he will be infertile after this proce dure. Which response should be made by the nurse?. 1. “This procedure will make you infertile.”. 2. “Has your surgeon discussed cryopreservation of your sperm?”. 3. “Since only one testicle is being removed your fertility will not be affected.”. 4. “Don’t be concerned about this now, at this point you need to be concerned about removal of the cancer.”.

950.A male client who is considering a vasectomy for contraception asks a nurse where the incision for the procedure will be made. The nurse utilizes the picture below to educate the client. On which area of the body should the nurse inform the client that the incision will most likely be made?. 1. Location A. 2. Location B. 3. Location C. 4. Location D.

951. A nurse is obtaining a health history on a client with a possible varicocele. What should be the nurse’s priority assessment question?. 1. “Did your father have any testicular problems?”. 2. “Does the left side of your scrotum feel different from the right side?”. 3. “Do you have any children?”. 4. “Do you have any discomfort in your groin?”.

952. A client tells a nurse that he and his wife really want a child but that he has learned he has a sperm count of “only 40 million.” He wonders if there is anything that would improve his ability to impregnate his wife. In planning care for the client, which factor should the nurse consider?. 1. The client’s lifestyle can be examined to determine if he is in contact with any gonadotoxins. 2. This sperm count is very low, and the chances of the client impregnating his wife are low. 3. The health-care practitioner may recommend testosterone supplementation. 4. The incidence of impregnation is decreased with a sperm count below 20 million.

953. While volunteering at a prenatal education booth at a health and wellness fair, a young married couple tells a nurse they have been attempting to achieve a pregnancy and have been unsuccessful. They are wondering if they should begin treatment for infertility. In response, which initial question should the nurse ask?. 1. “How long have you been having regular intercourse without contraception?”. 2. “How old are you both?”. 3. “Do either of you smoke cigarettes?”. 4. “Have either of you ever had an infection in your reproductive tract?”.

954.A nurse is discharging a client after an elective abor tion by suction curettage. Which statement should the nurse include in the client’s discharge instructions?. 1. Sexual intercourse can be resumed once vaginal discharge has stopped. 2. A vaginal douche with clean tap water should be performed bid for 48 hours. 3. If the vaginal discharge develops a foul odor, the health-care practitioner should be notified. 4. Plan to return to work in 1 week.

955. A 15-year-old female client is placed on oral contraceptives (OCPs) to control dysmenorrhea. The girl’s mother is concerned about this medical decision and asks a nurse why the physician would choose this mode of treatment. When formulating a response to the mother, which fact about oral contraceptives should the nurse consider?. 1. Oral contraceptives inhibit uterine inflammation which indirectly causes dysmenorrhea. 2. Oral contraceptives increase blood flow to the uterus during menstruation and promote uterine relaxation. 3. Oral contraceptives inhibit progesterone production, which stimulates uterine contractions and causes pain. 4. Oral contraceptives suppress ovulation and therefore prostaglandin production.

956.Which laboratory result should a nurse carefully review when completing a health assessment of a female client with menorrhagia of unknown origin?. 1. Calcium level. 2. Blood urea nitrogen (BUN). 3. Hemoglobin level. 4. White blood cell value.

957. A nurse is obtaining a health history from a 30-year old female client who describes multiple concerns. Which concerns should alert the nurse to the possibil ity of endometriosis? SELECT ALL THAT APPLY. 1. Bleeding between periods. 2. Vaginal dryness. 3. Premenstrual tension headache. 4. Pain during her menstrual period. 5. Inability to conceive. 6. Dyspareunia.

958.A health-care practitioner has prescribed mifepristone (Mifeprex®) for a 35-year-old female as treatment for a leiomyoma. Before beginning the medication, which information is most important for the nurse to obtain?. 1. A baseline blood pressure. 2. Results of a blood test for liver enzymes. 3. Results of a pregnancy test. 4. A baseline weight.

959.A female client has an abdominal hysterectomy to re move a uterine fibroid. Which action should a nurse include when caring for the client postoperatively?. 1. Monitor the perineal pad for bleeding. 2. Administer hormone replacement therapy. 3. Maintain bed rest for 48 hours. 4. Start a regular diet 6 hours postsurgery.

960.A 21-year-old college female, who has been diag nosed with polycystic ovary syndrome (PCOS), asks a nurse if there are any lifestyle changes that she could initiate to help to control her disease. Which statement is the nurse’s best response?. 1. “Decrease the amount of caffeine in your diet.”. 2. “Avoid using oral contraceptives for birth control.”. 3. “Avoid multiple sexual partners.”. 4. “Maintain your weight within the acceptable parameters for your height.”.

961. A student is preparing a seminar for college-age women about ways to decrease the risk of developing ovarian cancer. A registered nurse (RN) is reviewing the content the student nurse is planning to present. Which statement should the nurse delete from the student’s prepared content?. 1. Bear children if physically and psychologically able. 2. Decrease the fat in your diet. 3. Avoid using oral contraceptives for birth control. 4. Plan to breastfeed if you have children.

962.A primary care provider has written orders for a client who is 24 hours post–vulvectomy surgery. Which order should the nurse question?. 1. Cleanse perineal wound with warm saline daily. 2. Remove Foley catheter; straight catheterize if unable to void. 3. Begin low-residue diet when tolerating oral intake. 4. Position in low Fowler’s position.

963.A male client, who had been prescribed sildenafil (Viagra®) 2 weeks previously for erectile dysfunc tion, calls a urologic clinic to report that he takes his medication orally and waits for his erection to de velop but nothing happens. When responding to the client’s comment, which fact should form the basis for the nurse’s response?. 1. In clinical trials, the drug was only effective 20% of the time. 2. The drug is supposed to be inserted rectally and is not effective if taken orally. 3. In the absence of sexual stimuli, the drug will not cause an erection. 4. If taken with a high-fat meal, the drug is ineffective.

964. A client with erectile dysfunction is instructed on the use of alprostadil (Caverject®) via subcutaneous penile injection. A nurse determines that the client needs further instruction about alprostadil and its ad ministration. Which statement was most likely made by the client to lead the nurse to this conclusion?. 1. “I know I will have to keep the needle sterile before I inject my penis.”. 2. “I know I will not experience prolonged erections.”. 3. “I know the injection will produce an erection in 20 to 30 minutes. 4. “If feeling dizzy after an injection, I should report this.”.

965.While presenting a seminar on reproductive health to a group of college-age women, a seminar participant asks a nurse if there is a way that a woman can rec ognize when she is ovulating. The nurse should re spond that, at ovulation: 1. the mucus produced by the cervix becomes abundant and stretchy. 2. the body temperature drops and stays low for the rest of the menstrual cycle. 3. over-the-counter urine tests will be negative for luteinizing hormone. 4. the libido will decrease.

966.A healthy 56-year-old female client who is menopausal tells a nurse that she has been experienc ing vaginal itching, burning, and increased vaginal in fections over the last 2 years. Which statement is the nurse’s best response?. 1. “Frequent vaginal infections could be a precursor to vulvar cancer.”. 2. “Vaginal itching could be related to a contact allergy.”. 3. “Your vagina becomes more acidic after menopause. This could be causing your symptoms.”. 4. “An increase in vaginal pH during menopause predisposes you to these symptoms.”.

967. A female nurse is sitting at a table across from a Latino male she has been educating about the process of testicular self-examination. After a period of discussion, the client successfully verbalizes the process. The nurse excitedly praises the client, leans over the table, and makes the “OK” sign with her thumb and forefinger. The client immediately gets up and leaves the room. What caused the client’s discomfort?. 1. The client was uncomfortable discussing private body areas with a female nurse. 2. A nurse invaded the client’s personal space inappropriately. 3. Many Latinos consider the “OK” gesture obscene. 4. Latinos consider the “OK” gesture to be demeaning.

968. A client with asthma has pronounced wheezing upon auscultation. Suspecting an impending asthma attack, a nurse should: 1. have the client cough and deep breathe. 2. prepare to intubate the client. 3. prepare to administer a nebulized beta-2 adrenergic agonist. 4. have the client lay on his or her right side.

969.A nurse is teaching an elderly client about the impor tance of using the item that is attached to the inhaler. The nurse should explain that this item: 1. allows for a greater amount of medication to be delivered. 2. lets the client see the medication as it is delivered. 3. keeps the mouthpiece sterile. 4. allows for activating the medication canister by simply inhaling.

970. A client, newly diagnosed with asthma is preparing for discharge. Which point should a nurse emphasize during the client’s teaching?. 1. Contact care provider only if nighttime wheezing becomes a concern. 2. Limit exposure to sources that trigger an attack. 3. Use peak flow meter only if symptoms are worsening. 4. Use inhaled steroid medication as a rescue inhaler.

971. A nurse is working with a client to update the client’s asthma action plan. The nurse knows that this action plan should include information on: 1. medication adjustments that should be made if peak flow is less than 50% normal. 2. timeline for allergy skin testing. 3. the most direct route when the client drives to the hospital. 4. the best methods for chest physiotherapy (CPT).

972.Which finding should a nurse expect when complet ing an assessment on a client with chronic bronchitis?. 1. Minimal sputum with cough. 2. Pink, frothy sputum. 3. Barrel chest. 4. Stridor on expiration.

973. A client learning about chronic obstructive pul monary disease self-care at a community health class, asks a nurse why the participants are being taught about the “lip-breathing.” The nurse should respond by explaining that pursed-lip breathing can help to: 1. reduce upper airway inflammation. 2. reduce anxiety through humor. 3. strengthen respiratory muscles. 4. increase effectiveness of inhaled medications.

974. A home health nurse is visiting a client whose chronic bronchitis has recently worsened. Which in struction should the nurse reinforce with this client?. 1. Increase amount of bedrest. 2. Increase fluid intake. 3. Decrease caloric intake. 4. Reduce home oxygen use.

975.A client with chronic obstructive pulmonary disease (COPD) is in the third postoperative day following right-sided thoracotomy. During the day shift, the client has required 10 L oxygen by mask to keep his or her oxygen saturations greater than 88%. Based on this information, which action should be taken by the evening shift nurse?. 1. Work to wean oxygen down to 3 L by mask. 2. Call respiratory therapy for a nebulizer treatment. 3. Check respiratory rate and notify the physician. 4. Administer dose of ordered pain medications.

976. A nurse enters a client’s room after hearing the pulse oximeter alarm and sees the following tracing on the screen. Which action should be immediately taken by the nurse?. 1. Call a code. 2. Remove the machine and call maintenance. 3. Administer oxygen through a nasal cannula or mask. 4. Assess the client’s level of consciousness and skin color.

977. A client with a suspected pulmonary embolus re ceives a ventilation and quantification nuclear medi cine (VQ) scan to evaluate regional lung ventilation of airflow and regional lung blood flow. In consulting with a physician, a nurse learns that there is a VQ mismatch. Based on this information, which action should be taken by the nurse?. 1. Tell the client that tuberculosis treatment will be needed. 2. Reassure the client that he/she does not have a pulmonary embolus. 3. Explain to the client that further testing will be needed. 4. Inform the client that the test was normal.

978.A nurse is assessing lung sounds on a client with pneumonia who is having pain during inspiration and expiration. The nurse hears loud grating sounds over the lung fields. The nurse should document the client’s pain level and should document that: 1. lung sounds were clear upon auscultation. 2. fine crackles were heard upon auscultation. 3. wheezing was heard upon auscultation. 4. pleural friction rub was heard upon auscultation.

979. A nurse is helping a client with obstructive sleep apnea to apply a continuous positive airway pressure (CPAP) mask before going to sleep. The nurse knows that CPAP is intended to: 1. breathe for the client during sleep. 2. reduce intrathoracic pressure. 3. deliver high concentrations of oxygen. 4. prevent alveolar collapse.

980. A nurse begins to hear high-pressure alarms in the room of a client requiring respiratory assistance with a ventilator. Which is the best action by the nurse?. 1. Wait and allow the client time to regulate breathing in coordination with the ventilator. 2. Check ventilator tubing and connections. 3. Silence the alarm and restart the ventilator. 4. Lower the tidal volumes being delivered to the client.

981.A nurse is caring for a client requiring positive pres sure mechanical ventilation. The client has been fighting the ventilator-assisted breaths, and the client’s blood pressure has been steadily decreasing. Which would be the most appropriate intervention by the nurse?. 1. Place the client in the prone position. 2. Notify the respiratory therapist to increase the positive pressure settings. 3. Call the physician to suggest sedatives and paralytics. 4. Prepare to administer intravenous aminophylline.

982.On the third postoperative day following a total la ryngectomy, a client’s family asks a nurse when the client will be able to eat. Which response by the nurse is best?. 1. “We are going to start with a feeding tube, but eventually he should be able to eat normally.”. 2. “We are going to start with a feeding tube, but eventually he will have to learn a different way of swallowing to prevent aspiration.”. 3. “Because of his surgery, it will be several more days before his gastrointestinal tract begins functioning again.”. 4. “He will probably always have to be fed through a gastrostomy tube in his stomach.”.

983.A nurse is designing the plan of care for a client fol lowing total laryngectomy. Included in the plan of care is a referral to a nutritional support staff/ dietician. The nurse understands that the referral is essential because the client: 1. is most likely depressed and uninterested in eating. 2. will have to relearn how to swallow. 3. may have lost his or her sense of smell and taste. 4. must learn strategies for preventing aspiration.

984.A nurse is evaluating discharge teaching that has been completed for a client following total laryngec tomy. Which statement made by the client indicates that the client does not accept or understand the teaching?. 1. “I will be sure to carry an extra supply of facial tissue with me.”. 2. “I probably will not be able to go swimming.”. 3. “I will schedule an appointment for closure of my tracheostomy.”. 4. “I will check the batteries on our smoke detectors.”.

985.A client with a large facial tumor is scheduled for a radical neck dissection. A nurse in the preoperative area is explaining the procedure. Which action will best help the client considering the potential for an alteration in body image from the procedure?. 1. Show multiple photographs of clients who have had similar procedures. 2. Closely assess and monitor the client’s verbal and nonverbal communication. 3. Direct the client’s significant other to allow for the client’s complete dependence on him or her. 4. Remind the client that it is what is on the inside that counts.

986. A 17-year-old client with cystic fibrosis (CF) is visiting with a nurse in preparation for leaving home for college. The nurse knows that the client needs fur ther education if the client states: 1. “I will bring extra cough medicine so as to not wake up my roommate at night.”. 2. “I will contact the college’s health center and pass on my medical records.”. 3. “I will check to make sure they have good work out facilities.”. 4. “I will be really careful about washing my hands and staying away from sick friends.”.

987. A public health nurse is planning a flu shot clinic. The nurse is working on advertising. Which groups should be the highest priority to target when advertising the flu shot clinic? SELECT ALL THAT APPLY. 1. Pregnant women. 2. Grade school children. 3. Nursing assistants at a nursing home. 4. A hypertension clinic population. 5. Outpatient psychiatric population. 6. Spinal cord–injured population at an assisted living facility.

988.A nurse is working at a telephone health service. Which advice should the nurse give to a client who has had 3 days of symptoms that strongly suggest influenza?. 1. Return to work after another day of rest. 2. Rest and increase fluid intake to 3 liters of fluid per day. 3. Use over-the-counter antihistamines. 4. Make an appointment to get the flu shot.

989.A client, hospitalized for a severe case of pneumonia, is asking a nurse why a sputum sample is needed. The nurse should reply that the primary reason is to: 1. complete the first of three samples to be collected. 2. differentiate between pneumonia and atelectasis. 3. encourage expectoration of secretions. 4. help select the appropriate antibiotic.

990. A nurse is preparing to admit a client with a confirmed case of tuberculosis. Which action is es sential to infection control for this client?. 1. Providing a positive-pressure airflow room. 2. Wearing gown and gloves when handling the client’s stool or urine. 3. Using a National Institute for Occupational Safety and Health (NIOSH)–approved N95 respirator mask for staff and visitors. 4. Keeping the client quarantined in the room until antibiotic therapy has been initiated.

991. A client requires intravenous vancomycin (Vancocin®) for antibiotic-resistant pneumonia. The order calls for 500 mg to be administered, and the medication is supplied in a 100 mL piggyback that contains 5 mg per 1 mL to run over 1 hour. In order to administer the correct dose, a nurse should set the infusion pump to run at a rate of _____ mL per hour.

992.A nurse is planning care for a client with AIDS who has been hospitalized for a Pneumocystis carinii in fection. Which nursing diagnosis should be the nurse’s first priority for this client?. 1. Fatigue related to hypermetabolism. 2. Imbalanced nutrition, more than body requirements related to hypometabolism. 3. Ineffective coping related to HIV diagnosis. 4. Fluid volume excess related to oral and intravenous fluid intake.

993.A client presents to an emergency department follow ing a motorcycle crash. A nurse assesses the client and notes uncoordinated or paradoxical chest rise and fall as well as multiple bruises across the client’s chest and torso, crepitus, and tachypnea. Based on this assessment, the nurse should: 1. assist in the placement of a cervical collar. 2. anticipate the need to intubate the client. 3. provide chest compressions. 4. tape the chest wall.

994. A nurse is caring for a client in an emergency department who has five fractured ribs from blunt chest trauma. The client is rating pain at 9 out of 10 on a 0 to 10 numeric scale. For which pain man agement modality should the nurse advocate?. 1. NSAIDs. 2. Oral analgesics (narcotic + acetaminophen). 3. Regional/local analgesia (epidural or intercostal injection). 4. Intravenous (IV) bolus meperidine (Demerol®).

995.Following an unrestrained motor vehicle crash, a client presents to an emergency department with mul tiple injuries, including chest trauma. A physician no tifies the care team that the client has progressed to acute respiratory distress syndrome (ARDS) and requests that the family be updated on the client’s condition. The nurse should plan to discuss with the family that: 1. the condition generally stabilizes with positive prognosis. 2. the client can be discharged with home oxygen. 3. the condition is always fatal. 4. the condition is highly life-threatening and that end-of-life concerns should be addressed.

996.A nurse is caring for a client with a left-sided chest tube attached to a wet suction chest tube system. Which observation by the nurse would require immediate intervention?. 1. Bubbling in the suction chamber. 2. Dependent loop hanging off the edge of the bed. 3. Banded connections between tubing sections. 4. Occlusive dressing over chest tube insertion site.

997. A nurse checks on a client following lower lobectomy for lung cancer. The nurse finds that the client is dysp neic with respirations in the 40s, is hypotensive, has a SaO2 at 86% on 10 L close-fitting oxygen mask, has a trachea that is deviated slightly to the left, and notes that the right side of chest is not expanding. Which action should be taken by the nurse first?. 1. Notify the physician. 2. Give the client whatever medication was ordered to decrease anxiety. 3. Check the chest tube to make sure it is not obstructed. 4. Turn up the oxygen liter flow.

998.On the first postoperative day following right-sided thoracotomy, a nurse is assisting a client with arm and shoulder exercises. The client reports pain with the exercises and wants to know why they must be per formed. The nurse should explain that the exercises: 1. promote respiratory function. 2. increase blood flow back to the heart and venous system. 3. improve muscle mass to compensate for muscle removed during the procedure. 4. prevent stiffening and loss of function.

999. Following a thoracotomy to remove a lung tumor, a nurse is preparing a client to be discharged to home. Which are appropriate teaching points for the client? SELECT ALL THAT APPLY. 1. Avoid lifting greater than 20 pounds. 2. Build up exercise endurance. 3. Continue to build endurance even when dyspneic. 4. Expect return to normal activity level and strength within 1 month. 5. Make time for frequent rest periods with activity.

1000. A nurse is partnered with a patient care assistant (PCA) on a medical-surgical floor. The PCA provides information about the clients for whom the PCA has been caring. Based on the information from the PCA, which client should the nurse attend to first?. 1. The client with a pulmonary embolus who has not had a bowel movement in 2 days. 2. The client who underwent a video thoracoscopy with oxygen saturation readings from 88% to 90% on oxygen at 4 L/NC. 3. The client who underwent a wedge resection of right lung and has a blood pressure of 100/65 mm Hg. 4. The client who has rib fractures and has not voided for 6 hours after the urinary catheter was removed.

1001. A nurse is caring for a client following an open thoracotomy for removal of a large tumor. Extensive blood loss during the procedure required fluid resus citation of the client. The client is cyanotic and in respiratory distress with pink, frothy sputum coming from the mouth. The nurse should immediately: 1. put the client in high Fowler’s position. 2. give a 200 mL fluid bolus. 3. activate the respiratory code system. 4. have the client cough and deep breathe.

1002.A nurse observes for early manifestations of acute respiratory distress syndrome (ARDS) in a client being treated for smoke inhalation. Which signs indicates the possible onset of ARDS in this client?. 1. Cough with blood-tinged sputum and respiratory alkalosis. 2. Decrease in both white and red blood cell counts. 3. Diaphoresis and low SaO2 unresponsive to increased oxygen administration. 4. Hypertension and elevated PaO2.

1003.Elevated homocysteine levels are associated with the development of arteriosclerosis and venous thrombosis. A clinic nurse should teach a client that the dietary therapy to decrease homocysteine levels includes eating foods rich in. 1.monosaturated fats. 2.B-complex vitamins. 3.vitamin C. 4.calcium.

1004.An adult client has laboratory tests drawn during a routine physical examination. A nurse determines that the client has an increased risk for cardiovascu lar disease. Which laboratory value most likely led the nurse to this conclusion?. 1.White blood cell count. 2.Red blood cell count. 3.Hemoglobin and hematocrit. 4.Platelet count. 5.Total cholesterol. 6.Triglyceride level.

1005. A client tests positive for factor V Leiden (FVL). A nurse recognizes that because the genetic trait is associated with venous thromboembolism (VTE) the client is: 1.also at a greater risk for myocardial infarction. 2.more likely to be of African American heritage. 3.at risk for premature death. 4.at risk for VTE if taking estrogen as an oral contraceptive or hormone replacement.

1006.A client taking medication for treatment of essential hypertension has a serum potassium level of 3.2 mEq/L. A nurse is reviewing the list of medica tions being taken by the client. Which medication on the list should the nurse conclude to be the causative factor for this serum potassium level?. 1. Spironolactone (Aldactone®). 2. Potassium chloride (K-Dur®). 3. Enalapril (Vasotec®). 4. Hydrochlorothiazide (Esidrix®, HydroDIURIL®).

1007.A nurse teaches individuals at a seminar that essen tial hypertension, if untreated, predisposes a client to: SELECT ALL THAT APPLY. 1. stroke. 2. cirrhosis. 3. renal failure. 4. myocardial infarction. 5. peripheral arterial disease.

1008.A nurse is assessing a blood pressure of an adult client with a manual sphygmomanometer. The nurse places the bell diaphragm of the stethoscope over the brachial artery and pumps the cuff up to 180 mm Hg. The valve is released to allow a drop of 2 mm Hg per second. At 162 mm Hg the nurse hears the first tapping sound. The sound becomes muffled at 148 mm Hg. The sound changes to a soft thumping at the 138 mm Hg. The sound fades to a muffled blowing sound at 128 mm Hg and is last heard at 94 mm Hg. There is silence at 92 mm Hg. The nurse should document the blood pressure as: 1. 138/92 mm Hg. 2. 148/94 mm Hg. 3. 162/92 mm Hg. 4. 162/94 mm Hg.

1009.A primary care provider prescribes lisinopril (Zestril®, Prinivil®) to treat a client with hyperten sion. The client returns to the clinic for a follow-up appointment. A nurse should evaluate the client for adverse effects by asking the client if he or she is experiencing: 1. muscle weakness. 2. bleeding gums. 3. persistent cough. 4. petechiae.

1010. A client’s blood pressure is being taken at a screening clinic. Which client statement to a nurse demonstrates awareness of having a risk factor for hy pertension?. 1. “My doctor told me my body mass index is 23.”. 2. “I usually have a glass of wine or two to unwind when I come home from work.”. 3. “I should get my blood pressure checked more often because I am African American.”. 4. “I have colds during the winter, so I see my physician to get the flu vaccine every year.”.

1011. An 85-year-old female client seeks medical atten tion in an emergency department because of chest pain. She tells a nurse that the chest pain is stabbing through the chest into her back. Her blood pressure is 230/130 mm Hg. The nurse realizes that these findings are most suggestive of. 1. pulmonary embolism. 2. subclavian steal syndrome. 3. acute arterial occlusion. 4. aortic dissection.

1012.A client is discovered to have a popliteal aneurysm. Because of the aneurysm, a nurse should closely monitor the client for: 1. thoracic outlet syndrome. 2. ischemia in the lower limb. 3. pulmonary embolism. 4. Raynaud’s phenomenon.

1013. A nurse admits a client to a hospital and ob tains a nursing history. The client tells the nurse that he had an endovascular repair of an abdominal aor tic aneurysm found 1 year earlier during a routine screening. The nurse understands that this procedure consists of: 1. excision of the aneurysm and placement of a graft percutaneously. 2. an angioplasty with placement of a stent around the outside of the aorta. 3. placement of a filter within the aneurysm to block clots from becoming emboli. 4. placement of a stent graft inside the aorta that excludes the aneurysm from circulation.

1014.A client with an abdominal aortic aneurysm is hav inga high resolution computed tomography (CT) scan to determine the feasibility for an endovascular repair. Which collaborative interventions should a nurse anticipate to decrease the client’s likelihood of developing nephrotoxicity? SELECT ALL THAT APPLY. 1.Administration of sodium bicarbonate 1 hour before injection of the intravenous (IV) contrast dye. 2.Administration of 0.9% NaCl at 100 mL per hour before and after the CT scan. 3.Administration of acetylcysteine (Mucomyst®) orally before and after the study. 4.Monitoring aPTT level before and after the CT scan. 5.Placing the client on a low potassium diet.

1015.A nurse is preparing a client for a thoracic aneurysm repair. Which assessment findings lead the nurse to suspect that a rupture has occurred? SELECT ALL THAT APPLY. 1.Severe chest pain radiating to the back. 2.Abdominal distention. 3.Hypotension. 4.Dyspnea. 5.Oliguria.

1016. A client with symptoms of intermittent claudi cation receives treatment with a peripheral percuta neous transluminal angioplasty procedure with placement of an endovascular stent. During a fol low-up home visit,a nurse determines that the client is making lifestyle changes to decrease the likeli hood of re-stenosis and arterial occlusion. Which observations of the client’s actions support this conclusion? SELECT ALL THAT APPLY. 1.States participating in an exercise program. 2.Abstaining from nicotine. 3.Wearing support hose. 4.States receiving foot care from a podiatrist. 5.Following a low saturated fat diet. 6.Taking the medication rosuvastatin calcium (Crestor®).

1017. A client seeks medical attention because of pain that develops while walking. An ankle-brachial index (ABI) test is ordered, and the results show that the client has ratios of 1.4 and 1.3 bilaterally. Based on these results, a nurse determines that the client: 1. has severe peripheral arterial disease. 2. would benefit from the medication ticlopidine hydrochloride (Ticlid®). 3. is experiencing pain that is psychological in origin. 4. needs further medical consultation to determine the cause of pain.

1018. A client has an appointment at a vascular clinic af ter being treated with pentoxifylline (Trental®) for 6 weeks. A nurse determines the pentoxifylline has been effective by noting that the client: 1. has a decrease in lower extremity edema. 2. is experiencing less symptoms of withdrawal after quitting smoking. 3. has a venous ulcer on the ankle that has decreased in size and depth. 4. is able to walk a greater distance without claudication.

1019. A 31-year-old male client seeks care at a vascular clinic because of painful fingers and toes. He is di agnosed with Buerger’s disease (thromboangiitis obliterans). A nurse is teaching the client ways to prevent progression of the disease. Which prevention measure should be the nurse’s initial focus when teaching the client?. 1. Avoiding exposure to cold. 2. Maintaining meticulous hygiene practices. 3. Abstaining from all tobacco products in all forms. 4. Following a low-fat diet.

1020.A client with Raynaud’s disease is seen in a vascu lar clinic 6 weeks after nifedipine (Procardia®) has been prescribed. A nurse evaluates that the medica tion has been effective when which findings are noted?. 1.The client’s blood pressure is 110/68 mm Hg. 2.The client states experiencing less pain and numbness. 3.The client states that tolerance to heat is improved. 4.The client walks without claudication.

1021.A primary care provider orders that a client have an elastic bandage applied to the lower extremity to reduce edema. At which position on the client’s leg should the nurse start wrapping the elastic bandage?. 1.Location A. 2.Location B. 3.Location C. 4.Location D.

1022.A client is receiving continuous heparin therapy. The infusion is 25,000 units of heparin in 500 mL of 5% dextrose and is infusing at 12 mL per hour. The aPTT laboratory test result is 92 seconds. According to the heparin infusion protocol,the nurse should administer the heparin infusion at a rate of _____ mL/hr.

1023.A nurse is discussing healthy lifestyle practices with a client who has chronic venous insufficiency. Which practices should be emphasized with this client? SELECT ALL THAT APPLY. 1.Avoid eating an excess of dark green vegetables. 2.Elevate the legs while sitting. 3.Wear elastic stockings (TEDS®) daily,applying them before getting out of bed. 4.Increase standing time and shift weight from one leg to the other when standing in one place. 5.Sleep with legs elevated above the level of the heart.

1024.After seeing a primary care provider for a routine appointment, a 48-year-old client tells a nurse that she experienced pain in the calf of her left leg ear lier in the week, but she is pain-free now. The nurse assesses the client and finds the dorsalis pedis pulses palpable and no pain upon dorsiflexion bilat erally. A few varicose veins are visible in each leg. There is very slight swelling in the left foot and none in the right foot. Which is the best action by the nurse?. 1. Ask the client if she has been walking more lately. 2. Notify the primary care provider. 3. Ask the client if she has thought about taking a baby aspirin once a day. 4. Explain to the client that there are no significant findings but to call the office if the pain returns.

1025.A nurse is caring for multiple clients on a medical unit. Which client, who has been diagnosed with a lower extremity deep venous thrombosis (DVT), should the nurse plan for possible placement of a filter in the inferior vena cava to protect against pul monary embolism?. 1. A 22-year-old female who has been taking oral contraceptives. 2. A 65-year-old client admitted with a bleeding gastric ulcer. 3. A 55-year-old client who had a total knee joint replacement. 4. A 52-year-old female who had a vaginal hysterectomy 6 weeks earlier.

1026.A client returns to a unit after undergoing placement of a vena cava filter. When caring for this client, a nurse should anticipate: 1. beginning anticoagulation therapy as soon as possible. 2. assessing the dressing over the abdominal incision. 3. checking the orders to determine the client’s ordered activity. 4. forcing oral fluids to promote excretion of the dye used during the procedure.

1027. An experienced nurse tells a new nurse that lymphedema is a complication that commonly oc curs after women have received surgery for breast cancer. Which statement to the new nurse regarding lymphedema is correct?. 1. Lymphedema is characterized by severe swelling in the arm and hand on the affected side. 2. Lymphedema usually resolves after the cancer treatment is completed when collateral lymph circulation develops. 3. Lymphedema is mainly controlled by encouraging women to keep their arm elevated. 4. Lymphedema frequently signifies that there is a recurrence of the malignancy.

1028. A nurse is evaluating female clients who have been diagnosed with arm lymphedema. Which client demonstrates acceptance of her diagnosis and has included lymphedema management in her lifestyle?. 1. A client who inspects her involved arm and hand only when pain occurs and the swelling worsens. 2. The client who continues to knit because she enjoys making sweaters even though the repeated activity is painful. 3. The client who never wears the compression sleeve and glove in public places. 4. The client who asks her family members to perform tasks that include heavy lifting because the tasks have increased swelling in the past.

1029. A client receives treatment for uncomplicated lower extremity cellulitis. A nurse notes improve ment in the client’s condition when which observa tion is noted on assessment?. 1. Strong dorsalis pedis pulses palpated bilaterally. 2. Increased erythema in the involved area. 3. Temperature of 101.3°F (38.5°C) orally. 4. Decreased swelling in the involved area.

1030.A nurse is completing a health history on a client admitted to a hospital with recurrent lower extrem ity cellulitis. The client tells the nurse that he has athlete’s foot (tinea pedis). The nurse concludes that this is significant because: 1. the cellulitis is commonly caused by a fungus. 2. the cellulitis should resolve with topical fungicide therapy. 3. the client is at risk for developing a painful neuralgia after the infection has resolved. 4. the loss of skin integrity that occurs with tinea pedis allows bacteria to enter the tissue.

1031.A nurse admits a client with a diagnosis of severe cellulitis in a lower extremity. The nurse anticipates the prescribed treatment will include: 1. obtaining baseline coagulation laboratory tests and initiating anticoagulation therapy. 2. applying sequential compression devices. 3. administering intravenous antibiotic therapy. 4. débriding the involved area.

1032.A nurse reviews the symptoms of acute graft occlu sion with a client who has had a revascularization graft procedure of the lower extremity. Which symptom of acute arterial occlusion stated by the client indicates further teaching is needed?. 1. Severe pain. 2. Redness and warmth along the incisions. 3. Paresthesia. 4. Inability to move the foot.

1033.The report of a chest x-ray of a client who has had aortic femoral bypass graft surgery indicates that the client has atelectasis. Which priority intervention should a nurse plan to include in the client’s care?. 1. Assessing breath sounds. 2. Monitoring oxygen saturation. 3. Assisting the client to use the incentive spirometer every hour. 4. Monitoring respiratory rate.

1034.A nurse is caring for a male client the night before the client is scheduled for an amputation. The client has a 7-year history of peripheral artery disease. Recent surgeries have failed to revascularize the client’s leg. The client tells the nurse that he is a failure and all the efforts of his family and physician have been wasted. The most appropriate action by the nurse at this time is to: 1. explain that the hospital staff will help him through the surgery and recovery. 2. stay with the client, listen carefully, and encourage him to express his feelings. 3. offer to contact pastoral care. 4. offer to contact the primary care provider to obtain an antidepressant.

1035.A nurse in the postanesthesia care unit (PACU) is monitoring a client who has had a repair of an aortic aneurysm with graft surgery. The nurse is unable to palpate the posterior tibial pulse of one leg that was palpable 15 minutes earlier. The most appropriate initial action for the nurse is to: 1. recheck the pulse in 15 minutes. 2. reposition the leg. 3. notify the surgeon. 4. remove the surgical dressing.

1036.Two days ago, a client had a femoral-popliteal ar tery bypass graft surgery. A priority nursing action at this time should be to: 1. monitor intake and output. 2. report any edema that develops in the operative leg. 3. maintain the client at a 60-degree sitting position when resting in bed. 4. monitor the dorsalis pedis and posterior tibial pulses bilaterally every 4 hours.

1037. Which intervention should a nurse plan to in corporate in the care of a surgical client to decrease the risk of deep venous thrombosis (DVT) and pul monary embolism (PE)?. 1. Use of intermittent compression devices on the lower extremities. 2. Administration of heparin intravenously. 3. Coughing and deep breathing exercises. 4. Isometric leg exercises.

1038.A client is to receive a scheduled dose of digoxin (Lanoxin®). A nurse determines that the client’s api cal pulse is irregular at 92 beats per minute and that the client’s serum potassium level is 3.9 mEq/L. Which documentation by the nurse reflects the most appropriate action based on this information?. 1. Serum potassium level within normal limits. Digoxin administered for rapid apical pulse. 2. Digoxin withheld because the client’s heart rate is irregular. 3. Digoxin withheld to prevent toxicity due to the low serum potassium level. 4. Physician notified to report the irregular heart rate and low serum potassium level.

1039.A hospitalized client has been receiving clonidine (Catapres®) 0.1 mg via transdermal patch once every 7 days. When bathing the client, a nursing as sistant removes the patch thinking it is tape. Eight hours later, an on-coming nurse discovers that the transdermal patch is no longer on the client as pre scribed. Based on this information, which assess ment finding should be most concerning to the nurse?. 1. Skin tear noted on the client’s upper chest. 2. Excruciating headache reported. 3. Blood pressure is 182/100 mm Hg. 4. Electrocardiogram shows.

1040.A client, diagnosed with chronic, stable angina, tele phones a clinic nurse. The client reports a headache lasting for several days after taking one dose of isosorbide mononitrate (Imdur®). The client also re ports symptoms of orthostatic hypotension and pal pitations. Which is the nurse’s best action?. 1. Recommend that the client make an appointment with the health-care provider. 2. Have the client retime the dose to take it later in the day when the client is more active. 3. Instruct the client to take two acetaminophen 325-mg tablets when taking the Imdur® dose. 4. Teach the client that the headaches will subside over time with continued medication use.

1041.A client is taking metalazone (Zaroxolyn®) and dil tiazem (Cardizem®) for treatment of hypertension. A home health nurse is reviewing the medications with the client. Which client statement indicates that the client needs teaching about these medications?. 1. “I make sure that I eat foods high in potassium every day.”. 2. “Because metalazone makes me urinate more, I take my last dose at suppertime.”. 3. “I take my medications with a healthy breakfast of eggs, toast, grapefruit juice, and milk.”. 4. “Because ibuprofen (Motrin®) seems to affect my urine output, I prefer to take acetaminophen (Tylenol®) for pain.”.

1042.A health-care provider (HCP) adds a second med ication for blood pressure control for a client whose blood pressure has not been well-controlled with one antihypertensive medication. If the HCP orders the following medication combinations, which com bination should the nurse question?. 1. Atenolol (Tenormin®) and metoprolol (Lopressor®). 2. Metolazone (Zaroxolyn®) and valsartan (Diovan®). 3. Captopril (Capoten®) and furosemide (Lasix®). 4. Bumetanide (Bumex®) and diltiazem (Cardizem®).

1043.A nurse is assessing a client who is taking atorvas tatin (Lipitor®). For which manifestations should the nurse specifically assess?. 1. Constipation and hemorrhoids. 2. Muscle pain and weakness. 3. Fatigue and dysrhythmias. 4. Flushing and postural hypotension.

1044.A nurse is reviewing the chart of a client with a diagnosis of stage II heart failure (see abbreviated chart). The data should suggest to the nurse that: 1.medications should be administered as ordered. 2.the client may be experiencing digoxin toxicity. 3.hyperkalemia likely caused the client’s cardiac dysrhythmias. 4.the client’s visual disturbance likely resulted from the atrial fibrillation rhythm or effects of the anticoagulants.

1045. Which points should the nurse plan to include when teaching a client receiving a thiazide diuretic? SELECT ALL THAT APPLY. 1.Take the radial pulse before setting up the medication. 2.Include fruits such as melons and bananas in the diet. 3.Report side effects such as muscle cramps, nausea,or a skin rash. 4.Self-administer the last dose at bedtime when fluid tends to be at the highest levels. 5.Keep appointments for laboratory monitoring, including serum electrolytes,glucose,creatinine, blood urea nitrogen (BUN),and uric acid levels. 6.Minimize intake of high-fat foods because thiazide diuretics can increase serum cholesterol, low-density lipoprotein (LDL),and triglyceride levels.

1046. A home health nurse visiting an older adult client for the first time is reviewing the client’s medication list prepared by the client’s daughter (see exhibit). Which finding in the client’s medica tion list should be of most concern to the nurse and should be discussed first with the client?. 1.Some doses of medication are missing. 2.Some routes of medication are missing. 3.Some medications are duplicated. 4.Some medications have drug–drug interactions.

1047. A client, following a total hip replacement, asks a nurse why she is receiving enoxaparin (Lovenox®) for prevention of deep vein thrombosis (DVT) when, with her last hip surgery, she received heparin subcutaneously. What is the nurse’s best response?. 1. “Enoxaparin is less expensive and easier to administer than the heparin.”. 2. “There is less risk of bleeding with enoxaparin, and it doesn’t affect your laboratory results.”. 3. “Enoxaparin is a low-molecular-weight heparin that lasts twice as long as regular heparin.”. 4. “Enoxaparin can be administered orally whereas heparin is only administered by injection.”.

1048.A client, diagnosed with chronic renal failure (CRF), is receiving epoetin alfa (Epogen®). Which finding should indicate to a nurse that the action of the medication has been effective?. 1. Urine output increased to 30 mL per hour. 2. Hemoglobin is 12 g/dL, and hematocrit is 42%. 3. Blood pressure is 110/70, and heart rate is 68 bpm. 4. Client reports increased energy level and less fatigue.

1049.A client with a diagnosis of tonsillar cancer is re ceiving filgrastim (Neupogen®). Prior to administer ing the next dose of the medication the nurse notes that the client’s absolute neutrophil count is 11,000/mm3. What is the nurse’s best action?. 1. Administer the medication as ordered. 2. Place the client on neutropenic precautions. 3. Notify the health-care provider because treatment will likely be discontinued. 4. Apply gown, gloves, and a mask when entering the room to administer the medication.

1050.For which client should a nurse question a physi cian’s order to administer 5% albumin?. 1. A client of the Catholic faith who has refractory edema. 2. An African American client experiencing hypovolemic shock. 3. A client of the Jehovah’s Witnesses faith who has cerebral edema. 4. An Asian client experiencing adult respiratory distress syndrome (ARDS).

1051.Which assessment finding should a nurse expect following administration of phenylephrine (Neosynephrine®) eye drops to perform an ophthalmoscopic eye examination?. 1. Tremor. 2. Hypotension. 3. Pupil miosis. 4. Pupil mydriasis.

1052.A concerned client using latanoprost (Xalatan®) eye drops for treatment of glaucoma calls a clinic after noting a brown pigmentation of the iris. Which nursing action is most appropriate?. 1. Inform the client that the brown pigmentation is a side effect of latanoprost and that he/she should be seen as soon as possible. 2. Schedule an appointment for the client to see an internist for liver function studies. 3. Tell the client that the brown pigmentation is from the latanoprost, but will eventually regress. 4. Recommend that the client wear sunglasses when outdoors to decrease iris pigmentation.

1053.Tazarotene (Tzorac®) topical medication is pre scribed for a client with psoriasis vulgaris. Place an X on the illustration that shows the area about which a nurse should document applying a thin film of the medication.

1054.A nurse receives a physician’s order to start total parenteral nutrition (TPN) for a client who has a pe ripherally inserted central catheter (PICC). Into which type of catheter illustrated should the nurse plan to administer the TPN?. 1. A. 2. B. 3. C. 4. D.

1055.A nurse has just completed teaching for a client who will be receiving total parenteral nutrition at home. Which client statement indicates that further teaching is needed?. 1. “My refrigerator is large enough to accommodate several bags of the parenteral solution.”. 2. “I will keep my portable phone with me for emergency purposes.”. 3. “Because I will have an infusion pump, I plan on using the main floor bedroom.”. 4. “It will be easiest to remove my intravenous catheter cap and then attach the tubing if I am sitting at the table.”.

1056.A physician orders 1,200 milliliters (mL) of total parenteral nutrition (TPN) solution to be adminis tered over 24 hours for a homebound client. A home health nurse should instruct the client to set the in fusion pump to deliver TPN at _______ mL per hour.

1057. A nurse who is initiating an intravenous infusion of lactated Ringer’s (LR) for a client in shock recog nizes that the purpose of LR for the client is to: 1. increase fluid volume and urinary output. 2. draw water from the cells into the blood vessels. 3. provide dextrose and nutrients to prevent cellular death. 4. replace electrolytes of sodium, potassium, calcium, and magnesium for cardiac stabilization.

1058. A client is receiving multiple medications for treatment of Parkinson’s disease. Which signs and symptoms should a nurse recognize as adverse effects of carbidopa-levodopa (Sinemet®)?. 1. Dystonia and akinesia. 2. Bradykinesia and agitation. 3. Muscle rigidity and cardiac dysrhythmias. 4. Orthostatic hypotension and dry mouth.

1059.A client calls a clinic 2 weeks after beginning to use oral carbidopa-levodopa (Parcopa®), stating that the medication has been ineffective in controlling the symptoms of Parkinson’s disease. What nursing action is most appropriate?. 1. Review the correct procedure for taking the medication. 2. Contact the physician to change the dose of the medication. 3. Remind the client that it may take 1 to 2 months to note any effects of the medication. 4. Ensure that the client is eating a diet high in protein and vitamin B6 (pyridoxine).

1060.A nurse teaches a client with relapsing-remitting multiple sclerosis about glatiramer (Copaxone®). Which information addressed by the client indicates that the nurse’s teaching has been effective? SELECT ALL THAT APPLY. 1. Keep the medication vial refrigerated until it is to be used. 2. Glatiramer is administered by injection into the subcutaneous tissue. 3. Injection sites should be rotated so that no one spot is used more than once a week. 4. The thigh and abdomen are the appropriate subcutaneous injection sites. 5. Used syringes can be washed, air dried, and reused until the needle becomes dull. 6. Adverse effects to report immediately include chest pain and unusual muscle weakness.

1061.A nurse on a medical unit receives multiple med ication orders for adult clients with seizure disor ders. Which order should the nurse clarify with a physician?. 1. Administer fosphenytoin (Cerebyx®) 150 mg orally three times daily. 2. Obtain phenytoin level prior to administering additional doses of anticonvulsant medications. 3. Administer intravenous phenytoin (Dilantin®) 1 g in 100 mL 0.9% NaCl via intravenous piggyback (IVPB). 4. Document effectiveness of carbamazepine (Tegretol®) for the client’s seizure control and restless leg syndrome.

1062.A client with multiple sclerosis is prescribed ba clofen (Lioresol®). Which information is most im portant for a nurse to assess when caring for this client?. 1. Serum baclofen levels. 2. Muscle rigidity and pain. 3. Intake and urine output. 4. Client’s weight.

1063.A client with cerebral palsy is taking dantrolene (Dantrium®). A nurse evaluates that the medication is effective when noting that the client has: SELECT ALL THAT APPLY. 1. increased muscle spasticity. 2. increased urinary frequency. 3. increased mobility. 4. increased ability to maintain balance. 5. increased alertness.

1064.A nurse prepares to administer naloxone (Narcan®) 0.4 mg intravenously (IV) to a client experiencing respiratory depression from morphine sulfate ad ministered by patient-controlled analgesia (PCA). Naloxone is supplied in a 1 mg/mL vial. In order to give the correct dose, the nurse should administer ____ mL to the client.

1065. A nurse is caring for a group of clients all in need of pain medication. The nurse has determined the most appropriate pain medication for each client based on the client’s level of pain. Prioritize the or der in which the nurse should plan to administer the pain medications beginning with the analgesic for the client with the most severe pain. ______ Ketorolac (Toradol®) 10 mg oral. ______ Fentanyl (Sublimaze®) intravenously (IV) per patient-controlled analgesia (PCA) with a bolus dose. ______ Hydromorphone (Dilaudid®) 5 mg oral. ______ Morphine sulfate 4 mg IV. ______ Propoxyphene (Darvon®) 65 mg oral.

1066. A nurse applies a fentanyl (Sublimaze®) trans dermal patch to a client for the first time. Shortly af ter application, the client is experiencing pain. Which nursing action is most appropriate?. 1. Remove the transdermal patch and apply a new one. 2. Administer a short-acting opioid analgesic. 3. Rub the transdermal patch to enhance absorption of the medication. 4. Call the physician to request a fentanyl transdermal patch with a higher dosage.

1067. A nurse evaluates that sumatriptan (Imitrex®) has been an effective treatment when a client reports: 1. an improvement in mood. 2. a decrease in muscle spasms. 3. an increased ability to fall asleep and stay asleep. 4. relief of migraine headache attacks.

1068.A nurse is caring for a client with osteoarthritis re ceiving piroxicam (Feldene®). Which instruction is most important for the nurse to include in the med ication teaching plan?. 1. “Take the medication with food to decrease gastric irritation.”. 2. “If your pain is severe, you can take an additional dose of the medication.”. 3. “Lie down until the medication begins to be effective for pain control.”. 4. “If you feel you are lacking energy, you can safely take ginkgo for an energy boost.”.

1069.A nurse identifies the nursing diagnosis of Disturbed body image related to a client’s long term use of prednisone (Deltasone®). Which observations should support this diagnosis? SELECT ALL THAT APPLY. 1. Weight gain. 2. Increased muscle mass. 3. Fragile skin. 4. Acne. 5. Alopecia.

1070. Which is the priority nursing diagnosis for a client taking doxorubicin (Doxil®) for recurrent ovarian cancer?. 1. Risk for fluid volume deficit. 2. Risk for imbalanced nutrition: Less than body requirements. 3. Risk for alteration in cardiac output. 4. Risk for self-care deficit.

1071.A client with advanced prostate cancer is receiving abarelix (Plenaxis®). Due to the effects of the med ication, what should be the priority nursing action?. 1. Review with the client strategies to reduce constipation. 2. Monitor the client for breast pain and tenderness. 3. Observe the client for at least 30 minutes after abarelix administration. 4. Teach the client ways to improve sleep hygiene.

1072.Cyclosporine (Sandimmune®) and methotrexate (Rheumatrex®) are prescribed for a client with severe rheumatoid arthritis. Which points should a nurse address when teaching the client about these medications? SELECT ALL THAT APPLY. 1. Drinking grapefruit juice is best because the medications’ effects are enhanced. 2. Keep well hydrated to maximize the therapeutic effects of methotrexate. 3. Avoid use of St. John’s wort, echinacea, and melatonin, as these may interfere with immunosuppression. 4. These medications are administered weekly by subcutaneous injection. 5. Both methotrexate and cyclosporine suppress the immune system.

1073.A nurse is assessing the laboratory test results for a male client receiving testosterone replacement therapy for treatment of hypogonadism. Which laboratory finding is most important for the nurse to review?. 1. Fasting lipid profile. 2. Partial thromboplastin time. 3. Urinalysis. 4. Serum potassium.

1074. A client calls a clinic to renew the prescrip tion for insulin being administered subcutaneously via an insulin pump. Which insulin type, if pre scribed by a physician, should the nurse question?. 1. Insulin lispro (Humolog®). 2. Insulin aspart (Novolog®). 3. Insulin glulisine (Apidra®). 4. Insulin glargine (Lantus®).

1075. Exenatide (Byetta®) is prescribed for a client with type 2 diabetes mellitus in addition to a combi nation of metformin (Glucophage®) and glyburide (Micronase®). Which focus should be a nurse’s pri ority when teaching the client about exenatide?. 1. Teaching the client how to administer exenatide subcutaneously. 2. Informing the client that exenatide helps to reduce body weight due to slower gastric emptying. 3. Discussing exenatide’s action in reducing hemoglobin A1C and fasting plasma glucose levels. 4. Discussing the signs and symptoms of hypoglycemia.

1076. An unresponsive client with diabetes mellitus is ad mitted to an emergency department with a serum glucose level of 35 mg/dL. Which medication should a nurse plan to administer?. 1. Exenatide (Byetta®). 2. Pramlintide (Symlin®). 3. Miglitol (Glyset®). 4. Glucagon (GlucaGen®).

1077. A 40-year-old client is receiving levothyroxine (Synthroid®) for treatment of hypothyroidism. Which serum laboratory results should lead a nurse to conclude that the client’s dose is adequate?. 1. Thyroid-stimulating hormone (TSH) and cortisol. 2. TSH and free T4. 3. Triiodothyronine (T3) and free thyroxine (T4). 3. Triiodothyronine (T3) and free thyroxine (T4) 4. White blood cells (WBCs), glucose, and potassium (K).

1078.A client is receiving fludrocortisone (Florinef®) for treatment of adrenocortical insufficiency. A nurse is evaluating the client’s serum laboratory values for adverse effects of the medication. Place an X in the box for the laboratory values that the nurse should specifically assess related to the adverse effects of fludrocortisone.

1079.Oral terbutaline (Brethaire®) is prescribed for a client with bronchitis. Which comorbidity should prompt a nurse to monitor the client closely follow ing administration of this medication?. 1. Strabismus. 2. Hypertension. 3. Diabetes insipidus. 4. Hypothyroidism.

1080.A client is admitted to an emergency department with tachypnea, tachycardia, and hypotension. The client has been taking theophylline (Theo-Dur®) for treatment of asthma and erythromycin (Erythrocin®) for an upper respiratory tract infection. Which con clusion by the nurse and action taken is correct?. 1. The client is experiencing an asthma attack and the nurse requests an order for albuterol. 2. The client is experiencing septicemia and the nurse requests an order for blood cultures. 3. The client is experiencing theophylline toxicity and the nurse requests an order for a serum theophylline level. 4. The client is experiencing an allergic reaction to erythromycin and the nurse requests an order for diphenhydramine (Benadryl®).

1081. A client is admitted to an emergency department with a severe asthma attack. A nurse has a standing order to administer 0.5 mg epinephrine (Adrenalin®) subcutaneously. The medication is supplied in a vial for injection that contains 5 mg/mL. In order to administer the correct dose, the nurse should quickly inject ____ mL subcutaneously.

1082. A client is unable to control gastroesophageal reflux with lifestyle modifications. A nurse instructs the client that by using which over-the-counter med ication the client’s symptoms can be successfully decreased?. 1. Aspirin once a day. 2. Famotidine (Pepsid®). 3. Ibuprofen (Advil®). 4. Desloratadine (Claritin®, Tavist®, Alavert®).

1083.A client has a new order for metoclopramide (Reglan®). On review of the client’s chart, a nurse identifies that the client has a contraindication for the medication and that the order should be ques tioned. Which contraindication did the nurse most likely note?. 1. Use of nasogastric suctioning. 2. History of diabetes mellitus (DM). 3. History of seizure disorders. 4. Chemotherapy treatment for cancer.

1084.A client with ulcerative colitis is started on the med ication sulfasalazine (Azulfidine®). A nurse over hears the client talking with family members about this medication and recognizes the need for more teaching when the client says: 1. “This medication will help to control my diarrhea.”. 2. “Sulfasalazine will decrease the inflammation in my colon.”. 3. “After taking this medication for a year, I will be cured of the disease.”. 4. “The medication will help to prevent future exacerbations of my disease.”.

1085.A nurse evaluates that pancrelipase (Pancrease®) is having the optimal intended benefit for a client with cystic fibrosis when assessing that the client has: 1. lost weight. 2. relief of heartburn. 3. increased steatorrhea. 4. improved nutritional status.

1086.Medications are ordered for a client on admission to a hospital. A nurse notes that the client’s serum cre atinine level, which was normal upon admission, has now risen to 3.7 mg/dL. Which ordered medica tion should prompt the nurse to call a physician to request a change in dosage?. 1. Ceftriaxone (Rocephin®). 2. Insulin glargine (Lantus®). 3. Diltiazem (Cardizem®). 4. Furosemide (Lasix®).

1087. A nurse is to administer vancomycin (Van cocin®) to a client diagnosed with sepsis. The client is to have a peak and trough level completed on this dose of the medication. Which action should the nurse initiate first?. 1. Determine if the trough level has been drawn on the client. 2. Determine medication compatibilities before infusing into an existing intravenous line. 3. Check the client’s culture and sensitivity (C&S) report. 4. Check the amount of time over which the medication dose should infuse.

1088.A client is to receive a first dose of oral sul famethoxazole (Gantanol®) 1 gram every 12 hours for treatment of recurrent urinary tract infections. Which information about the client should prompt the nurse to immediately notify the physician to question the medication order?. 1. History of gastric ulcer. 2. Type 1 diabetes mellitus. 3. Urine culture positive for Escherichia coli. 4. Near-term pregnancy.

1089.A hospitalized client is being treated for tuberculo sis (TB). When administering medications, which medication on the client’s medication administration record (MAR) should a nurse conclude is used for the treatment of TB?. 1. Isoniazid (Nydrazid®). 2. Fluconazole (Diflucan®). 3. Azithromycin (Zithromax®). 4. Acyclovir (Zovirax®).

1090. Ciprofloxacin (Cipro-XR®) is prescribed for a client to treat a urinary tract infection. Which point should a nurse stress when teaching the client about the medication?. 1. Avoid taking ciprofloxacin with milk or yogurt. 2. Treat diarrhea, a side effect of ciprofloxacin, with bismuth subsalicylate (Pepto-Bismol®). 3. Avoid fennel because it will increase the absorption of the ciprofloxacin. 4. Take dietary calcium tablets 1 hour before or 2 hours after ciprofloxacin.

1091.Which finding should indicate to a nurse that acy clovir (Zovirax®), administered orally for treatment of herpes zoster, is effective?. 1. Drying and crusting of genital lesions. 2. Crusting and healing of vesicular skin lesions. 3. Urticaria decreased and pruritus relieved. 4. Decrease in intensity of chickenpox lesions.

1092.A nurse is caring for various clients being seen in a clinic. Ganciclovir (Cytovene®) is prescribed for one of the clients for lesions that have not healed and are recurring (see illustrations). For which client with the problem illustrated should the nurse document that teaching about ganciclovir was completed?. 1.Client A. 2.Client B. 3.Client C. 4.Client D.

1093.Various children are being seen in the clinic for well-baby checks. By what age should a nurse ex pect a child to begin to use simple words to com municate needs?. 1. Age 10–12 months. 2. Age 1–2 years. 3. Age 6–9 months. 4. Age 2–3 years.

1094.A nurse in a clinic is assessing the weight of an infant. Which infant’s weight indicates to the nurse that the infant’s weight is normal for the infant’s age?. 1. The baby’s weight has tripled in the first 6 months of life. 2. The baby’s weight has doubled in the first year of life. 3. The baby’s weight has doubled in the first 6 months of life and tripled in the first year. 4. The baby’s weight has doubled in the first 6 months and doubled again in the next 6 months.

1095.A student explains to an instructor that the infant period is categorized as the “oral phase” according to Freud’s theory. Which statements by the student suggest an understanding of this phase? SELECT ALL THAT APPLY. 1. An infant sucks for nourishment as well as pleasure. 2. An infant does not find pleasure in sucking but does find enjoyment from the nourishment. 3. An infant may have more pleasure in breastfeeding than bottle feeding because it expends more energy. 4. An infant does not find pleasure in use of a pacifier. 5. An infant explores the world through the mouth. 6. An infant begins to explore the genital area to learn sexual identity.

1096.An 8-month-old baby girl, who is developing ap propriately, is admitted to a pediatric unit for res piratory syncytial virus (RSV). The baby is crying and being held by her mother. A nurse wants to provide appropriate care based on Erikson’s de velopmental stages. In which stage is this baby, according to Erikson’s theory?. 1. Punishment versus obedience orientation. 2. Oral stage. 3. Initiative versus guilt. 4. Trust versus mistrust.

1097. A nurse is caring for a 3-month-old infant. Based on the developmental age of the child, which motor skill should the nurse expect to see during an assessment?. 1. Bangs objects held in hand. 2. Begins to grab objects using a pincer grasp. 3. Grabs objects using a palmar grasp. 4. Looks and plays with own fingers.

1098.A 10-month-old child reaches the 9- to 12-month developmental stage. Which nursing action is most appropriate for providing tactile stimulation for this child?. 1. Caress the child while diaper changing. 2. Give the child a soft squeeze toy. 3. Swaddle the child at nap time. 4. Let the child squash and mash food while sitting in a high chair.

1098.A 10-month-old child reaches the 9- to 12-month developmental stage. Which nursing action is most appropriate for providing tactile stimulation for this child?. 1. Caress the child while diaper changing. 2. Give the child a soft squeeze toy. 3. Swaddle the child at nap time. 4. Let the child squash and mash food while sitting in a high chair.

1099. A clinic nurse is meeting with a mother and her 3-year-old son. The toddler is acting out, and the mother asks the nurse what a good form of discipline would be for her son. The nurse recommends a “time-out” for the child. Which statement regarding a time-out is most accurate?. 1. The child should sit still for as many minutes as he misbehaved. 2. The child should sit still at a time-out for as many minutes as his age in years. 3. The child should be able to read a book during time-out. 4. Children should not be expected to sit still until they are in school.

1100. A clinic nurse is caring for a 2-year-old client. Dur ing the examination the child’s parents ask the nurse when their toddler should be toilet trained. Which response by the nurse is most appropriate?. 1. “Children should be placed on the potty chair often so they get used to the task and should be rewarded immediately for staying on the potty chair.”. 2. “Children need sphincter control, cognitive understanding of the task, and the ability to delay immediate gratification.”. 3. “Children should be ready to toilet train at about 2 years old.”. 4. “First put training pants on your child so the child gets used to not wearing a diaper.”.

1101. A nurse is preparing a 4-year-old boy for surgery. Which nursing action is appropriate for preoperative teaching based on Erikson’s developmental stages?. 1. Allowing the child to make a project related to the surgery. 2. Having the child put a surgical mask on a doll. 3. Asking the child how he feels about surgery. 4. Allowing the child to listen to music without further instructions.

1102. A nurse case manager is meeting with the parents of an 8-year-old client. The 8-year-old is scheduled for surgery to repair a cleft palate. The parents ask the case manager when they should discuss and explain the surgery to their child. Based on the child’s developmental age, which is the best response by the nurse?. 1. Explain the surgery immediately before it is carried out. 2. Explain the surgery 1 to 2 hours before it is carried out. 3. Explain the surgery up to 1 week before it is carried out. 4. Explain the surgery several days before it is carried out.

1103. A 7-year-old child lived in foster homes when he was an infant. He was adopted at the age of 1 year to an intact family who provided him with love and security. Which developmental task was this child most likely unable to complete as an infant?. 1. Trust versus mistrust. 2. Industry versus inferiority. 3. Autonomy versus shame and doubt. 4. Initiative versus guilt.

1104. A clinic nurse is completing a school physical on an adolescent girl. The girl is concerned because she is 13 years old and has not yet started menstruating. Which statement by the nurse should be most helpful when addressing the girl’s concerns?. 1. “The average age for a girl to experience menarche is 12.5 years. That means some girls will be younger and some will be older than 12.5.”. 2. “Don’t worry about it; your period will come.”. 3. “I can see why you are concerned, since some girls get their period when they are 10 years old.”. 4. “I can refer you to a specialist who can answer your questions.”.

1105. A nurse in a clinic is asked to teach a 13-year-old boy diagnosed with asthma. The nurse assesses that the child is developmentally on task. Which consid eration should the nurse include when teaching this client?. 1. The client is unable to differentiate cause and effect, so keep it simple. 2. The client is discovering new properties of objects and events, so expect many questions. 3. The client is not developmentally able to remember information, so handouts are necessary. 4. The client needs explanations of the physiology of asthma and demonstrations of appropriate interventions.

1106. A clinic nurse assesses an infant diagnosed with thrush. Place an X on the photograph illustrating a thrush infection.

1107.A nurse is planning to use the Denver Articulation Screening Examination (DASE) for a 4-year-old child. To properly use the DASE, the nurse should plan to ask the child to: 1.read a favorite book at the child’s developmental level. 2.read a phrase and tell the nurse the meaning of the phrase. 3.repeat familiar words that are read to the child. 4.ask the child to state the letters of the alphabet.

1108.Which result should a nurse expect if a 4-year-old child’s visual acuity test is normal for the child’s developmental age?. 1.10/10. 2.20/20. 3.20/40. 4.40/40.

1109.A nurse has reviewed the upper arm blood pressure (BP) results for multiple children between the ages of 3 and 5 years. Which BP reading should the nurse evaluate as being an abnormalBP for this age group?. 1.96/42 mm Hg. 2.101/57 mm Hg. 3.112/66 mm Hg. 4.115/68 mm Hg.

1110.When taking an infant’s blood pressure,which points are important for a nurse to remember? SELECT ALL THAT APPLY. 1.It is best to use an infant cuff on an infant. 2.The cuff used should be no more than two-thirds of the length of the upper arm. 3.The cuff used can be a Doppler ultrasound device. 4.The reading of the upper arm should be higher than the thigh. 5.A similar reading on the arm and the thigh could indicate coarctation of the aorta.

1111. A 22-month-old toddler is walking into the exami nation room independently in front of the toddler’s mother. Which method should the nurse plan to use to weigh the child?. 1. A standing scale should be used because the toddler is able to stand independently. 2. Weigh using an infant scale because this is the method for all infants until the age of 2 years. 3. Ask the mother which would be best for the child. 4. Have the mother weigh herself and then weigh herself holding her child. Then subtract the mother’s weight from the combined child and mother’s weight.

1112. An experienced nurse is orienting a new nurse to the care of children in a clinic. Which immuniza tions should the experienced nurse inform the new nurse to plan to administer to normally healthy chil dren between ages 1 and 5 years? SELECT ALL THAT APPLY. 1. Inactivated poliovirus. 2. Diphtheria, tetanus, pertussis (DTaP). 3. Measles, mumps, rubella (MMR). 4. Hepatitis B (HepB). 5. Meningococcal.

1113. A nurse at a clinic is preparing the immunizations for a 6-month-old baby. The mother says, “My baby is afraid of strangers and afraid of separating from me. My mother-in-law is upset and thinks I am causing it.” Which response by the nurse is most appropriate?. 1. “Give your baby to strangers while you are present, so your baby gets used to strangers.”. 2. “Your mother-in-law is correct; you need to include her more in your baby’s needs.”. 3. “Separation anxiety is an important component of a parent-child attachment.”. 4. “Just let your baby cry for a while; your baby will get used to being separated from you.”.

1114. A nurse is assessing the nutritional needs of a 1-year-old client. According to recommendations for introducing milk products, which type of milk should a 1-year-old child be drinking?. 1. 2% milk beginning at the age of 1. 2. 1% milk. 3. Whole milk until the age of 2 years. 4. Skim milk.

1115. A nurse is teaching the parents of children between the ages of 2 and 3 years old about nutritional in take. The nurse should teach the parents that the percentage of the daily total intake of fat should be no more than which percentage?. 1. 20% to 25%. 2. 50%. 3. 30%. 4. 10% to 20%.

1116. A mother brings her 5-month-old to the clinic for a well-child appointment. A nurse is doing an assess ment when the mother asks when she can give her baby solid foods. What response is most appropriate?. 1. Inquire if the baby can sit well with support and if the baby’s tongue thrust has decreased. 2. Ask the mother is she feels the baby is ready for solids. 3. Ask the mother if the baby seems hungry after bottle feeding. 4. Tell the mother to ask the pediatrician.

1117. A school nurse is concerned about the lack of physical activity in the high school. The nurse has gathered data related to appropriate activity from the document Healthy People 2010: Understanding and Improving Health. Which recommendation for physical activity should the school nurse recom mend for this age group?. 1. Adolescents should get at least 60 minutes of physical activity daily. 2. High school students should be required to participate in physical education classes. 3. Teenagers should be exercising at least 30 minutes three to five times per week. 4. Adolescents should be exercising every day for at least 15 minutes.

1118. A school nurse is teaching adolescents about oral care. Which point should the nurse address with the students?. 1. The adolescent should floss daily, brush teeth twice a day, and see the dentist two times per year. 2. The adolescent should brush once a day and see the dentist twice per year. 3. The adolescent should see the dentist once a year and brush teeth twice a day. 4. The adolescent should floss daily, brush teeth twice a day, and see the dentist once a year.

1119. A nurse is caring for a 14-year-old client who was admitted for dehydration from nausea and vomiting. The client is ready for discharge and says to the nurse, “I will tell you something, but you can’t tell anyone.” Which nursing action is most appropriate?. 1. Promise the client that the information will not be told to anyone due to Health Insurance Portability and Accountability Act (HIPAA) laws. 2. Tell the client that the information will be confidential unless it is life threatening or harmful. 3. Tell the client that only the physician will be told; otherwise the information will remain confidential. 4. Ask the client to tell a social worker who then can follow through with the information if it is concerning.

1120. A school nurse is teaching adolescents about sexual activity and how the human papilloma virus (HPV) is contracted and prevented. Which state ments should the nurse include when teaching about HPV? SELECT ALL THAT APPLY. 1. HPV can be contracted by oral sex. 2. HPV can be contracted on the toilet seat. 3. HPV is so common that most people can get it soon after becoming sexually active. 4. HPV is contracted through vaginal sex. 5. HPV is contracted through anal sex. 6. Condom use can fully protect against contracting the HPV virus.

1121. A school nurse is presenting the latest infor mation related to driving under the influence (DUI) of alcohol to high school students. The nurse in forms the students that all 50 states and the District of Columbia have laws defining it as a crime to drive with a blood alcohol concentration (BAC) at or above a prescribed level of: 1. 0.1%. 2. 1.0%. 3. 0.08%. 4. 0.8%.

1122. The American Academy of Pediatrics lists safety tips for adolescents who drive a motor vehi cle. When teaching a group of parents with teenagers, which statement should a nurse include in the teaching?. 1. Nighttime driving is okay as long as the teenager is not fatigued. 2. A lack of experience will motivate the teenager to want to practice driving longer. 3. Transportation of other teenagers by a teenage driver should be avoided. 4. Although teenagers tend to use safety belts, reminders are always important.

1123. A 4-year-old child is hospitalized with a high fever. While the child is in bed, the child comforts himself by sucking the thumb. The mother of the child be comes concerned because her child has not sucked his thumb for 6 months. Which nursing response to the mother’s concerns is most appropriate?. 1. “I don’t know why he is sucking his thumb; maybe your child just needs more attention.”. 2. “This is a form of developmental regression and can be a normal response for a child who is hospitalized. Continue to love and support your child.”. 3. “Is there anything else going on in your family right now that may be causing your child to feel anxious?”. 4. “Where is the child’s father? Maybe the child wants his father?”.

1124. A pediatric nurse is to perform a head-to-toe as sessment on a toddler who is admitted to a hospi tal for nausea and vomiting. Which is most impor tant for the nurse to consider before beginning the examination?. 1. Making sure the parents are present. 2. Using a firm tone to settle the child down for the examination. 3. Waiting until the child is ready to cooperate. 4. Preparing for a physical examination based on the child’s developmental age.

1125. A nurse is assessing an infant for attachment behav ior with a parent. Which observations are important in assessing this relationship? SELECT ALL THAT APPLY. 1. The kind of body contact between the parent and infant. 2. If the parent is holding and cuddling the infant. 3. The kind of comfort techniques being used by the parent. 4. The comfort level of the parent while interacting with the baby. 5. Whether the infant is crying.

1126. A nurse is preparing to consult with an adolescent being seen in a clinic. Which principle is most im portant for the nurse to consider when interacting with the client?. 1. Avoid a straightforward approach because adolescents cannot fully process their health needs. 2. Reassure the teenager that it is unnecessary to answer all questions; however, before the examination is complete the client will need to provide all information. 3. Avoid conveying surprise over comments made by the client. 4. Because adolescents want to be treated as adults, the same cognitive information should be provided as if they were an adult.

1127. A nurse in a clinic is caring for a 16-year-old mother and her baby. The mother seems anxious about her new role as a mother. She looks at the nurse and says, “I don’t think I can do this.” What are some conclusions that the nurse might make about this situation? SELECT ALL THAT APPLY. 1. There may be a concern for postpartum depression. 2. This mother may be at risk for abandoning her baby. 3. An intervention could be providing information for the nearest safe house for the baby. 4. The mother should have been taught how to deal with this situation in prenatal classes. 5. The mother should be encouraged to give up the infant for adoption.

1128. A nurse is performing a physical assessment of a pediatric client. While auscultating the heart, the nurse hears physiological splitting of S2 when the child takes a deep breath. Which action should be taken by the nurse?. 1. Notify the provider of suspected atrial-septal defect. 2. Notify the provider of suspected pulmonary stenosis. 3. Follow institutional policy for initiating an emergency response. 4. Document the findings as a normal finding.

1129. A nurse assesses the pain level of a Native American pediatric client recovering from cardiac surgery. Knowing that Native American pediatric clients may not express pain, the nurse reviews the child’s pulse and blood pressure readings following anal gesic administration. Which finding should indicate to the nurse that the client’s pain is not well-controlled?. 1. Decreased heart rate and decreased blood pressure. 2. Increased heart rate and increased blood pressure. 3. Increased heart rate and decreased blood pressure. 4. Decreased heart rate and increased blood pressure.

1130. An emergency department nurse is assessing a pedi atric client suspected of having acute pericarditis. Which assessment finding should the nurse con clude supports the diagnosis of acute pericarditis?. 1. Bilateral lower extremity pain. 2. Pain on expiration. 3. Pleural friction rub. 4. Pericardial friction rub.

1131. A new nurse is managing the care of a pediatric client preparing for a cardiac catheterization under the supervision of an experienced nurse. Which factor identified by the new nurse demonstrates an understanding of the information that can be col lected during cardiac catheterization? SELECT ALL THAT APPLY. 1. Oxygen saturation of blood within the chambers and great vessels. 2. Pressure of blood flow within the heart chambers. 3. Cardiac output (CO). 4. Anatomic abnormalities. 5. Ankle brachial index (ABI). 6. Ejection fraction.

1132. A nurse is interpreting an ECG rhythm strip for a 2-year-old child with heart failure secondary to a congenital heart defect. In analyzing the rhythm, the nurse notes the measurements of PR interval is 0.26 seconds, the QRS is 0.08 seconds, and the QT is 0.28. The ventricular rate is 126 bpm. A nurse interprets the rhythm as: 1. sinus bradycardia. 2. sinus rhythm with a bundle branch block. 3. sinus rhythm with a first-degree AV block. 4. sinus tachycardia with a first-degree AV block.

1133. A nurse is caring for a pediatric client who has con gestive heart failure (CHF). The client is receiving digoxin therapy. Which laboratory test result is most important to evaluate when preparing to administer digoxin?. 1. Serum potassium levels. 2. Serum magnesium levels. 3. Serum sodium levels. 4. Serum chloride levels.

1134. A nurse is caring for a pediatric client re cently diagnosed with hypertension. Which diag nostic tests should the nurse anticipate being or dered for this client? SELECT ALL THAT APPLY. 1. Complete blood count (CBC). 2. Serum chemistry. 3. Renal ultrasound. 4. Drug screen. 5. Glucose tolerance test (GTT).

1135. A nurse is preparing to perform an electrocardio gram (ECG) on several pediatric clients. Which client would not benefit from an ECG?. 1. A 4-year-old with tachycardia. 2. A 3-year-old with bradycardia. 3. A 10-year-old with an irregular pulse. 4. An infant with a splitting of the S2 heart sound only when the infant takes a deep breath.

1136.Which method should a nurse use to assess the arterial oxygen saturation of a pediatric client?. 1. Finger pulse oximetry. 2. Arterial blood gases. 3. Hemoglobin levels. 4. Peak flow.

1137. A nurse documented a nursing outcome of oxygen saturation (SaO2) greater than 95% for a pediatric client diagnosed with heart failure. When the nurse obtains a SaO2 value of 90%, the nurse determines that the outcome was not achieved and intervenes by administering oxygen. The nurse’s intervention is based on the nurse’s knowledge that the 90% SaO2 value indicates a PaO2 value of: 1. 40 mm Hg. 2. 60 mm Hg. 3. 80 mm Hg. 4. 90 mm Hg.

1138. A school nurse is educating school-aged chil dren on modifiable risk factors for coronary artery disease (CAD). Which modifiable risk factors should the nurse include in the presentation? SELECT ALL THAT APPLY. 1. Diabetes mellitus. 2. Hypertension. 3. Age. 4. Family history. 5. Sedentary lifestyle. 6. Obesity.

1139.A nurse is taking a history on an adolescent client who has a new onset of hypertension. The nurse is aware that a history of substance abuse may con tribute to this condition and questions the adoles cent. Which abused substances acknowledged by the adolescent could contribute to hypertension? SELECT ALL THAT APPLY. 1.Amphetamines. 2.Cocaine. 3.Hallucinogens. 4.Alcohol. 5.Ecstasy. 6.Marijuana.

1140.A nurse is educating the parents of a pediatric client with a cardiovascular disorder in preparation for home electrocardiogram (ECG) monitoring. The nurse uses a picture to explain the different compo nents of a normal ECG tracing. Place an X on the illustration where the nurse should be pointing when explaining repolarization of the ventricles.

1141. A nurse is caring for a pediatric client immediately following a permanent pacemaker placement. Which intervention should be the nurse’s first prior ity for this client?. 1. Initiate continuous electrocardiogram (ECG) monitoring. 2. Administer only non-narcotic analgesic medications to avoiding masking signs and symptoms of complications. 3. Transport the child to the radiology department for a chest x-ray. 4. Administer antibiotic therapy to prevent infection.

142. The parents of a pediatric client report that their child is experiencing palpitations, dizziness, di aphoresis, and chest pain. The client is diagnosed with supraventricular tachycardia (SVT). A nurse instructs the parents on techniques to reverse future episodes of SVT. Which technique stated by a par ent indicates further teaching is needed?. 1. Wrap the child’s head with a cold, wet towel. 2. Massage the child’s carotid arteries bilaterally. 3. Have the child perform the Valsalva’s maneuver. 4. Administer medications after taking the child’s pulse for 1 full minute.

143. A nurse is taking the health and social his tory of an adolescent client experiencing episodes of palpitations. Which components of the social history could contribute to the palpitations? SELECT ALL THAT APPLY. 1. Alcohol intake. 2. Sexual history. 3. Nicotine use. 4. Caffeine intake. 5. A sports injury to the chest.

1144. A hospitalized preterm infant diagnosed with tetral ogy of Fallot is experiencing a hypercyanotic spell. Which actions should be taken by the nurse? SELECT ALL THAT APPLY. 1. Place the infant in a knee-chest position. 2. Administer 2 L of oxygen via nasal cannula. 3. Administer intramuscular morphine sulphate. 4. Use a calm and comforting approach. 5. Administer oral propranolol (Inderal®). 6. Prepare for emergency surgery.

1145. A nurse is using a picture to educate the parents of a child with a congenital murmur about the etiology of the condition. The nurse demonstrates the loca tion of the tricuspid valve. Place an X on the valve that the nurse is locating for the child’s parents.

1146. A nurse is managing the care of an infant with an unrepaired heart defect. Which health pro motion strategy should the nurse recommend to the parent in planning for discharge?. 1. Vaccinate against the respiratory syncytial virus (RSV) monthly during the RSV season. 2. Restrict the child’s level of physical activity. 3. Encourage weight loss by restricting caloric intake. 4. Delay immunizations as the child’s immune system may be too impaired.

1147. A pediatric nurse is providing discharge instructions to the parents of an infant with a history of hypox emia. The nurse teaches the parents about the signs and symptoms associated with hypoxemia. Which signs or symptoms should prompt the parents to no tify the practitioner immediately?. 1. Weight loss or gain. 2. Excessive crying. 3. Dehydration and respiratory infection. 4. Not achieving developmental milestones.

1148.A nurse is managing the care of a pediatric client in congestive heart failure (CHF). Which medically delegated interventions should be included in the care of the client? SELECT ALL THAT APPLY. 1. Oral positive inotropic agents. 2. Diuretics. 3. ACE inhibitors. 4. Hypolipidemic agents. 5. Oral positive chronotropic agents. 6. Beta blockers.

1149. A nurse is planning the care of a pediatric client with congenital heart disease. For which specific complications related to congenital heart disease should the nurse plan to monitor the client?. 1. Congestive heart failure and pulmonary hypotension. 2. Congestive heart failure and hypoxemia. 3. Hypoxemia and pulmonary hypotension. 4. Pulmonary hypotension and cyanosis.

1150. A pediatric client presents with tachycardia, edema, dyspnea, orthopnea, and crackles. A nurse performs a physical assessment of the client and notifies a physician immediately. Which condition does the nurse most likely suspect?. 1. Right-sided heart failure. 2. Rheumatic fever. 3. Kawasaki disease. 4. Left-sided heart failure.

1151. A nurse is providing discharge teaching to the parents of a pediatric client following cardiac sur gery. Which information should the nurse include in the discharge teaching? SELECT ALL THAT APPLY. 1. Action and side effects of medications. 2. Care of the incision and circumstances in which to contact the health-care provider. 3. Activity restrictions and follow-up appointments. 4. Age-appropriate diet with vitamin C to promote wound healing. 5. Prevention of pericarditis following dental procedures and prophylactic antibiotic use.

1152. A pediatric nurse evaluates that a nursing assistant knows emergency procedures when the nursing as sistant activated the emergency response system for a 6-year-old child admitted with a diagnosis of heart failure. The sign observed by the nurse indicating that lifesaving measures were necessary likely was: 1. gagging. 2. coughing. 3. inability to speak. 4. heart rate of 125 bpm.

1153. A nurse is suctioning a pediatric client who has just had cardiac surgery. The nurse observes tachypnea, the use of accessory muscles to breathe, and rest lessness. Which action should be taken by the nurse?. 1. Continue suctioning, as these are expected during the procedure. 2. Continue suctioning, but monitor closely as these could be signs of distress. 3. Discontinue suctioning, carefully monitor the client, and notify the physician immediately. 4. Discontinue suctioning and notify the physician to insert a chest tube.

1154. The parent of a child diagnosed with rheumatic heart disease questions the nurse following the doctor’s statement that the child has a heart mur mur. The nurse explains that a heart murmur is an abnormal or extra heart sound produced by which malfunctioning structure of the heart?. 1. Heart valve. 2. Heart vessel. 3. Heart chamber. 4. Heart conduction.

1155. A nurse is caring for a child who has liver en largement secondary to infectious endocarditis. For which associated cardiac condition should the nurse assess the client?. 1. Dysrhythmia. 2. Right-sided heart failure. 3. Myocardial infarction (MI). 4. Tetralogy of Fallot.

1156. A school nurse assesses a child who was stung by an insect and is beginning to exhibit signs of dis tress. The nurse is aware of the child’s severe al lergy to bee stings and immediately contacts emer gency medical services (EMS). Which assessment finding reported to the EMS personnel should be questioned?. 1. Signs of airway obstruction. 2. Bronchospasm. 3. Hypertension. 4. Weak thready pulse.

1157. A nurse arrives at a local park to find a group of people surrounding a pediatric victim. Witnesses report the child collapsed just seconds ago. The child is not breathing and is without a pulse. While another person dials for emergency assistance, the nurse prepares to initiate single rescuer CPR. Which compression-to-ventilation ratio should be used by the nurse?. 1.30:2. 2.15:2. 3.30:1. 4.15:1.

1158.An emergency department nurse receives a pediatric client who has just been in ventricular fibrillation (VF) and has been defibrillated. The nurse is in formed that the child is currently in normal sinus rhythm (NSR) with a blood pressure of 95/51. Which action should be taken by the nurse?. 1.Carefully assess the child’s cardiac status. 2.Prepare for cardioversion. 3.Begin CPR. 4.Prepare the client for transfer to the pediatric unit.

1159.A nurse receives an order to administer oral digoxin 10 micrograms/kilogram (mcg/kg) to a full-term in fant. Knowing that the infant weighs 8 lbs, the nurse carefully calculates the dosage and adminis ters _______mcg oral digoxin.

1160. A nurse receives an order to administer digoxin to a 6-year-old child. Prior to administering the medica tion, the nurse reviews the child’s laboratory report. Which laboratory value should concern the nurse and be reported to the physician?. 1. K 3.2 mEq/L. 2. Hgb 10 g/dL. 3. Digoxin level 1.8 ng/mL. 4. Creatinine 0.3 mg/dL.

1161. Before administering oral digoxin (Lanoxin®) to a pediatric client, a nurse notes that the child has bradycardia and mild vomiting. Which is the nurse’s most appropriate action?. 1. Explain to the parent that bradycardia is an expected effect of the digoxin. 2. Administer the medication, document the observations, and reevaluate after the next dose. 3. Withhold the medication and immediately notify the prescriber because these are signs of toxicity. 4. Administer an oral beta-blocker medication.

1162. A sexually active female adolescent has been diag nosed with hyperlipidemia. After several months of lifestyle changes, the levels have not significantly decreased, and a statin medication is prescribed. A nurse is educating the client about this class of medications. Which instruction should be included in the nurse’s teaching plan for this client?. 1. Discontinue therapy and contact the prescriber if having new-onset muscle aches or dark urine. 2. Continue therapy even if she becomes pregnant. 3. Take the medication in the morning because it would be most effective. 4. Discontinue lifestyle modifications because these are ineffective in treating the condition.

1163. A nurse is administering medications to a pediatric client with hypertension. Which oral antihyperten sive medication ordered for a child should the nurse question?. 1. ACE inhibitor. 2. Calcium channel blocker. 3. Diuretic. 4. Nitrate.

1164. A 12-year-old child’s medication regimen for treating type 1 diabetes mellitus is changed from administering NPH and rapid-acting insulin to a basal-bolus insulin regimen. To achieve tight glu cose control and for therapy to be effective, the nurse should instruct that the child and/or parent to: SELECT ALL THAT APPLY. 1. administer a once daily dose of a long-acting insulin such as glargine (Lantus®). 2. administer rapid-acting insulin such as aspart (NovoLog®) with each meal and snack based on the carbohydrate grams consumed. 3. administer extra rapid-acting insulin when the amount of the child’s daily exercise increases. 4. consistently count the amount of carbohydrates the child consumes throughout the day. 5. monitor the child’s blood glucose four to eight times a day. 6. monitor the child’s blood glucose at midnight and 3 a.m. once a week.

1165. A nurse understands that to modify the risk for early cardiovascular disease in children diag nosed with type 1 diabetes mellitus a child should: 1. exercise at least 30 minutes every day. 2. eat a diet that is low in fat and high in protein. 3. maintain optimal management of blood sugar levels. 4. have a cardiac workup at each visit for the diabetes.

1166. A 9-year-old child with a history of type 1 diabetes mellitus for the past 6 years is admitted with a diag nosis of diabetic ketoacidosis (DKA). In preparing for the child’s arrival to the nursing unit, the nurse should prepare to: 1. add sodium bicarbonate to the current IV fluids. 2. add potassium chloride to the current IV fluids. 3. use either 0.9% or 0.45% saline for the base IV fluid. 4. administer insulin by subcutaneous injection.

1167. A pediatric nurse is administering metformin (Glucophage®) to a child at risk for developing type 2 diabetes mellitus. The nurse understands that an important use of metformin in children is to: 1. delay the development of type 2 diabetes mellitus in high-risk children. 2. restore fertility in adolescent females. 3. reduce blood sugars in children who have type 1 diabetes mellitus. 4. restore renal function in children who have type 1 diabetes mellitus.

1168. The parents of a 7-year-old child diagnosed with type 1 diabetes mellitus are planning to drive 1,200 miles for a vacation at the beach. They question the nurse about insulin storage for the trip. Which re sponse by the nurse is most accurate?. 1. “Because insulin must be refrigerated, you will need to obtain the medication from a pharmacy at your destination.”. 2. “Freeze the insulin before you leave home and take it in a cooler; it should be thawed by the time you get to the beach.”. 3. “Keep the insulin in a cooler with an ice pack and out of direct heat and sunlight for the trip. Store unopened insulin in the refrigerator at your destination.”. 4. “Because it is illegal to transport needles and syringes across most state lines, you will need to obtain a prescription from your doctor and purchase the insulin and the syringes at your destination.”.

1169. A nurse explains to a parent who has a child with type 1 diabetes mellitus that the most important rea son for counting the child’s grams of carbohydrate intake is to: 1. lower blood glucose levels. 2. supply energy for growth and development. 3. provide consistent glucose to prevent hypoglycemia. 4. attain metabolic control of glucose and lipid levels.

1170. An adolescent client is taught how to use a contin uous subcutaneous insulin infusion pump for tight glucose control of type 1 diabetes mellitus. Which statement by the client indicates the need for addi tional teaching?. 1. “I can put in the number of carbohydrates that I consume, and the insulin pump will calculate the bolus insulin dose that I will receive.”. 2. “I must still check my blood glucose levels with meals and snacks and calculate the amount of carbohydrates I consume to ensure I get the correct bolus dose of insulin.”. 3. “As my blood glucose control improves with the use of the insulin pump, I should see a drop in the weight that I have gained.”. 4. “Every 2 to 4 days, I will need to change the syringe, catheter, and site moving the site away at least 1 inch from the last site.”.

1171. A 10-year-old child with a 6-year history of type 1 diabetes mellitus has been seen in a clinic for enuresis over the past 2 weeks. Which conclusion by the nurse regarding the likely cause of the enure sis is correct?. 1. Sustained blood sugar levels lower than normal. 2. Acquired adrenocortical hyperfunction. 3. Sustained blood sugar levels higher than normal. 4. Acquired syndrome of inappropriate antidiuretic hormone (SIADH).

1172. Which laboratory test results should a nurse moni tor in evaluating the long-term success of a child’s control of type 1 diabetes mellitus?. 1. Hemoglobin A1c levels. 2. Blood insulin levels. 3. Blood glucose levels. 4. Urinary glucose levels.

1173. A child with a history of type 1 diabetes mellitus presents in the school nurse’s office about an hour before the lunch period reporting disorientation. Which information is most important for the nurse to obtain?. 1. Blood sugar. 2. Temperature. 3. Morning insulin dose. 4. Urine ketones.

1174. The mother of a 12-year-old child diagnosed with type 1 diabetes mellitus asks a nurse what changes in the daily routine should be made during atten dance at summer camp. The child will be at camp for 4 weeks. Which is the best response by the nurse?. 1. “The child will have an increased need for insulin due to the high carbohydrate content of camp food.”. 2. “The child’s food intake should be decreased by 10% while the insulin should be increased by 10%.”. 3. “The child’s food intake should be increased as activity increases; monitor blood glucose levels three to four times a day to evaluate results.”. 4. “The child’s insulin injection should be given before every meal and snack to ensure that the food being consumed at camp can be utilized by the body.”.

1175. A health-care provider prescribes for an 8-year-old child to receive 1 unit of aspart insulin for every 15 grams of carbohydrates consumed at mealtime. Additionally, the client is to receive insulin per the sliding scale insulin as noted below. The 8-year-old child’s fingerstick blood glucose before breakfast is 82, and the child ate 30 grams of carbohydrates at breakfast. Based on this information and the sliding scale below, the nurse should administer ______ unit(s) to the child.

1176. A nursing assistant reports to a nurse that a 4-year-old child diagnosed with type 1 diabetes consumed 1/2 cup of oatmeal, 60 mL of orange juice, and 60 mL of milk for breakfast. The child’s blood glucose was 150 mg/dL before breakfast, and the child did not receive insulin before breakfast. The nurse should conclude that: SELECT ALL THAT APPLY. 1. the total volume of fluid intake should be recorded as 120 mL. 2. insulin will need to be administered to cover for the carbohydrates eaten. 3. insulin will not be needed because the child’s blood glucose was normal before breakfast. 4. a double-check of the amounts of carbohydrate eaten is needed before administering insulin. 5. the child should have received insulin before breakfast because the blood sugar is elevated.

1177. A health-care provider prescribes glucagon 0.5 mg subcutaneously for a client with type 1 diabetes mellitus. A nurse determines that glucagon is used to treat: 1. hypoglycemia resulting from too little food intake. 2. hyperglycemia resulting from too much food intake. 3. hypoglycemia resulting from too much insulin intake. 4. hyperglycemia resulting from too little insulin intake.

1178. A child’s parents inform a nurse about how they care for their 12-year-old child with type 1 dia betes mellitus, including sick day management, treating hyperglycemia, and managing ketosis. In which situation could the parents safely manage the child’s care at home?. 1. Child’s blood glucose level is 280 mg/dL; skin turgor very poor; lips and mouth parched. 2. Child’s blood glucose level is 250 mg/dL; vomiting and dizziness; complains of double vision. 3. Child’s blood glucose level is 240 mg/dL; large amounts of urine output decreasing to 100 mL total output for the last 8 hours. 4. Child’s blood glucose level is 300 mg/dL; urine tested positive for ketones; skin is hot, flushed, and dry.

1179. An infant diagnosed with hypothyroidism is pre scribed levothyroxine sodium (Synthroid®). Which independent nursing intervention would assist the nurse in evaluating the effectiveness of this medication?. 1. Monthly assessments of growth and development. 2. Monthly serum calcium and thyroxin levels. 3. Bimonthly catecholamine levels and electrocardiogram (ECG). 4. Absence of thyroid excess.

1180. A child is admitted in thyrotoxic crisis. Which man ifestations should a nurse expect to observe during assessment? SELECT ALL THAT APPLY. 1. Delirium. 2. Hypothermia. 3. Bradycardia. 4. Nausea. 5. Vomiting.

1181. A nurse is educating the parents of a school-aged child newly diagnosed with hyperthyroidism. Until the disease is under control, which instruction should be included in the education provided by the nurse?. 1. Discontinue physical education classes at school. 2. Increase stimulation in the school environment. 3. Restrict the number of calories from carbohydrate foods. 4. Dress your child in cold weather clothing even in warm weather.