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NCLEX Question Trainer Test 6
Terms in this set (200)
The nurse returns to the nurse's station after making client rounds and finds four phone messages. Which of the following messages should the nurse return FIRST?
1. A client with hepatitis A who states, "My arms and legs are itching."
2. A client with a cast on the right leg who states, "I have a funny feeling in my right leg."
3. A client with osteomyelitis of the spine who states, "I am so nauseated that I can't eat."
4. A client with arthritis who states, "I am having trouble sleeping at night."
Following total hip arthroplasty, an elderly client is ordered to begin ambulation with a walker. Which of the following statements by the nurse is BEST?
1. "Sit in a low chair for ease in getting up to use the walker."
2. "Make sure rubber caps are in place on all four legs of the walker."
3. "You will begin weight bearing on the affected hip soon."
4. "Practice tying your own shoes before you begin ambulating."
A client comes to the hospital at term in the early stages of labor. A diagnosis of complete placenta previa is made. It is MOST important for the nurse to take which of the following actions?
1. Start an IV of terbutaline (Brethine) and monitor the patient's vital signs closely.
2. Prepare the patient for an immediate cesarean section.
3. Maintain the patient on bedrest until spontaneous vaginal delivery is achieved.
4. Monitor the patient's length and duration of contractions.
Which of the following nursing observations indicates to the nurse that a child diagnosed with epiglottitis is having an early complication of hypoxemia?
1. Heart rate of 148 beats per minute (bpm).
2. Bluish discoloration of the skin.
3. Bluish discoloration around the mouth.
4. Difficulty swallowing.
After stabilizing a client with severe multiple trauma injuries from a motor vehicle accident, which of the following actions by the nurse is BEST?
1. Limit visiting hours to promote optimal rest.
2. Arrange for clergy to visit with the client and family as requested.
3. Arrange for a psychologist to visit with the family.
4. Arrange for the family to meet with a social worker to discuss financial aid.
The nurse's aide comes to take a client by wheelchair for a magnetic resonance imaging (MRI) scan of the head and neck. Which of the following observations, if made by the nurse, requires an intervention?
1. The client removes her dentures and gives them to her spouse.
2. The client's vital signs are BP 120/70, pulse 80, respirations 12, temperature 99°F (37.3°C).
3. The client has a nitroglycerine patch on the right chest area.
4. The client has red nail polish on both fingers and toes.
The neonatal nurse instructs the family of a newborn about an apnea monitor. The nurse is MOST concerned if a family member makes which of the following statements?
1. "We will be able to leave our baby for brief periods of time."
2. "We plan to sleep by our baby's crib."
3. "We can remove the monitor during our baby's bath."
4. "A family member will closely watch the monitor all the time."
A client has a cast applied for a fracture of the right femur. Three hours later, the client complains that it is hot and painful under the cast. Which of the following is the MOST appropriate action for the nurse to take?
1. Assess the cast for wet spots, and increase air circulation in the room.
2. Check the circulation in the casted extremity, and change the client's position.
3. Take the client's temperature, and observe for other signs of infection.
4. Medicate the client for pain, and notify the physician of his complaint.
A client is admitted to the hospital with dry mucous membranes and decreased skin turgor. The client's vital signs are BP 120/70, temperature 101°F (38.3°C), pulse 88, respirations 14. Laboratory tests indicate the serum sodium is 150 mEq/L and the Hct is 48%. The nurse expects the physician to order which of the following IV fluids?
2. 0.45% NaCl.
3. 0.9% NaCl.
4. Lactated Ringer's.
Which of the following plans is MOST appropriate for the nurse to use to prepare a 10-year-old for a cardiac catheterization?
1. Show a videotape specifically prepared for children about cardiac catheterization.
2. Provide the child with a pamphlet about the procedure, and encourage him to read it.
3. Draw a picture of a heart, and explain where the tube will go and what the doctor will see.
4. Present a puppet show explaining the anatomy and physiology of the heart.
The nurse cares for a client complaining of moderate pain. Which of the following nursing actions is MOST important to provide the patient with effective pain relief?
1. Teach the patient about the pain.
2. Establish a trusting relationship with the patient.
3. Determine how various relaxation techniques affect the pain.
4. Provide alternative measures to relieve pain
A client diagnosed with a necrotizing spider bite is to perform dressing changes at home. The nurse determines which of the following statements, if made by the client, indicates a correct understanding of aseptic technique?
1. "I need to buy sterile gloves to redress this wound."
2. "I should wash my hands before redressing my wound."
3. "I should keep the wound covered at all times."
4. "I should use an over-the-counter antimicrobial ointment."
An adult client is admitted to an acute locked psychiatric unit one month prior to an election. The client requests the opportunity to vote in the upcoming election. Which of the following responses by the nurse is BEST?
1. "You are not eligible to vote because you are a psychiatric patient."
2. "I'll make the appropriate arrangements for you to vote."
3. "You may vote only if you are discharged by Election Day."
4. "I'll contact the Election Board to see if you are registered to vote."
The nurse administers sublingual nitroglycerin (Nitrostat) to a client complaining of chest pain. Which of the following observations is MOST important for the nurse to report to the next shift?
1. The client indicates the need to use the bathroom.
2. Blood pressure has decreased from 140/80 to 90/60.
3. Respiratory rate has increased from 16 to 24.
4. The client indicates that the chest pain has subsided.
One of the goals the nurse and a client diagnosed with posttraumatic stress disorder (PTSD) mutually agreed upon is that the client will increase participation in out-of-the apartment activities. Which of the following recommendations, if made by the nurse, is MOST therapeutic to achieve this goal?
1. Take a day trip with a friend.
2. Take an 11-minute bus ride alone.
3. Join a support group, and participate in a victim assistance organization.
4. Take a 10-minute walk with the spouse around the block.
A client is scheduled for a traditional abdominal cholecystectomy. Which of the following statements, if made by the nurse to the client the night before surgery, is MOST important?
1. "It is important for you to eat foods from every level of the food pyramid and avoid excessive fats in your diet."
2. "Place the pillow against your abdomen, take three deep breaths, hold your breath, and then cough two or three times."
3. "There will be a machine available to you after surgery for you to use to continuously receive pain medication."
4. "You may come back from surgery with a tube in your nose that drains your gallbladder."
A mother of a 4-year-old boy comes to the prenatal clinic to confirm her second pregnancy. During the initial visit, it is MOST important for the nurse to take which of the following actions?
1. Assess the client's feelings about pregnancy, labor, and delivery.
2. Obtain a history of the client's last labor and delivery.
3. Determine how the client's 4-year-old feels about the pregnancy.
4. Identify the client's general health needs.
The nurse prepares the client for a skin biopsy. Which of the following client statements should the nurse report to the physician?
1. "I've been taking aspirin for my sore knees."
2. "Using lotion has helped my dry skin."
3. "I went to the tanning salon yesterday."
4. "I had a big breakfast this morning."
The nurse cares for a client diagnosed with a perforated bowel secondary to a bowel obstruction. At the time the diagnosis is made, which of the following should be a priority in the nursing care plan?
1. Maintain the client in a supine position.
2. Notify the client's next of kin.
3. Prepare the client for emergency surgery.
4. Remove the nasogastric tube.
The doctor writes an order for piperacillin (Pipracil) 3 g IV q6h for an adult client. Before administering this drug, the nurse should take which of the following actions?
1. Check for known allergies to medications.
2. Ensure that the client's respiratory rate is over 12.
3. Administer dexamethasone sodium phosphate (Decadron) 2 mg IV stat.
4. Check the client's blood pressure both sitting and standing.
A mother brings her 17-month-old son to the well-baby clinic for a routine checkup. She confides to the nurse that she is concerned because her son sucks his thumb, especially at night when he is put to bed. Which of the suggestions by the nurse is BEST?
1. "If you want the behavior to stop, put a negative reinforcer, such as red pepper, on his thumb."
2. "Don't intervene at this time. This behavior usually subsides after 24 months of age."
3. "What you are seeing is a common form of self-stimulation. You should discourage this behavior."
4. "This behavior will cause malformation of his teeth. You should wrap his thumb at bedtime."
The nurse cares for clients in the outpatient clinic. A young adult female is seeking help for weight loss. The client's weight is 257 pounds, and the client is 5'7". Which of the following indicates the MOST appropriate diet choices for breakfast?
1. Applesauce, cream of wheat, toast.
2. Scrambled eggs and toast, one slice of bacon.
3. One glass of grapefruit juice.
4. Bagel with two ounces of cream cheese and a banana.
A toddler admitted with an elevated blood lead level is to be treated with intramuscular (IM) injections of calcium disodium edetate (Calcium EDTA) and dimercaprol (BAL). Which of the following nursing actions has the highest priority?
1. Keep a tongue blade at the bedside.
2. Encourage the child to participate in play therapy.
3. Apply cool soaks to the injection site.
4. Rotate the injection sites.
The nurse instructs a client being discharged on tranylcypromine sulfate (Parnate). The nurse determines further teaching is needed if the client makes which of the following statements?
1. "To celebrate, my wife and I are going out for pepperoni pizza and wine tonight."
2. "I plan to use sunblock at the beach this summer."
3. "When I get home, I am going to start a diet so that I can lose some weight."
4. "Now that I feel so much better, I have more energy."
The triage nurse for a women's health center receives a phone call from each of the following women. The nurse should direct which of the following women to come to the health care facility IMMEDIATELY?
1. A multipara woman at four weeks' gestation reporting unilateral, dull abdominal pain.
2. A primigravida woman at five weeks' gestation having vaginal spotting and some cramping.
3. A multigravida woman at six weeks' gestation reporting frank, red vaginal bleeding with moderate cramps.
4. A primipara woman at seven weeks' gestation reporting an increase in whitish vaginal secretions.
A client has just been admitted after sustaining a second-degree thermal injury to the right arm. Which of the following nursing observations is MOST important to report to the doctor?
1. Pain around the periphery of the injury.
2. Gastric pH less than 5.0.
3. Increased edema of the right arm.
4. An elevated hematocrit.
A college student was in a motor vehicle accident six months ago. Although the client was minimally injured, a friend was killed. The client comes to Student Health Services with the complaints of not being able to study, not sleeping, and thinking he's "going crazy." Which of the following actions by the nurse is MOST important?
1. Perform a complete physical and social history.
2. Obtain a complete drug and alcohol history, including reports from a drug screen.
3. Review the significant events of the last year.
4. Explore how he coped with the motor vehicle crash and his friend's death.
A urinalysis is obtained from a client complaining of dysuria, urinary frequency, and discomfort in the suprapubic area. After evaluating the results, the nurse should order a repeat urinalysis based on which of the following findings?
1. Negative glucose.
2. RBCs present.
3. No WBCs or RBCs reported.
4. Specific gravity 1.018.
To minimize the side effects of a DPT immunization for a 6-month-old, the nurse should instruct the parents to take which of the following actions?
1. Give the child an alcohol bath for an elevated temperature.
2. Administer antipyretics for discomfort, irritability, and fever.
3. Place an ice bag on the child's leg for 1 hour.
4. Check the child's temperature every four hours for three days.
The clinic nurse observes that a 10-year-old child with leukemia has a large burn on her arm and the burn appears to be oily. The child tells the nurse that she touched a hot pan, and her mother put cooking fat on it so that it would not blister. Which of the following actions should the nurse take FIRST?
1. Document the findings in the chart.
2. Call the physician immediately to report the injury.
3. Teach the client that oil holds germs and makes infection more likely.
4. Wash the burn with soap and water to remove the oil.
The nurse instructs a client about how to perform self-monitoring blood glucose (SMBG) using a blood glucose monitor. Which of the following actions, if performed by the client, indicates to the nurse the need for further teaching?
1. The client dangles the hand before sticking the finger with the lancet.
2. The client sticks the finger on the side of the distal phalanx.
3. The client touches the strip with a large drop of blood hanging from the fingertip.
4. The client milks the finger after sticking it.
A client receives nifedipine (Procardia) tid, and the nurse notes the client's pulse is 50. Which of the following nursing actions is MOST appropriate?
1. Withhold the medication.
2. Check the urinary output.
3. Administer the medication.
4. Increase the potassium intake.
A multipara comes to the prenatal clinic during her fifth month of pregnancy. The client complains to the nurse that her breasts are sensitive and sore. Which of the following suggestions by the nurse is BEST?
1. "Apply warm compresses to your breasts, and take two aspirin as needed."
2. "Massage your breasts with lotion, and wear loose-fitting clothing."
3. "Apply cold compresses to your breasts, and wear a well-fitting, supportive bra."
4. "Take a diuretic once a day, and avoid touching your breasts."
The nurse cares for a patient diagnosed with hyperparathyroidism. Which symptom is MOST important for the nurse to report to the next shift?
1. Abdominal discomfort.
3. Muscle weakness.
Two days after a client is admitted, a client's sputum culture is reported as positive for tuberculosis. While awaiting orders from the physician, the nurse should take which of the following actions?
1. Initiate measures to transfer the client to a tuberculosis unit.
2. Institute measures to initiate airborne precautions.
3. Arrange for all of the client's personal effects to be decontaminated.
4. Notify the client's family that they have been exposed to a contagious disease.
A nursing assistant is assigned to constant observation of a suicidal patient, and the nurse overhears the nursing assistant talking with the patient. Which of the following statements made by the nursing assistant requires IMMEDIATE intervention by the nurse?
1. "Let's put your clothes in the dresser."
2. "I'll stay in the bathroom with you while you take your shower."
3. "You're going to be moved to a private room later today."
4. "I'll be right back with something for you to eat."
The nurse obtains a history from a client just admitted to the unit. The client informs the nurse that any information shared with the nurse during the interview is to remain confidential. Which of the following responses by the nurse is BEST?
1. "I'll share any information you give me with staff members only with your approval."
2. "If the information you share is important to your care, I'll need to share it with the staff."
3. "We can keep the information just between the two of us."
4. "I have an obligation to maintain nurse/patient confidentiality about anything you tell me."
The nurse performs discharge teaching for a client diagnosed with multiple sclerosis. It is MOST important for the nurse to include which of the following instructions?
1. Ambulate as tolerated every day.
2. Avoid overexposure to heat or cold.
3. Perform stretching and strengthening exercises.
4. Participate in social activities.
A client is diagnosed with lung cancer and undergoes a pneumonectomy. In the immediate postoperative period, which of the following nursing assessments is MOST important?
1. Presence of breath sounds bilaterally.
2. Position of the trachea in the sternal notch.
3. Amount and consistency of sputum.
4. Increase in the pulse pressure.
After abdominal surgery, a client is admitted from the recovery room with intravenous fluid infusing at 100 ml/hour. One hour later, the nurse finds the clamp wide open and notes that the client has received 850 ml. The nurse is MOST concerned by which of the following?
1. A CVP reading of 12 and bradycardia.
2. Tachycardia and hypotension.
3. Dyspnea and oliguria.
4. Rales and tachycardia.
The nurse admits a client to the unit from the postoperative recovery area after abdominal exploratory surgery. After the nurse determines the client's vital signs, which of the following activities should the nurse perform NEXT?
1. Position the client on her left side, supported with pillows.
2. Check the chart, and determine the status of the fluid balance from surgery.
3. Check the client's abdominal dressing for any evidence of bleeding.
4. Monitor the incision and pulmonary status for the presence of infection.
A client comes to the local outpatient complaining of dizziness and palpitations. The physical exam and laboratory results are normal. The client reports the family-owned company is on the verge of bankruptcy. Which of the following responses, if made to the client by the nurse, is BEST?
1. "When did you first notice these symptoms?"
2. "Have you shared this information with anyone?"
3. "Are you concerned about your financial difficulties?"
4. "Would you like to discuss your situation with me?"
A client has a radical mastectomy for cancer of the right breast. After the client returns to the unit, which of the following actions, if performed by the nurse, is MOST appropriate?
1. Position the client on the left side with the right arm protected in a sling.
2. Position the client on the right side with the right arm elevated.
3. Position the client in semi-Fowler's position with the right arm elevated.
4. Position the client in the prone position with the right arm elevated.
When the nurse walks into a client's room, the client states, "I just love hot-blooded redheads." The client pats his bed and says, "Why don't you sit down here and get off your feet for a while." Which of the following responses by the nurse is BEST?
1. "I feel very uncomfortable when you make those suggestive remarks. It makes it difficult for me to do my job."
2. "I don't think my husband or your wife would like me doing that."
3. "You must be very lonesome. I'll come back later and spend some time with you."
4. "I bet you flirt with all the nurses like that."
The nurse answers the psychiatric unit's desk phone. The caller identifies himself as the spouse of a patient and inquires about the patient's condition. Which of the following responses by the nurse is MOST appropriate?
1. "I cannot deny or confirm any patient's presence in this hospital."
2. "Patients are not allowed to use this phone. Please call the patient's phone number directly."
3. "I cannot give information over the phone. If you come in, we can discuss her condition."
4. "I will have to ask her if she wishes for me to give out that information."
Several days after a client had a myocardial infarction, the physician places the client on a 2-gm sodium diet. Which of the following selections indicates to the nurse an understanding of the diet?
1. Scrambled egg, orange slices, and milk.
2. Instant oatmeal, toast, and orange juice.
3. Poached egg, bacon, and milk.
4. Biscuit, fruit cup, and sausage.
The nurse leads a class for expectant mothers. Which of the following comments indicate to the nurse that a pregnant woman understands the recommended dietary caloric increase for pregnancy?
1. "I will need to double my calorie intake because I am now eating for two."
2. "I can add an additional 500 calories by drinking milkshakes."
3. "I need to add 300 calories by increasing my intake of the basic food groups."
4. "I really need to watch my calorie intake so that I will not gain too much weight."
The nurse cares for a 17-year-old married male scheduled for a hernia repair. The nurse administers meperidine hydrochloride (Demerol) 50 mg and hydroxyzine pamoate (Vistaril) 25 mg IM. Thirty minutes later the nurse discovers that the informed consent is unsigned. Which of the following actions by the nurse is BEST?
1. Cancel the surgery.
2. Ask the client to sign the informed consent.
3. Notify the physician.
4. Ask the client's mother to sign the informed consent.
The nurse instructs a client receiving naproxen sodium (Anaprox) 250 mg enteric-coated tablets PO bid. Which response, if made by the client, indicates that the nurse's instruction about the medication is effective?
1. "I have a glass of wine with dinner."
2. "I should avoid milk and dairy products when I take this pill."
3. "I should call my doctor if my stools turn very dark."
4. "I don't like to take pills, so I will crush the pill and add it to some applesauce."
A client at 39 weeks' gestation in active labor screams, "I have to push, I have to push." The nurse notes that the client is 8 cm dilated. The nurse should take which of the following actions?
1. Instruct the client to take a deep breath and bear down.
2. Apply gentle but firm pressure to the client's abdomen.
3. Coach the client in relaxation techniques.
4. Tell the client to pant with pursed lips.
A client has an appendectomy for a ruptured appendix. The nurse observes a student nurse perform a wet-to-dry dressing change on the 2-inch incision. Which of the following behaviors, if performed by the student nurse, requires an intervention by the nurse?
1. The old dressing is saturated with sterile saline before it is removed.
2. Dry dressings are placed over the saline-saturated gauze in the incision.
3. Wound debris and necrotic tissue are removed with the old dressing.
4. The gauze is saturated with sterile saline before it is packed into the incision.
A client is presently employed as a night watchman. When the client comes to the clinic for a visit, the client complains of difficulty sleeping and fatigue. Which of the following responses by the nurse is BEST?
1. "Tell me about your usual sleeping habits."
2. "You probably sleep when you can during your night tour."
3. "This is normal for your age group."
4. "Working the night shift is known to disrupt sleep patterns."
Before administering calcium gluconate 10% 500 mg IV stat, it is MOST important that the nurse assess for which of the following?
1. Stability of the respiratory system.
2. Adequacy of urine output.
3. Patency of the vein.
4. Availability of magnesium sulfate injection.
An 18-month-old is brought by her parent to the well-baby clinic for a routine immunization. Just before the nurse gives the child the injection, the toddler begins to cry. Which of the following comments by the nurse is the MOST appropriate?
1. "Don't cry. It will be better if you try to behave."
2. "I know you are frightened. It will be over with soon."
3. "A big girl like you shouldn't cry. It's only going to hurt a little."
4. "Please stop crying. There is nothing to be afraid of."
A child admitted with failure to thrive has just had a positive sweat test. The nurse anticipates which of the following changes in the child's plan of care initially?
1. Administration of replacement enzymes.
2. Administration of oxygen.
3. A salt-restricted diet.
4. Initiate intravenous therapy.
The nurse plans discharge for a client who suffered a mild myocardial infarction (MI) and smokes one pack of cigarettes per day. Which of the following recommendations by the nurse is BEST?
1. Participate in a program such as nicotine avoidance.
2. Avoid aerobic physical activity.
3. Install a humidifier in the home heating system.
4. Strict adherence to a low-calorie, low-sodium, high-lipid diet.
The home care nurse visits an infant who had a myelomeningocele repair. The home care nurse determines the parents are accepting of their infant if which of the following is observed?
1. The parents state that the infant will outgrow this problem in time.
2. The parents ask a neighbor to perform bladder expression.
3. The parents measure the head circumference daily.
4. The parents relate that they believe the child will walk in 1 year.
A patient has a Sengstaken-Blakemore tube in place. The nurse enters the room and finds the patient in respiratory distress. Which of the following actions should the nurse take FIRST?
1. Notify the physician immediately to remove the tube.
2. Elevate the head of the bed, and administer oxygen.
3. Cut the balloon ports and remove the tube.
4. Call a code, and begin rescue breathing.
The nurse instructs a prenatal client about the importance of prenatal vitamins. It is MOST important for the nurse to include which of the following instructions?
1. "Take prenatal vitamins with orange juice at bedtime."
2. "Take the prenatal vitamins at breakfast with coffee."
3. "Take the prenatal vitamins with milk at lunch."
4. "Take the prenatal vitamins with water at dinner."
The nurse performs teaching for a client being discharged on risperidone (Risperdal). Which of the following client statements indicates to the nurse that teaching is successful?
Select all that apply.
1. "I may gain weight when taking this medication."
2. "I should avoid extremes in temperatures."
3. "I can take over-the-counter sedatives if I have trouble sleeping."
4. "I can drink alcohol as long as I drink in moderation."
5. "I will wear long sleeves when I am out in the sun."
6. "I will change positions slowly."
A patient diagnosed with bipolar disorder refuses to put down the mop that he is swinging to threaten other patients and staff. What information is MOST important for the nurse to consider before administering a PRN IM dose of lorazepam (Ativan)?
1. The patient is harmful to himself.
2. The patient is psychotic.
3. A restrictive intervention failed.
4. The patient is harmful to others.
To promote safety in the environment of a client with a marked depression of T cells, the nurse should take which of the following actions?
1. Keep a linen hamper immediately outside the room.
2. Restrict eating utensils to spoons made of plastic.
3. Provide masks for anyone entering the room.
4. Remove any standing water left in containers or equipment.
The physician prescribes sucralfate (Carafate) 1 gm PO tid and 2 Maalox tablets tid for a client in the outpatient clinic. The client asks the nurse when to take these medications. Which of the following instructions by the nurse is BEST?
1. Take the Carafate and the Maalox 1 hour ac.
2. Take the Maalox 1 hour ac and the Carafate 1 hour pc.
3. Take the Carafate and the Maalox 2 hours pc and hs.
4. Take the Carafate 1 hour ac and the Maalox 1 hour pc.
A female client is diagnosed with human papillomavirus (HPV). Which of the following client statements, if made to the nurse, illustrates an understanding of the possible sequelae of this illness?
1. "I will need to take antibiotics for at least a week."
2. "I will use only prescribed douches to avoid a recurrence."
3. "I will return for a Pap smear in six months."
4. "I will avoid using tampons for eight weeks."
A client develops severe, crushing chest pain radiating to the left shoulder and arm. Which of the following PRN medications should the nurse administer?
1. Diazepam (Valium) PO.
2. Meperidine (Demerol) IM.
3. Morphine sulfate IV.
4. Nitroglycerine (Nitrostat) SL.
The nurse makes a home visit for a client with an abdominal wound. When irrigating the draining wound with a sterile saline solution, which of the following sequences is MOST appropriate for the nurse to follow?
1. Pour the solution, wash hands, and remove the soiled dressing.
2. Wash hands, prepare the sterile field, and remove the soiled dressing.
3. Prepare the sterile field, put on sterile gloves, and remove the soiled dressing.
4. Remove the soiled dressing, flush the wound, and wash hands.
The nurse cares for a client with internal radiation. Which of the following actions, if taken by the nurse, is MOST important?
1. Restrict visitors who may have an upper respiratory infection.
2. Assign male caregivers to the client.
3. Plan nursing activities to decrease nurse exposure.
4. Wear a lead-lined apron whenever delivering client care.
The nurse prepares a client for a myelogram. It is MOST important for the nurse to ask which of the following questions?
1. "Do you have any allergies?"
2. "Have you been drinking lots of fluids?"
3. "Are you wearing any metal objects?"
4. "Are you taking medication?"
The nurse cares for a client diagnosed with dementia in a long-term care facility. Which of the following actions by the nurse is BEST?
1. Encourage the client to verbalize feelings about being placed in a nursing home.
2. Ask the client what favorite pastimes and what type of activities the client used to participate in.
3. Orient the client to the present time and assist the client to be alert and oriented when the family comes to visit.
4. Direct conversation toward assisting the client to reminisce and talk about important past events in life.
A client has a nasogastric tube in place after extensive abdominal surgery. The client complains of nausea. The nurse notes the client's abdomen is distended and there are no bowel sounds. Which of the following actions should the nurse take FIRST?
1. Administer the PRN pain medication and an antiemetic.
2. Irrigate the nasogastric tube with normal saline.
3. Determine if the nasogastric tube is patent and draining.
4. Check the placement of the nasogastric tube by auscultation.
Which of the following is the FIRST nursing action that should be implemented for a client after a vaginal delivery?
1. Check the patient's lochial flow.
2. Palpate the patient's fundus.
3. Monitor the patient's pain.
4. Assess the patient's level of consciousness.
A client diagnosed with a fracture of the left femur is placed in Buck's traction with a 7-lb weight. The nurse notes the patient keeps sliding down in bed. The nurse should take which of the following actions?
1. Elevate the patient's left thigh on two pillows.
2. Elevate the foot of the bed on blocks.
3. Raise the knee gatch on the bed 30°.
4. Instruct the patient to remain in the middle of the bed.
The nurse reviews charts on a medical/surgical unit. The nurse identifies which of the following is a properly recorded client chief complaint in a nursing health history?
1. "Complains of midepigastric discomfort with flatus after meals."
2. "Area above umbilicus appears to be painful and tender to palpation."
3. "My stomach hurts after dinner every night."
4. "Rebound tenderness present in mid- to upper-abdominal area."
A client comes to the nurse's station for the prescribed antipsychotic medication. The nurse notes that the client has torticollis, an arched back, and rapid movement of the eyes. Which of the following actions should the nurse take FIRST?
1. Determine what other medications the patient is taking.
2. Perform a neurological assessment.
3. Administer haloperidol decanoate (Haldol D) IM stat.
4. Administer the PRN trihexyphenidyl (Artane) IM immediately.
The home health nurse performs a follow-up visit for an elderly client receiving isoniazid (INH) 200 mg every day for six months. The nurse is MOST concerned if the client makes which of the following statements?
1. "I have blurred vision at times."
2. "My legs and knees hurt."
3. "My hands and feet tingle."
4. "I think I had a migraine yesterday."
During the nursing history interview, a preschool client's mother reports that the child has frequent bouts of gastroenteritis. It is MOST important for the nurse to ask which of the following questions?
1. "Are there other children in the family?"
2. "Does the child attend a day care center?"
3. "Does the child play with neighborhood children?"
4. "Is the child current on his immunizations?"
A young adult client is scheduled for the first debridement of a deep partial thickness burn of the left arm. It is MOST important for the nurse to take which of the following actions?
1. Assemble all necessary supplies and medications.
2. Plan adequate time for the dressing change and provide emotional support.
3. Prepare the client and family for the pain the client will experience during and after the procedure.
4. Limit visitation prior to the procedure to reduce stress.
The nurse cares for a client diagnosed with hypovolemia. Which of the following observations should the nurse identify as the desired response to fluid replacement?
1. Urine output 160 ml/8 h.
2. Hgb 11 g, Hct 33%.
3. Arterial pH 7.34.
4. CVP reading of 8 cm of water pressure.
The nurse prepares a client for a lumbar puncture. It is MOST important that the nurse makes which of the following statements?
1. "Don't worry because a general anesthetic will be used."
2. "You can't drink fluids for eight hours before the test.
3. "You will remain flat in bed for eight hours after the test."
4. "A compression bandage will be in place for 10 hours after the test."
The emergency room nurse cares for a client demonstrating the following symptoms: elevated vital signs, hallucinations, and aggressive behavior. The client's friend tells the nurse that the client used hallucinogenic drugs. The nurse should take which of the following actions?
1. Place the client in full restraints.
2. Decrease environmental stimulation.
3. Call the security guards.
4. Administer a PRN dose of chlorpromazine (Thorazine).
A client with a 25-year history of alcohol abuse is seen in the outpatient clinic for treatment of chronic cirrhosis. Which of the following symptoms suggests to the nurse that the client is in the early stages of hepatic encephalopathy?
1. The patient's abdomen is distended with a protruding umbilicus.
2. The patient has difficulty describing what he does at work.
3. The patient's respirations are 32, and he appears to be drowsy.
4. The patient's upper extremities are adducted, and his lower extremities are internally rotated.
A 32-year-old multipara is seen in the prenatal clinic. The nurse notes the client is in her fifth month of pregnancy and has a weight gain of 14 lb. The history indicates that prenatally the client was of average height and weight. The nurse should advise the client about which of the following?
1. The client has gained too much weight, and her diet should be re-evaluated.
2. The client has not gained enough weight, and her diet should be re-evaluated.
3. The weight gain is appropriate, and she should continue on her present diet.
4. The weight gain indicates that she may have difficulties later in pregnancy.
A client is currently hospitalized with renal failure and has 3+ pitting edema of the lower extremities. Which of the following nursing observations indicates a therapeutic response to therapy for the edema?
1. Serum potassium 4.0 mEq/L.
2. Plasma glucose 140 mg/dL.
3. Increased specific gravity of the urine.
4. Weight loss of 5 lb over last two days.
The nurse cares for patients on the surgical floor and has just received report from the previous shift. Which of the following patients should the nurse see FIRST?
1. A 35-year-old admitted three hours ago with a gunshot wound; 1/5 cm area of dark drainage noted on the dressing.
2. A 43-year-old who had a mastectomy two days ago; 23 ml of serosanguinous fluid noted in the Jackson-Pratt drain.
3. A 59-year-old with a collapsed lung due to an accident; no drainage noted from chest tube in last eight hours.
4. A 62-year-old who had an abdominal perineal resection three days ago; patient complains of chills.
Which of the following behaviors by a client should the nurse record to indicate that the client is experiencing hallucinations?
1. The client sits immobilized for long periods of time.
2. The client turns and tilts his head as if talking to someone.
3. The client expresses the belief that the physician is out to get him.
4. The client wrings his hands and paces constantly.
A young adult comes to the AIDS clinic for treatment of large, painful, purplish-brown open areas on his right arm and back. The nurse should instruct the client to take which of the following actions?
1. Clean the area carefully with soap and warm water every day, and cover them with a sterile dressing.
2. Soak in a warm tub twice a day, and rub the areas with a washcloth before covering them.
3. Shower daily using a mild antimicrobial soap from a pump dispenser, and leave the lesions uncovered.
4. Clean the lesions twice a day with a diluted solution of povidone-iodine (Betadine), and leave them open to the air.
The nurse knows that which of the following is the BEST assessment indicating relief from abdominal pain for a child who received meperidine (Demerol) IM 1 hour ago?
1. The child states that his pain has gone away.
2. The child's heart rate has changed from 80 to 95.
3. The child sleeps except when receiving nursing care.
4. Results from the incentive spirometer have improved.
The nurse cares for patients in an acute care facility. The nurse identifies which of the following patients as a likely candidate for developing acute renal failure?
1. A young female with recent ileostomy due to ulcerative colitis.
2. A middle-aged male with elevated temperature and chronic pancreatitis.
3. A teenager in hypovolemic shock following a crushing injury to the chest.
4. Child with compound fracture of the right femur and massive laceration of the left arm.
The nurse prepares an older client for discharge after treatment for dehydration. Which of the following statements, if made by the patient to the nurse, indicates that further teaching is needed?
1. "I should weigh myself daily."
2. "I should drink fluids throughout the day."
3. "I can use a measuring cup to find out how much I drink during the day."
4. "I should let my doctor know if I get dizzy when I change positions."
A client is diagnosed with metastatic cancer with a poor prognosis. Recently, the client complained of increased pain, is less communicative, very irritable, and anorexic. Which of the following nursing goals should be a priority at this time?
1. Encourage client to talk about the possibility of dying.
2. Provide pain assessment and effective pain management.
3. Manage nutrition and hydration.
4. Verify that the physician has discussed the prognosis with the family.
An adult client with a nasogastric tube has an order for acetaminophen (Tylenol) 650 mg PRN for a temperature greater than 101°F (38.3°C). The nurse should take which of the following actions when administering this medication?
1. The tablets should be swallowed carefully with sips of water.
2. The medication should be withheld until the nasogastric tube is removed.
3. Placement of the nasogastric tube should be checked prior to giving the medication.
4. Powdered medication should be used and mixed with water to form a solution.
The nurse assesses an infant who had a repair of a cleft lip and palate. The respiratory assessment reveals that the infant has upper airway congestion and slightly labored respirations. Which of the following nursing actions is MOST appropriate?
1. Elevate the head of the bed.
2. Suction the infant's mouth and nose.
3. Position the infant on one side.
4. Administer oxygen until breathing is easier.
The nurse cares for a patient following a cardiac catheterization. Two hours after the procedure, the nurse checks the patient's insertion site in the antecubital space, and the patient complains that the hand is numb. The nurse should take which of the following actions?
1. Change the position of the client's hand.
2. Check the client's grip strength in both hands.
3. Notify the physician.
4. Instruct the patient to exercise the fingers.
A client who is a gravida 2, para 1 is admitted for induction of labor with oxytocin (Pitocin). It is MOST important for the nurse to take which of the following actions?
1. Mix Pitocin in D5W, begin at 5 mg/ml as primary IV to gravity flow.
2. Decrease the rate/flow of Pitocin if the fetal heart rate is below 150.
3. Piggyback the Pitocin into the mainline IV, and maintain the flow by gravity.
4. Start an IV line, and piggyback the Pitocin with an infusion pump.
A client is admitted with a diagnosis of renal calculi and is experiencing severe pain. Meperidine (Demerol) 75 mg IM is given prior to the change of shift. Which of the following symptoms is MOST important for the nurse to report to the next shift?
1. Nausea with a small amount of vomitus.
2. Pain of 5 on a scale of 1 to 10.
3. Change in the location and character of pain.
4. No known drug allergies.
The nurse plans discharge for a group of clients. It is MOST important to refer which of the following clients for home care?
1. A postoperative appendectomy client who is complaining of incisional pain.
2. A diabetic client who had a cardiac catheterization in the early AM.
3. A postoperative cholecystectomy client who is complaining of incisional pain.
4. A client with congestive heart failure who underwent diuresis in the hospital.
The nurse plans care for a patient hospitalized with bipolar disorder. While the patient is in the manic phase, nursing interventions should involve which of the following?
1. Talk to the patient, and reinforce behaviors.
2. Distract the patient, and redirect behaviors.
3. Implement limit-setting, and isolate the patient.
4. Orient and remind the patient about the rules of the hospital.
The nurse supervises the staff caring for clients on the medical/surgical unit. The nurse observes the student nurse enter wearing a gown, gloves, and a mask. The nurse determines that the precautions are correct if the student nurse is caring for which of the following clients?
1. An infant diagnosed with respiratory syncytial virus.
2. A young child with a wound infected with S. aureus.
3. A teenager diagnosed with toxic shock syndrome.
4. A teenager diagnosed with rubella (German measles).
The physician orders metronidazole (Flagyl) 250 mg PO tid for seven days for a client. The nurse instructs the client about the medication. Which of the following statements, if made by the client to the nurse, indicates teaching is effective?
1. "I should take this medication between meals to increase absorption."
2. "I shouldn't drink alcohol while I am taking this medication."
3. "If I experience a metallic taste in my mouth while taking this medication, I should notify the physician."
4. "I should avoid strong sunlight while I am taking this medication."
The nurse supervises a student nurse obtaining an infant's vital signs. Which of the following actions should the student nurse complete FIRST?
1. Obtain the infant's temperature.
2. Count respirations for 15 seconds and multiply the number by 4.
3. Count respirations for a minute prior to arousing the infant.
4. Use a stethoscope with a 1.5-inch diaphragm to count the apical pulse.
The nurse determines further teaching is necessary if the parents of a 4-year-old child diagnosed with sickle cell anemia state which of the following?
1. "When my daughter complains of pain, I give her baby aspirin."
2. "I try to keep my daughter away from people with infections."
3. "I sometimes have to give my daughter some of her Demerol for pain."
4. "I encourage my daughter to drink a lot of water."
An 8-year-old boy falls off the swings at school and hits his head. He is examined by a physician at an urgent care center, diagnosed with a minor head injury, and sent home. Which of the following statements, if made by the mother to the nurse, require further teaching by the nurse?
1. "He should avoid blowing his nose or cleaning his ears for two days."
2. "I should wake him every three hours tonight and tomorrow night to check him."
3. "I can give him Tylenol every four hours if he complains of a headache."
4. "He will be well enough to play in his soccer game tomorrow."
A client receives digoxin (Lanoxin) 0.25 mg PO qd and furosemide (Lasix) 40 mg PO bid. The client calls the physician for complaints of mild diarrhea. The physician prescribes Kaopectate 60 mg after each bowel movement for two days and instructs the client to call back if symptoms don't subside. The client asks the office nurse if there should be any changes to the medication schedule. The nurse should instruct the woman to take which of the following actions?
1. Continue the medication schedule.
2. Wait 1 hour before taking the scheduled medications if the Kaopectate is taken.
3. Hold the scheduled medications until the diarrhea subsides.
4. Take the Lanoxin but hold the Lasix if the client takes the Kaopectate.
A client comes to the outpatient psychiatric clinic for treatment of a fear of heights. The nurse identifies which of the following is the best plan of care to meet the needs of this client INITIALLY?
1. Point out to the client the secondary gain that results from her behavior.
2. Demonstrate to the client the irrational nature of these fears.
3. Encourage the client to rely on significant others for support.
4. Allow the client to avoid the situations that are anxiety provoking.
Which of the following findings indicates to the nurse that a client's Salem sump tube (nasogastric) was functioning effectively?
1. Fluctuation of the fluid level in the water seal chamber.
2. Active bubbling in the suction bottle.
3. The presence of a hissing sound from the blue lumen tube.
4. A pressure of 25 mm Hg in the esophageal balloon.
A client in labor is receiving magnesium sulfate IV. Which assessment is MOST important to give during the report to the nurses on the next shift?
1. Respiratory rate changed from 13/minute to 15/minute.
2. Increase in anxiety and hyperactivity.
3. Presence of nausea and refusal to take clear liquids.
4. Urine output decreased from 60 ml/h to 25 ml/h.
A client is seen in the clinic for complaints of back pain. The nurse discusses and demonstrates how to perform activities of daily living to decrease the incidence of back pain. Which of the following actions, if performed by the client, indicates to the nurse that teaching is effective?
1. The client bends over to put on and tie her tennis shoes.
2. The client stands on her toes to place a box on the top shelf of a closet.
3. The client sits in a recliner with her feet elevated to watch TV.
4. The client stands with her feet close together and shifts her weight between her feet.
Which of the following actions, if performed by the nurse, is considered negligence?
1. Obtain a Guthrie blood test on a 4-day-old infant.
2. Massage lotion on the abdomen of a 3-year-old diagnosed with Wilms' tumor.
3. Instruct a 5-year-old asthmatic to blow on a pinwheel.
4. Play kickball with a 10-year-old with juvenile arthritis (JA).
At an inpatient psychiatric unit, a patient insists on staying in the room and repeatedly comments to the nurse, "Special agents are here. Maybe you are one." Which of the following responses, if made by the nurse, is BEST?
1. "You can trust me. There are no agents here."
2. "You must feel afraid if you believe that, but there are no agents here."
3. "No one here will hurt you. They are here to help you."
4. "Agents? Tell me more about what you mean."
A postoperative client is returned to the assigned room from the surgical recovery area. The client is sleeping, and the nurse notes that the client is disoriented when aroused. Which of the following actions, if taken by the nurse, is BEST?
1. Place the call bell within the client's reach.
2. Stay with the client until he is totally oriented.
3. Restrain all four extremities until the client is oriented.
4. Elevate the side rails until the client is fully awake.
The nurse cares for a patient with deep partial thickness and full thickness burns. The client receives morphine sulfate 15 mg IV. The nurse notes a decrease in bowel sounds and slight abdominal distention. Which of the following actions, if taken by the nurse, is BEST?
1. Recommend that the morphine dose be decreased.
2. Withhold the pain medication.
3. Administer the medication by another route.
4. Explore alternative pain management techniques.
The visiting nurse evaluates the progress of a client recently diagnosed with type 1 diabetes. As part of the treatment plan, the client receives Humulin N 32 units and Humulin R 8 units each morning. Which of the following actions, if performed by the client while preparing the morning insulin injection, requires an intervention by the nurse?
1. After drawing up 8 units of Humulin R, the client adds Humulin N to the syringe for a total of 40 units.
2. The client draws up 32 units of the clear insulin followed by 8 units of cloudy insulin for a total of 40 units.
3. Initially, the client injects air into the Humulin N vial without drawing up any insulin.
4. The client injects air into each bottle of insulin equal to the amount of insulin to be withdrawn.
Which of the following statements by the client BEST indicates to the nurse an emotional readiness for surgery?
1. "I know the doctor isn't telling me everything, but at this point I can't do anything about it."
2. "I've never heard of this specialist before. Does he do much work here?"
3. "I'm glad the trapeze is on my bed so that I can start working on my exercises as soon as I wake up."
4. "Can you please check my record to be sure it says I have type 2 diabetes?"
The clinic nurse is obtaining a throat culture from a client diagnosed with pharyngitis. It is MOST important for the nurse to take which of the following actions?
1. Quickly rub a cotton swab over both tonsillar areas and the posterior pharynx.
2. Obtain a sputum container for the client to use.
3. Irrigate with warm saline, and then swab the pharynx.
4. Hyperextend the client's head and neck for the procedure.
A mother brings her 7-year-old daughter to the outpatient clinic for a routine check-up. The girl weighs 50.25 lb (22.85 kg) and is 48 inches (121.7 cm) tall. The nurse notes that the child has gained 2.5 lb and grown 3 inches in the past year. Which of the following responses by the nurse is BEST?
1. "Your daughter's height and weight are within normal limits."
2. "Your daughter's height is normal, but she needs to gain some weight."
3. "Your daughter's height is normal, but she needs to lose some weight."
4. "Your daughter's weight is normal, but she is shorter than normal."
During the first 24 hours after total parenteral nutrition (TPN) therapy is started, the nurse should take which of the following actions?
1. Monitor vital signs every two hours.
2. Determine urinalysis results.
3. Evaluate blood glucose levels.
4. Compare weight with the previous readings.
The nurse is caring for an elderly patient recovering from a fractured pelvis in a long-term care facility. The patient's activity order reads: "ambulate with walker bid." After the nurse implements the order, which of the following charting entries is BEST?
1. "Patient ambulated well with walker. States has no c/o stiffness or pain. Did not appear fatigued."
2. "Ambulated without difficulty for 20 minutes. Vital signs remained stable. Color good."
3. "Walked full length of hall with walker. No difficulty with balance. Using walker correctly."
4. "Patient ambulated 60 ft independently with walker. Gait steady. Respirations 14 and unlabored."
A client is brought into the emergency room for treatment of a suspected drug overdose. The client appears to be highly agitated, fearful, and may be hallucinating. Which of the following actions should the nurse take FIRST?
1. Offer immediate support from family and friends who accompanied her.
2. Greet the client with a warm, friendly approach.
3. Place the client in a quiet, darkened room.
4. Make an immediate referral to a social service agency.
The nurse receives a phone call from a nursing assistant who states that her 5-year-old child has developed chickenpox. It would be MOST important for the nurse to ask which of the following questions?
1. "Have your other children had chickenpox?"
2. "Does your child have a temperature?"
3. "Have you had the chickenpox?"
4. "Do you have someone to watch your child?"
Butorphanol tartrate (Stadol) 1 mg IM is ordered for a woman 1 day postpartum. Which of the following actions is MOST important for the nurse to take after administering the medication?
1. Observe the woman for sedation.
2. Monitor the vital signs.
3. Assess for visual disturbances.
4. Evaluate fluid status.
The nurse knows that which of the following plans would be a priority for an infant with a positive PKU blood test?
1. Place the infant on Lofenalac formula.
2. Administer medium-chain triglyceride (MCT) oil with each feeding.
3. Provide genetic counseling for the family.
4. Place the infant on Lorenzo's Oil treatments.
The nurse conducts preoperative teaching with the family of a client scheduled for a total laryngectomy. Which of the following statements, if made by the family, indicates to the nurse a need for further teaching?
Select all that apply.
1. "We will need to learn other ways to communicate with each other."
2. "My husband will require a feeding tube for several months."
3. "My father will require a special kind of tube in his neck for his airway."
4. "Dad may develop some difficulty with taste and smell after the surgery."
5. "Dad is looking forward to learning how to laugh using tracheoesophageal puncture."
6. "We will encourage Dad to cough and deep breathe after surgery."
The nurse sees a client in the emergency department in severe emotional distress. The client's respirations are 42/minute, and the blood gases reveal a pH of 7.5 and a PaCO2 of 34. Initially, the nurse should take which of the following actions?
1. Instruct the client to breathe into a paper bag.
2. Start an IV of D5W.
3. Administer oxygen.
4. Place the client's head between his knees.
Twenty-four hours after abdominal surgery, which of the following plans is a nursing priority to prevent complications of flatulence?
1. Encourage the client to drink carbonated beverages daily.
2. Instruct the client to turn from side to side.
3. Encourage the client to do leg exercises in bed.
4. Assist the client to walk in the hall every two hours.
A man is seen in the outpatient clinic for treatment of hypertension. The client expresses concern to the nurse that his wife has been unemployed for more than six months. He is afraid that soon they will be unable to pay their rent. Which of these responses by the nurse is BEST?
1. "These things always have a way of working themselves out."
2. "It's important for your health that you not worry too much."
3. "You're worried that you won't be able to pay the rent?"
4. "A social worker might be able to help you with this problem."
While a nurse obtains a nursing history from a teenaged client, the client states that she drinks "lots" of fluids and still feels thirsty. It is MOST important for the nurse to ask which of the following questions?
1. "Has your weight recently changed?"
2. "What medications do you take?"
3. "Do you have any allergies to food or medication?"
4. "How often do you menstruate?"
The nurse cares for a client after delivery of a 7 lb 10 oz baby boy. The patient has decided to bottle-feed her infant. The nurse should encourage the patient to take which of the following actions?
1. Use the manual breast pump.
2. Apply warm packs to the breast.
3. Massage the breasts.
4. Wear a well-supportive bra.
A client complains of chronic constipation. The nurse in the health care clinic should advise the woman to do which of the following?
1. Reduce intake of highly seasoned foods and fats.
2. Drink 1,000 ml of fluids daily.
3. Increase intake of cereals, fresh fruits, and vegetables.
4. Ask the physician to prescribe Dulcolax 5 mg enteric-coated tablets daily.
The nurse cares for clients in the postanesthesia care unit (PACU). Which of the following clients require IMMEDIATE attention by the nurse?
1. A client with a new tracheotomy with a small amount of serosanguineous drainage on the dressing.
2. A client who is responsive with a moderate amount of clear fluid draining from the NG tube.
3. A client with a chest tube and dark red drainage in the collection chamber.
4. A client who is unresponsive to verbal stimuli with the oral airway out of place.
A client admitted with metastatic cancer has received chemotherapy for three months. Lab values include RBC 3.8 million/mm3, WBC 3,000/mm3, Hgb 9.3 g/dL, platelets 50,000/mm3. The nurse expects the patient to exhibit which of the following symptoms?
1. BP 120/70, pulse 100, respirations 22.
2. Ankle edema and ascites.
3. Flushed face and light stools.
4. Nausea, anorexia, and vomiting.
A physician writes an order for an HIV-positive infant to receive IPV immunization. Which of the following nursing actions is MOST appropriate?
1. Wear gloves and a gown when administering the immunization.
2. Administer the immunization.
3. Contact the physician for clarification of the order.
4. Determine if child has a history of seizures.
The nurse cares for a client receiving amphotericin B (Fungizone) 1 mg in 250 ml of 5% dextrose in water IV over a 2-hour period. The nurse is MOST concerned if which of the following is observed?
1. BUN 7.2 mg/dL, creatinine 0.5 mg/dL.
2. BP 90/60, complaints of fever and chills.
3. Complaints of burning on urination, thirst, and dizziness.
4. AST (SGOT) 12 U/L, ALT (SGPT) 14 U/L, total bilirubin 0.2 mg/dL.
A staff member informs the nurse that the staff member's 6-year-old child has head lice. It is MOST important for the nurse to take which of the following actions?
1. Inspect the staff member's head for louse and nits.
2. Inform the staff member that he cannot care for clients until further notice.
3. Request that the staff member contact his physician.
4. Instruct the staff member about how to use Kwell.
A client who attends an outpatient clinic is taking chlorpromazine hydrochloride (Thorazine) 100 mg tid. The client reports to the nurse that he is sleeping through the day. Which of the following actions by the nurse is MOST appropriate?
1. Contact the physician to change the dose to 100 mg BID.
2. Change the time of the medication to 100 mg in the morning, 100 mg after dinner, and 100 mg at hs.
3. Instruct the man to take frequent naps during the day.
4. Encourage the man to be more active during the day.
Which of the following is a priority nursing goal in the plan of care for a client diagnosed with paralysis due to cerebrovascular accident (CVA)?
1. Maintain adduction of the affected shoulder.
2. Prevent flexion of the affected extremities.
3. Observe active range of motion (ROM) daily to all extremities.
4. Maintain external rotation of the affected hip.
The physician orders an arterial blood gas (ABG) for a client receiving oxygen at 6 L/minute. What information concerning the patient is MOST important for the nurse to document on the lab slip that accompanies the blood sample?
1. The patient's position in bed and the respiratory rate.
2. The site used to obtain the blood specimen.
3. The use of supplemental oxygen.
4. The patient's diagnosis and blood type.
Which of the following statements, if made by the parents of a 9-year-old client with an ostomy, indicates to the nurse that the parents are providing quality home care?
1. "We change the bag at least once a week, and we carefully inspect the stoma at that time."
2. "We change the bag every day so that we can inspect the stoma and the skin."
3. "We encourage our daughter to watch TV while we change her ostomy bag."
4. "We only have to change the ostomy bag every 10 days."
The nurse cares for a client after a bronchoscopy. The nurse is MOST concerned if which of the following was observed?
1. Depressed gag reflex.
2. Sputum streaked with blood.
4. Complaints of a sore throat.
The nurse observes for which of the following when assessing pain in an 8-month-old infant?
1. Decreased pulse rate.
2. Increased fluid intake.
3. Decreased respiratory rate.
4. Rubbing a body part and crying.
A client is placed on cephalexin monohydrate (Keflex) prophylactically after surgery. Which of the following foods should the nurse encourage?
1. Bran cereals and fruits.
2. Egg whites and lean meats.
3. Yogurt and acidophilus milk.
4. Fish and poultry meats.
The home care nurse is scheduling clients for the day. Which of the following clients should the nurse visit FIRST?
1. A primigravida client, 10 days postpartum, is anxious about caring for her newborn.
2. A middle-aged client, six days postoperative, complaining of pain in the midsternal incision.
3. A client with AIDS who had a chest tube removed yesterday and is complaining of crackling under his skin.
4. A client receiving amiloride hydrochloride (Midamor) who complains of dizziness when arising in the morning.
The nurse enters the room of a client and finds that the tracheostomy tube inserted two days ago has been accidentally dislodged. The nurse should take which of the following actions?
1. Immediately replace the tracheostomy tube.
2. Suction the patient's airway using sterile technique.
3. Provide oxygen at 8 L/minute per mask over the stoma.
4. Check for bilateral breath sounds immediately.
When a nurse performs a physical examination on a newborn, which of the following nursing assessments should be reported to the doctor?
1. Head circumference of 40 cm.
2. Chest circumference of 32 cm.
3. Acrocyanosis and edema of the scalp.
4. Heart rate 160 and respirations 40.
A client is scheduled for a cholangiogram. Meglumine diatrizoate (Gastrografin) is ordered for the client. The nurse should take which of the following actions?
1. Identify the client before administering the medication.
2. Administer the medication two hours before the procedure.
3. Administer an enema after administering the medication.
4. Instruct the client to take medication slowly with water.
Which of the following actions, if performed by the nurse, is considered negligence?
1. The nurse performs range-of-motion (ROM) exercises for a client with deep partial thickness and full thickness burns of the chest.
2. The nurse sits with a client who suffers from depression while he eats his lunch.
3. The nurse caring for a client with myasthenia gravis administers the 7 AM dose of neostigmine bromide (Prostigmin) PO at 7:45 AM.
4. The nurse instructs a 15-year-old girl who is sexually active about different types of contraceptives without consulting her parents.
The nurse cares for an elderly patient following a right total hip replacement. The nurse's notes indicate that since the surgery, the patient has become disoriented and confused at night. One evening as the nurse prepares the patient for sleep, the patient glances to his left and says, "Oh, you think so?" and starts to laugh. Which of the following responses by the nurse is the BEST?
1. "Do you hear voices talking to you?"
2. "Tell me why you are laughing so I can laugh too."
3. "What is it that you find amusing?"
4. "I notice you're laughing."
A client is scheduled for a cardiac catheterization at 0800. The client's laboratory work was completed five days ago, and the results include K+ 3.0 mEq/L, Na+ 148 mEq/L, glucose 178 mg/dL. The client complains of muscle weakness and cramps. Which of the following actions by the nurse is BEST?
1. Administer the 0700 dose of spironolactone (Aldactone).
2. Encourage eating bananas for breakfast.
3. Obtain stat K+ level.
4. Call for 12-lead EKG.
A client has a chest tube inserted for treatment of a hemothorax. Which of the following findings indicates to the nurse that there is a problem with the effective functioning of the chest tube?
1. Fifteen centimeters of water is present in the suction control chamber.
2. Constant bubbling is observed in the water seal chamber.
3. Two centimeters of water is present in the water seal chamber.
4. Clots of blood are observed in the collection chamber.
The nurse's assessment of a disoriented male client reveals that the client has a self-care deficit (feeding). Which of the following indicates to the nurse that the client has made a positive response to the plan of care?
1. Client explains the relationship between weight loss and change in mental status.
2. Client identifies the basic four food groups.
3. Client states that he needs to drink more water.
4. Client feeds self when the nurse stays with him and cues him.
The nurse instructs a client with newly diagnosed type 1 diabetes about proper foot care. Which of the following statements, if made by the client to the nurse, indicate that further teaching is necessary?
1. "I should cut my toenails straight across."
2. "I should not go barefoot."
3. "I should inspect my feet once a week."
4. "I should bathe my feet daily in warm water."
The labor and delivery nurse begins the admission procedure for a client who is at 38 weeks' gestation and is diagnosed with pregnancy-induced hypertension (PIH). Which of the following is the priority nursing action?
1. Start an IV.
2. Obtain the vital signs.
3. Administer magnesium sulfate.
4. Notify the lab to draw blood.
An elderly client is oriented during the day but becomes disoriented during the evening. Which of the following nursing actions is MOST appropriate?
1. Place a clock where the client can see it.
2. Restrain all four extremities.
3. Keep a light on in the client's room.
4. Place the side rails in an upright position.
The nurse is caring for clients in the diabetic clinic. Which of the following clients should the nurse see FIRST?
1. A client with sunken eyeballs and a fruity breath odor.
2. A client who complains of pain in his calves when he exercises.
3. A client who states that she drinking liquids frequently and is always hungry.
4. A client says that she is having difficulty sleeping and cries frequently.
A client is admitted with the following symptoms: dependent pitting edema, abdominal distention, and a recent 10-lb weight gain. The client receives 80 mg of furosemide (Lasix). Which of the following nursing observations is MOST important to report to the next shift?
1. Complaints of nausea and vomiting.
2. Urine output of 200 ml in two hours.
3. Quiet and withdrawn behavior after lunch.
4. Blood pressure changes from 160/90 to 150/90.
A 3-year-old boy was shown to have delays on the Denver Development Screening Test (DDST). The mother asks the nurse, "Does this mean my child is going to be slow?" Which of the following responses by the nurse is BEST?
1. "Maybe he is just having a bad day. I'm sure he will do much better next time."
2. "The test indicated a delay, and we will have to investigate to learn more."
3. "What are your thoughts about how your child performed on the test?"
4. "The results may not be accurate. Let's set up a time to retest your child."
At 11 AM a patient returned to the nursing unit from the postanesthesia care unit (PACU) following a bowel resection. At noon the patient complains of pain. The physician ordered meperidine (Demerol) 50 mg IV q 3-4 hours. The chart indicates that the patient was given Demerol 50 mg IV at 9:15 AM. Which of the following actions by the nurse is MOST appropriate?
1. Ask the physician if the dosage of Demerol can be increased.
2. Give the patient Demerol 25 mg IV now.
3. Inform the patient the next dose of Demerol will be given at 1 PM.
4. Give the patient Demerol 50 mg IV now.
The clinic nurse is giving instructions to the family of a school-aged child diagnosed two weeks ago with hepatitis A. The family asks if the child can return to school. Which of the following responses by the nurse is BEST?
1. "You must isolate your child at home for two more weeks."
2. "Why don't you speak with the physician about this matter?"
3. "Your child may return to school this week."
4. "Your child may return to school in two weeks but cannot participate in sports."
Which finding indicates to the nurse that a client experiencing alcohol withdrawal is in need of more sedation to control the severity of withdrawal symptoms?
1. Increasing lethargy.
2. Uncoordinated motor movements.
3. Elevated pulse rate.
4. Improved orientation to time and place.
A client developed diabetes insipidus following a craniotomy. The nurse provides discharge instructions for the client and spouse. Which of the following statements, if made by the client, indicates to the nurse that further teaching is needed?
1. "I should keep a daily record of my fluid intake and how much I go to the bathroom."
2. "I should call my doctor if I seem thirsty a lot and my urine specific gravity is less than 1.005."
3. "I should weigh myself every day and drink less fluid if I gain more than 5 lb over a week."
4. "I will need to take the nose spray medication for the rest of my life."
During the physical assessment, the nurse determines the need to perform the bulge test. Which of the following statements, if made by the nurse, is BEST?
1. "Please lie down and extend your legs."
2. "Please bend over and touch your toes."
3. "Please hold both hands behind your back."
4. "Please bend your elbow."
The nurse performs a routine IV tubing change on a patient with a central line. Fifteen minutes later, the nurse re-enters the patient's room to find the patient cyanotic, short of breath, and complaining of pain. The patient's vital signs are BP 84/62, pulse 112, respirations 18. What is the FIRST action the nurse should take?
1. Call the physician to report the patient's symptoms.
2. Lower the head of the bed and place the patient on the left side.
3. Place the patient in high Fowler's position.
4. Start oxygen at 4 L/minute via nasal cannula.
Which of the following should be the nursing priority for an infant admitted to the pediatric unit with possible Haemophilus influenzae meningitis?
1. Encourage intake of oral fluids to prevent dehydration.
2. Restrain the child appropriately to maintain the integrity of the IV site.
3. Place the child on droplet precautions.
4. Encourage the parents to hold and rock the infant to promote comfort.
The nurse cares for a client who has overdosed on a large quantity of diazepam (Valium). Which of the following nursing actions should take priority during the first several days of this client's inpatient treatment?
1. Complete a full psychiatric assessment.
2. Contact client's family to involve them in treatment.
3. Observe and record vital signs frequently, including neurological symptoms.
4. Determine whether this client may need long-term therapy after this hospitalization.
During the second session of individual therapy, a client sits quietly with arms folded and eyes cast down. Which of the following statements by the nurse is BEST?
1. "What is the weather like outside?"
2. "Do you not want to talk with me today?"
3. "Are you cold sitting here?"
4. "You seem to be feeling sad today."
The nurse performs in-service education about the use of the defibrillator. It is MOST important for the nurse to make which of the following statements?
1. "Do not touch the bed when using the defibrillator."
2. "Check the defibrillator every 24 hours."
3. "Do not leave the defibrillator plugged in."
4. "Do not place the paddles over the electrodes."
A 4-year-old comes to the outpatient clinic for a routine exam. The child's mother is concerned because the child often talks to an "imaginary best friend." The nurse should advise the mother to take which of the following actions?
1. Insist the child play more often with other children.
2. Tell her child that this friend is not a real person.
3. Allow the child to engage in imaginary play.
4. Encourage the child to explain the friend to her.
The nurse cares for a client diagnosed with hyperthyroidism. Which of the following actions, if taken by the nurse, is BEST?
1. Provide the client with extra blankets.
2. Instill artificial tears PRN.
3. Offer the client reading material.
4. Offer frequent low-calorie snacks.
The nurse has just received report from the previous shift. Which of the following patients should the nurse see FIRST?
1. An elderly woman, eight hours postoperative, following an open-reduction and internal fixation of the right hip.
2. An elderly man admitted four hours ago with status asthmaticus.
3. A middle-aged man admitted two days ago with pneumonia that has a temperature of 101.2°F (38.4°C).
4. A middle-aged woman who suffered a myocardial infarction (MI) three days ago.
In planning care for a client with signs of increased intracranial pressure (ICP), the nurse should include which of the following?
1. Encourage coughing and deep breathing to prevent pneumonia.
2. Suction the airway every two hours to remove secretions.
3. Position the client in the prone position to promote venous return.
4. Determine cough reflex and ability to swallow prior to administering PO fluids.
While doing a physical examination of a 1-year-old child, which of the following assessments should be completed by the nurse LAST?
1. Examine infant's ears.
2. Auscultate the breath sounds.
3. Auscultate the apical heart rate.
4. Evaluate motor functions.
A patient returns from surgery with a Jackson-Pratt drain in place. The nurse observes a student nurse perform a dressing change for the patient. Which of the following activities, if performed by the student nurse, requires an intervention by the nurse?
1. Documents the amount and character of the drainage in the patient's chart.
2. Attaches the drain to the top sheet on the bed.
3. Empties the reservoir of the drain.
4. Records the amount of drainage on the output sheet.
An unaccompanied client at 24 weeks' gestation is admitted to the nursing unit with vaginal bleeding. Which of the following comments, if made by the client, indicates to the nurse the need to assess the adequacy of the client's emotional support?
1. "My husband will be so angry with me if I lose this baby."
2. "I'm afraid I am going to lose my baby."
3. "I can't stay here. I don't have any insurance."
4. "I feel so guilty. I didn't want to get pregnant."
When the nurse assesses the incision of a client two days after surgery, a shiny, pink, open area is noted with the underlying bowel visible. Which of these actions should the nurse take FIRST?
1. Cover the open area with sterile gauze soaked in normal saline.
2. Reapply a sterile dressing after cleaning the incision with peroxide.
3. Pack the opened area with sterile 0.75-in gauze soaked in normal saline.
4. Apply Neosporin ointment and cover the incision with Tegaderm dressing.
The nurse cares for a newborn to be discharged in the morning. The nurse should instruct the child's mother to perform which of the following?
1. Apply a sterile gauze dressing with petroleum jelly to the cord.
2. Position the diaper over the umbilicus to keep it dry.
3. Clean the cord several times a day, and expose it to air frequently.
4. Apply erythromycin ointment to the cord several times a day.
A client is transferred from a nursing home to the hospital with an indwelling urinary catheter. The urine appears cloudy and foul-smelling. Which of the following nursing measures is MOST appropriate?
1. Clean the urinary meatus every other day.
2. Encourage the client to increase fluid intake.
3. Empty the drainage bag every two to four hours.
4. Irrigate the Foley catheter every eight hours.
The nurse has just returned to the desk and has four phone messages to return. Which of the following messages should the nurse return FIRST?
1. A man with swelling of his left wrist following a fall from a ladder two hours ago.
2. A woman who had a cholecystectomy one week ago and now complains of redness and tenderness at the incision site.
3. A mother of a child reports that her son's lips are swollen following a fire ant bite.
4. A man with COPD reports he is coughing up large amounts of green-tinged sputum and has a temperature of 101°F (38.4°C).
The nurse cares for a client diagnosed with pneumonia. Which of the following nursing observations indicates a therapeutic response to the treatment?
1. Oral temperature of 101°F (38.3°C), increased chest pain with nonproductive cough.
2. Cough, productive of thick, green sputum, client reports feeling tired.
3. Respirations at 20 with moderate amount of thin, white sputum, denies dyspnea.
4. White cell count of 10,000 mm3, urine output at 40 ml/hour, decreasing amount of sputum.
When preparing discharge plans for a client being treated for syphilis, it is MOST important for the community health nurse to include which of the following information?
1. Practice restraint of sexual activity.
2. The practice of safe sex.
3. Information about Planned Parenthood.
4. Signs of a secondary infection.
The clinic nurse receives a call from the parent of a 12-year-old child receiving albuterol (Proventil). The parent states the child is irritable and complains, "I can feel my heart pounding." Which of the following responses by the nurse is MOST appropriate?
1. Instruct the parent to decrease external stimuli in the child's room.
2. Ask the parent to administer an ordered analgesic.
3. Ask the parent how long the child has been taking the medication.
4. Explain to the parent that this is expected.
The nurse is informed that there will be two new admissions to the unit. One of the new admissions is diagnosed with pneumonia, and the other new patient is diagnosed with AIDS. Which of the following assignments is MOST appropriate?
1. Assign both patients to one room with one nurse caring for both patients.
2. Place both patients in the same room, and assign the care to two different nurses.
3. Assign each patient to a private room, and assign both clients to one nurse.
4. Place each client in a private room, and assign each patient to a different nurse.
The nurse counsels a client who has been abusing alcohol and other drugs for 6 years. The nursing diagnosis is ineffective individual coping. Which of the following nursing actions should take priority during the working stage of the nurse/client relationship?
1. Observe the client every half hour to determine the extent of drug-seeking behavior.
2. Monitor the intake of fluids, meals, and snacks to ensure adequate nutrition.
3. Help the client obtain a sponsor through a 12-step group in the client's local area.
4. Meet individually with the client to discuss the consequences of drug-using behavior and examine other options.
The nurse supervises care of a client with a stage III pressure ulcer of the sacrum with foul-smelling, purulent drainage. The nurse should intervene in which of the following situations?
1. The LPN/LVN enters the room wearing a gown and gloves.
2. The nursing assistant enters the room wearing a mask.
3. The client's family brings the client a milkshake.
4. The staff lifts the client to reposition him.
The nurse performs discharge teaching for a client receiving fluticasone (Flovent) by inhalation. Which statement by the client indicates that the teaching was successful?
1. "I will use Flovent when I feel an asthma attack beginning."
2. "I use my albuterol inhaler after I inhale the Flovent."
3. "The medication will prevent infection in my leg."
4. "I will rinse my mouth every time after I inhale the Flovent."
A client develops orthopnea, dyspnea, and basilar crackles. Which of the following nursing actions is MOST appropriate for this client?
1. Elevate the legs to promote venous return.
2. Decrease the IV fluids, and notify the physician.
3. Orient the client to time, place, and situation.
4. Prevent complications of immobility.
During auscultation of the fetal heart rate during labor, the nurse assesses a rate of 59 beats per minute. Which of the following actions should the nurse take FIRST?
1. Turn the mother on her right side, increase the intravenous flow rate, and call the physician.
2. Turn the mother on her left side, administer oxygen by nasal cannula, and start an IV.
3. Call the physician, and make preparations for an immediate emergency cesarean section.
4. Position the mother in Trendelenburg's position, administer oxygen, and force fluids.
After a client has returned to the floor from thyroidectomy surgery, it is MOST important for the nurse to take which of the following actions?
1. Monitor vital signs every four hours.
2. Observe for frequent swallowing.
3. Monitor for signs of respiratory distress every hour.
4. Position the client in the supine position.
The nurse cares for clients on the psychiatric unit. Suddenly, a male client's behavior begins to escalate into aggressive behavior. It is MOST important for the nurse to take which of the following actions?
1. Utilize an organized team to place the client in seclusion.
2. Leave the client alone in his room to identify feelings of anger.
3. Redirect the client to a quiet activity to divert his attention and not disturb the other clients.
4. Assist the client to identify and express his feelings of increasing anxiety, frustration, and anger.
The nurse instructs the parents of a child diagnosed with celiac disease. The nurse determines teaching is effective when the parents make which of the following statements?
1. "My child's diet should include raw vegetables, fruits, and crackers."
2. "My child's diet should be high in carbohydrates, high in calories, and high in proteins."
3. "The only restriction in my child's diet should be breads and cereals."
4. "My child's diet should be high in calories, high in protein, and restrict foods containing rye, oats, wheat, and barley."
The nurse reviews physician's orders. The nurse determines which of the following orders warrants further clarification?
1. Administer haloperidol (Haldol) 5 mg.
2. Instruct client to use incentive spirometer q 1 hour while awake.
3. D5W 1/4 NS + KCl 20 mEq/L at 100 mL/hour.
4. CBC with differential and platelets at 0800.
In developing discharge plans for the family of the client diagnosed with stage four Parkinson's disease, the nurse should include which of the following activities?
1. Ambulate twice daily.
2. ROM exercise to all extremities four times a day.
3. Include activities such as knitting and putting puzzles together.
4. Encourage and provide writing materials.
A patient is admitted with abdominal pain and nausea. The physician orders stool for guaiac times three days. The nurse asks the health care technician to obtain the stool specimen. Which of the following statements, if made by the technician, requires an intervention by the nurse?
1. "I'll remind the patient to use the bedpan instead of the bathroom toilet."
2. "I'll use a tongue blade to collect a small amount of stool in a clean container."
3. "I'll get a couple of specimens this afternoon because the patient is having loose stools."
4. "I'll ask the patient if he has ingested any red meat recently."
The home care nurse visits a client receiving levothyroxine sodium (Synthroid) 0.1 mg PO daily. Which of the following findings indicates to the nurse that the client is getting favorable results from the medication?
1. Decreased blood pressure.
2. Increased urine output.
3. Decreased pulse rate.
4. Increased respiratory rate.
A 24-year-old woman at 30 weeks' gestation is seen in the outpatient clinic for a routine visit. The nurse is MOST concerned if the client makes which of the following statements?
1. "During the day I seem to get hot flashes and chills."
2. "I am having some trouble with constipation and hemorrhoids."
3. "At the end of the day I have leg cramps."
4. "When I put my hand on my abdomen, I can feel it tense and relax."
The nurse prepares an older client for an intravenous pyelogram (IVP). Which of the following information is MOST important for the nurse to obtain before the procedure?
1. The date of the client's last EKG.
2. The time of the client's last meal.
3. A list of the client's allergies.
4. A list of the medications the client takes at home.
A client receives heparin via continuous IV infusion for management of deep vein thrombosis (DVT). The partial thromboplastin time (PTT) is 1.5 times greater than normal. Which of the following actions by the nurse is MOST appropriate?
1. Discontinue the heparin infusion.
2. Slow down the heparin infusion.
3. Check the prothrombin time (PT) results.
4. Continue to monitor the client.
The home care nurse is visiting an elderly client with osteoarthritis. It is MOST important for the nurse to include which of the following instructions?
1. "Swimming is the only helpful exercise for osteoarthritis."
2. "Warm-up exercises should be done prior to exercising."
3. "Exercises should be done routinely, even if severe joint pain occurs."
4. "Isometric exercises are most helpful to prevent contractures."
The nurse observes a new graduate nurse palpating the uterine contractions of a primipara in active labor. Which of the following actions, if taken by the new graduate nurse, is appropriate?
1. The graduate nurse places the palm of one hand on the fundus and moves the hand around the abdomen.
2. The graduate nurse places the heels of both hands on the lower abdomen and presses lightly.
3. The graduate nurse places one hand on the abdomen over the fundus, and with the fingertips, presses gently.
4. The graduate nurse places the palms of the hands on either side of the abdomen and presses firmly.
The nurse is assigned to a team with another registered nurse and an LPN. Which of the following patients should the nurse assign to the LPN?
1. A 67-year-old man who is NPO and scheduled for a transurethral resection of the prostate (TURP) in three hours.
2. A 53-year-old woman with an IV of 0.9% NaCl at 100 ml/hour who had a lumbar laminectomy two days ago.
3. A 40-year-old woman with a Hemovac drain and a large surgical dressing from a mastectomy two days ago and who is showing signs of depression.
4. A 27-year-old woman scheduled for discharge later today after receiving chemotherapy through a portacath for treatment of leukemia.
The nurse knows that for a client to manage at home alone following discharge from the hospital, the client diagnosed with rheumatoid arthritis must be able to perform which of the following tasks?
1. Climb up and down stairs.
2. Lace and tie his/her shoes.
3. Comb his/her hair and brush his/her teeth.
4. Walk without assistance.
A nurse was sued for malpractice but is proved innocent. Which fact from the case was decisive in determining the outcome?
1. Negligence was implied.
2. The suit was filed under the law of negligent tort.
3. No harm was actually suffered by the patient.
4. The nurse failed to give competent care.
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