NURSING 6001 Test Bank questions and answers

NURSING 6001 Test Bank questions and answers Quiz 1 The nurse provides care for a client diagnosed with acute pancreatitis. The nurse intervenes if the client makes which statement? ( Select all that apply. ) 1. “I may need to take antibiotics.” 2. 3. 4. 5. “I should stop drinking alcohol.” 6. “I cannot have anything to eat or drink.” The nurse in the day care center observes a toddler squatting and panting after chasing a ball. Which action does the nurse take first? 1. Remove the child from the playground and encourage rest. 2. 3. Ask the child about a sore throat or achy joints. 4. Restrict the child from playing ball. The nurse cares for clients in the outpatient clinic. In which order will the nurse return the messages? Correct Answer •1. The "soft spot" on the head of the 4-day-old feels slightly elevated when asleep. •2. The circumcision site of the 3-day-old is slightly swollen. •3. The umbilical cord of the 5-day-old is soft and draining exudate. •4. When bed is bumped, a 2-day-old rapidly extends the extremities. The parents of a child diagnosed with hemophilia ask the nurse to explain the cause of the disease. Which response by the nurse is best? 1. "The father transmits the gene to the son." 2. "Both the mother and the father carry a recessive trait." 3. 4. "There is a 50% chance that the mother will pass the trait to each of the daughters." The 6-month-old is brought to the clinic for a well-baby checkup. During the exam, the nurse expects to observe which assessment findings? Select all that apply. 1. A pincer grasp. 2. 3. Tripling of the birth weight. 4. Presence of the posterior fontanelle 5. 6. A client with an endotracheal tube requires suctioning. Which statement is an accurate description of how the nurse performs the procedure? 1. Inserts the suction catheter 4 in into the tube. Applies suction for 30 seconds, using a twirling motion as the catheter is withdrawn. 2. Hyperoxygenates the client. Inserts the suction catheter into the tube, and suctions while removing the catheter in a back and forth motion. 3. Explains the procedure to the client. Inserts the catheter gently while applying suction, and withdraws using a twisting motion. 4. A client comes to the outpatient psychiatric clinic for treatment of a fear of heights. The nurse knows that phobias involve which behaviors? 1. 2. Sublimation and internalization. 3. Rationalization and intellectualization. 4. Reaction formation and symbolization. The nurse cares for the prenatal client at 8 weeks’ gestation with a positive VDRL. When the nurse prepares the teaching plan, it is most important for the nurse to include which information? 1. Advise the client not to take any over-the-counter medications. 2. 3. Inform the client to refrain from sexual activity. 4. Maintain the confidentiality of sexual partners or contacts. The nurse performs range-of-motion (ROM) exercises for an elderly client recently immobilized. The nurse identifies which statement as correct about range-of-motion? 1. Passive ROM exercises increase muscle strength. 2. A full ROM must be completed for the elderly client. 3. Exercises should be completed to the point of discomfort. 4. The nurse cares for an older client scheduled for a colon resection this morning. The nurse notes the client had polyethylene glycol-electrolyte solution and a soapsuds enema the previous evening. This morning the client passes a medium amount of soft brown stool. Which conclusion by the nurse is most accurate? 1. 2. The client ate something after midnight. 3. This is an expected finding before this type of surgery. 4. The client passed the last stool left in the colon. The nurse cares for the newborn infant diagnosed with fetal alcohol syndrome. The nurse expects to see which characteristics? 1. An infant large for gestational age (LGA), craniofacial abnormalities, and hydrocephalus. 2. 3. An infant with a large head circumference, low birth weight, and excessive rooting and sucking behaviors. 4. An infant with a normal head circumference, low birth weight, and respiratory distress syndrome. The nurse watches as a parent and infant interact. The infant throws a toy to the floor numerous times. The parent picks up the toy and gives it back to the infant. If the parent does not immediately return the toy, the infant cries loudly. Which statement by the nurse is best? 1. “Be sure to wipe the toy off each time before you give it back. These floors are filthy.” 2. “Your baby is either stubborn or wants attention, I cannot figure out which.” 3. “I remember when my own baby used to do that.” 4. The nurse admits an older adult client who reports fever and chills to the medical unit. Which assessment finding most concerns the nurse? 1. 2. The client's RR is 18 breaths/min and BP is 110/70 mm Hg. 3. The client's white blood cell count is 16000/µL (16.00×109/L). 4. The client's platelet count is 325 ×10 3/µL (325×109/L). The nurse provides care for a client in an outpatient clinic who reports vaginal itching. Which recommendation to the client by the nurse isappropriate? 1. “Supplement your diet with yogurt and dairy products.” 2. “Douche with an over-the-counter preparation.” 3. “Wash the area with soap and water several times a day.” 4. The nurse supervises care of a client in Buck traction. Which observations does the nurse determine are appropriate? ( Select all that apply. ) 1. 2. 3. The staff provides back care for the client once per shift. 4. 5. The staff offers magazines to the client when the client reports pain. 6. The nurse assesses an older adult client who experienced a stroke. Which findings indicate to the nurse that the client has cognitive impairment? ( Select all that apply. ) 1. Ataxia. 2. 3. Upper arm flaccidity. 4. 5. Flat affect. The nurse assesses a 2-hour old newborn. The nurse notes the newborn’s hands and feet are bluish in color. To which reason does the nurse attribute this finding? 1. A lack of adjustment to environmental temperature. 2. 3. A lowered oxygen tension. 4. A low hemoglobin level. A client is prescribed 8 units of regular insulin per hour. The insulin is prepared with 500 units in 250 mL of 0.9% normal saline. At which rate in mL/hr will the nurse set the infusion pump? ( Do not round. Record your answer using a whole number. ) Ans: 4 mL/hr A toddler is prescribed phenobarbital 120 mg by mouth. The vial contains 160 mg of the medication in 5 mL. Which amount of medication in milliliters will the nurse administer to the client? (Record your answer using one decimal place. Do not round.) Ans: 3.7 mL The health care provider prescribes estrogen daily for a middle-age adult client. Which client statement indicates to the nurse that further teaching is necessary? 1. "There may be a change in my libido." 2. "I may experience a change in my weight." 3. "I may have some difficulty wearing my contact lenses." 4. A nurse in a rural community assesses residents for risk factors for heart disease. The nurse determines that which resident is at greatest risk to develop heart disease? 1. A resident who participates in a competitive weight lifting program. 2. 3. A resident whose grandfather died of heart failure at age 72. 4. A resident who drinks a glass of beer every night. The nurse provides care to a group of clients. In which order will the nurse complete care for these clients? (Please arrange in order. All options must be used.) Correct Answer •1. Assess a client diagnosed with a decreased level of consciousness who had an ischemic stroke yesterday. •2. Assess a client reporting weakness and tingling in the lower extremity accessed for a cardiac catheterization. •3 . Notify the health care provider of serum potassium of 5.2 mEq/dL (5.2 mmol/L ) in a client diagnosed with acute kidney failure. •4. Administer morning medications to a client scheduled for hemodialysis within the hour. The nurse provides care for a client diagnosed with Parkinson disease. Which client statements indicate a need for additional follow-up by the nurse? ( Select all that apply. ) 1. 2. "I've read that deep brain stimulation may help my shakiness." 3. "I don't have enough energy to do yard work." 4. 5. "My family 6. A client receiving parenteral nutrition is to receive an intravenous fat emulsion infusion. Which action will the nurse take when administering the fat emulsion? 1. 2. Provide it as intravenous boluses. 3. Wrap the infusion container in aluminum foil. 4. Infuse it through a central line. The nurse performs discharge teaching for an older adult client diagnosed with peripheral artery disease. It is important for the nurse to include which instruction? 1. “Soak in a tub of warm water twice per day or perform foot soaks.” 3. “Elevate your legs above the level of your heart four times per day.” 4. “Sit for a total of 6 hours per day with your feet resting on the floor.” The nurse assesses a 1-month old infant. Which finding will the nurse investigate further? 1. Anterior fontanel taut when the infant cries. 2. Head lag present when the infant is pulled from a lying to a sitting position. 3. 4. Left arm and leg extend when the head is turned to the left. A client diagnosed with a head injury is being prepared for a lumbar puncture. Which action will the nurse take first? 1. Obtain informed consent. 2. 3. Explain the procedure to client. 4. Locate a lumbar puncture tray. A client weighing 53 lb is prescribed IV atropine 0.02 mg/kg now. The medication available is 0.8 mg/mL. Which amount in milliliters will the nurse provide to the client? (Round at the end of the equation. Record your answer using one decimal place.) Ans: 0.6 mL The nurse provides care to a client admitted with mild hyponatremia secondary to excessive water consumption. Which intervention does the nurse anticipate including in the client's plan of care? 1. Administering 0.45% sodium chloride IV. 2. 3. Administering 3% sodium chloride IV. 4. Encouraging frequent ambulation. A client is to undergo an electroencephalogram (EEG) the following day as part of the workup for evaluation of seizure activity. Which statement is approrpiate for the nurse to include when preparing the client for the test? 1. 2. “You will need to wash your hair after the test, so do not bother washing it beforehand.” 3. “Be careful not to eat or drink anything for at least 6 hours before the test.” 4. “There will be harmless pricking sensations during the test as the electricity enters your brain.” The nurse provides care for a client diagnosed with spinal cord injury at the level of T1. The nurse notes profuse sweating, and the client reports a pounding headache and nasal stuffiness. In which order does the nurse provide care for this client? (Please arrange in order. All options must be used.) • 1 . Place the client in a sitting position. • 2 . Check the indwelling catheter tubing for kinks or obstruction. • 3 . Monitor the blood pressure every 10 to 15 minutes. • 4 . Label the chart with a visible note about the risk for autonomic dysreflexia. • 5. Instruct the client about how to prevent autonomic dysreflexia. The nurse provides care for a comatose client. The nurse is unable to elicit a reaction after applying the trapezius squeeze, supraorbital pressure, mandibular pressure, and sternal rub. Which action does the nurse take next? 1. Administer diuretics as prescribed. 2. Lower the head of the bed. 3. 4. Begin cardiopulmonary resuscitation. A client with type 2 diabetes mellitus is prescribed pioglitazone and metformin. Which client health history information causes the nurse to question the prescription of these medications? ( Select all that apply. ) 1. History of essential hypertension. 2. Weight loss of 30 lb (13.6 kg) over the past 6 months. 5. A child History of lactic acidosis. with failure to thrive has a positive sweat test. Which change does the nurse anticipate in this client's plan of care? 1. 2. Apply oxygen. 3. Provide a salt-restricted diet. 4. Initiate intravenous therapy. The outpatient clinic nurse cares for an elderly client diagnosed with type 1 diabetes. Because the client is unwilling to perform blood glucose monitoring, the client tests urine for glucose and acetone. The nurse knows that blood glucose monitoring is preferred over urine testing for glucose because of which reason? 1. 2. Blood glucose monitoring is easier and less costly for clients to perform. 3. Urine testing for glucose provides false-positive readings. 4. Determination of the color on a reagent strip varies from person to person. The health care provider orders hydromorphone hydrochloride 15 mg IM for a client. The nurse observes for which adverse effects? 1. Photosensitivity and constipation. 2. 3. Tardive dyskinesia and diplopia. 4. Dry mouth and tinnitus. The outpatient clinic nurse cares for an elderly client diagnosed with type 1 diabetes. Because the client is unwilling to perform blood glucose monitoring, the client tests urine for glucose and acetone. The nurse knows that blood glucose monitoring is preferred over urine testing for glucose because of which reason? 1. The renal threshold for glucose is elevated in the elderly. 2. Blood glucose monitoring is easier and less costly for clients to perform. 3. Urine testing for glucose provides false-positive readings. 4. Determination of the color on a reagent strip varies from person to person. At 32 weeks gestation, the client has an order for an ultrasound. The nurse determines that the client understands the procedure if the client makes which statement? 1. 2. This test will evaluate the baby's lungs. 3. The test will show us if there is any problem in the baby's genes. 4. Early problems with the baby's blood can be identified with this test. The nurse cares for the child diagnosed with pediculosis capitis (head lice) who is being treated with permethrin 1% cream rinse. The nurse includes which information when instructing the child’s parents? 1. Apply the cream rinse every other day for 1 week. 2. Wash the child’s clothing and personal belongings in soap and cool water. 3. 4. Comb the child's hair weekly with a nit comb. The nurse supervises an LPN/LVN administering an enema to a client. The nurse determines the LPN/LVN’s actions are appropriate if which action is observed? 1. The LPN/LVN places the solution 20 inches above the anus. 2. The LPN/LVN adjusts the temperature of the solution. 3. The LPN/LVN inserts the tube 6 inches. 4. Individual Study The nurse teaches a group of nursing students about elder abuse. Which older adult client does the nurse list as most likely to be a victim of abuse? 1. A male diagnosed with moderate hypertension. 2. A male with newly diagnosed cataracts. 3. 4. A female diagnosed with early stage Lyme disease. A parent asks the nurse when an infant can begin to eat solid foods. The nurse assesses the infant’s readiness to begin eating solid foods. Which assessment finding indicates to the nurse that the parent should wait to introduce solid foods? 1. Intact suck-swallow reflex. 2. Drooling present. 3. 4. Easily distracted from breastfeeding. The nurse performs discharge teaching for a client after a right side mastectomy. It is important for the nurse to include which instruction? 1. Place a heating pad under the right shoulder nightly. 2. Keep the right arm in a sling for 4 weeks. 3. Attend the Reach to Recovery support group every day. 4. The nurse provides care to a client receiving total parenteral nutrition (TPN). Which intervention will the nurse include in the care plan for this client? 1. 2. Maintain the client on complete bed rest. 3. Stop the infusion every 4 hours to give medications. 4. Flush the line with water prior to starting nutritional support. The nurse overhears two unlicensed assistive personnel (UAP) discuss a client’s protected health information (PHI) in a public elevator. Which action does the nurse take next? 1. Assess the elevator for visitors and nonstaff passengers. 2. Contact the supervisor on the floor where the UAPs work. 3. 4. Notify the hospital risk manager and ethics committee. The nurse discusses immunizations with a client in the third trimester of pregnancy. Which information is appropriate for the nurse to include? ( Select all that apply. ) 1. “Sin 2. “If n vaccine should not be taken while you are pregnant. ” 4. 5. “If you are not immune to varicella, you should get the vaccination now. ” Which technique does the nurse implement when performing a physical examination of an infant during a well-child visit? 1. Avoid auscultating breath sounds while the infant sleeps. 2. Undress the infant, including the diaper, for the entire assessment. 3. 4. Assess the infant’s ears first. The nurse prepares to obtain a wound culture from a client in long-term care. In which order will the nurse perform the steps necessary to culture the wound? (Please arrange in order. All options must be used.) • 1. Assess pain level at wound site. • 2. Perform hand hygiene and apply sterile gloves. • 3. Clean exudate from wound and wound edges. • 4. Insert tip of sterile swab into wound and rotate gently. • 5. Ensure swab tip is in culture medium in collection container. The nurse observes a preschooler interact with the parent. Which observation by the nurse is most concerning? 1. The parent explains that injections will burn like a bee sting. 2. 3. The parent offers to let the child sit in the parent’s lap while the nurse administers an injection. 4. The parent tells the child that it is okay to cry. The nurse instructs a client about the care of a new colostomy. Which information does the nurse include? ( Select all that apply. ) 1. Change the ostomy appliance following a meal. 2. Use a moisturizing soap to clean skin around stoma. 3. 4. 5. 6. The spouse of a client recovering from an amputation contacts the home care nurse because the client experiences severe pain in the missing limb. Which response is the best for the nurse to make to the spouse? 1. “Is the client lying on the abdomen as prescribed? ” 2. “Please try to calm down. There is nothing to be upset about. ” 3. “Is the residual limb bleeding or does it have an unusual odor? ” 4. The nurse provides care to oncology clients. Which clients require further intervention from the nurse? ( Select all that apply. ) 1. The client receiving chemotherapy treatment for breast cancer who reports “always feeling tired.” 2. The client receiving a chemotherapeutic a implanted port with redness on the chest. lkylating agent intravenously via an 3. The client with bladder cancer reporting that “nothing tastes good” and who drinks four cans of nutritional supplement daily. 4. The client receiving radiation for lymphoma who reports there are handfuls of hair on the pillow every morning. 5. 6. The client who reports frequent bouts of manageable with occasional sips of fluid. diarrhea but states the The nurse provides care for a client diagnosed with left-sided weakness and impaired speech. Which intervention is appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? ( Select all that apply. ) 1 2. Monitor blood pressure regularly. 3. Obtain medical history for risk factors. 4. 5. Determine readiness for smoking cessation. The nurse provides care for a client before surgery. Thirty minutes after administering the preoperative medication, the nurse observes the unlicensed assistive personnel (UAP) ambulate the client to the bathroom. Which action should the nurse take first? 1. 2. Ask the UAP if the client had difficulty walking. 3. Determine why the UAP ambulated the client. 4. Ensure that the UAP receives the appropriate training. The nurse prepares to collect a 24-hour urine specimen for creatinine clearance. Which action does the nurse take? 1. 2. Discard the last voided specimen prior to ending the collection. 3. Obtain a prescription from the health care provider for a urinary catheter. 4. Determine the client’s weight prior to beginning the urine collection. The nurse manager prepares to implement self-scheduling for the unit. In which order does the nurse manager proceed with this task? (Please arrange in order. All options must be used.) • 1. Assess unit staffing needs. • 2. Discuss unit staffing needs with supervisor. • 3. Hold a unit meeting to educate staff about self-scheduling. • 4. Post a blank schedule on the unit for staff to choose their shifts. • 5. Review the schedule and revise as needed. A client with a possible fracture of the right femur comes to the emergency department. The nurse supervises the transfer of the client from the car to a stretcher. Which is the bestaction by the nurse? 1. Instruct the client to stand on the left leg and to ease onto the stretcher. 2. Determine if the client fell from a high place. 3. 4. Ask the client if there is movement in the right hip or right knee. The nurse provides care for a client diagnosed with heart failure and treated with furosemide. Which client statement indicates to the nurse that the client is experiencing an adverse medication effect from furosemide? ( Select all that apply. ) 1. 2. “I can’t seem to catch my breath.” 3. “I can’t g 4. 5. “My feet feel like two balloons.” The nurse provides an albuterol nebulizer treatment to a client recovering from respiratory failure. Which finding does the nurse expect to observe after treatment? (Select all that apply.) 1. 2. Increased wheezes in upper lobes. 3. Decreased crackles in lower lobes. 1. Reports o 2. The unlicensed assistive personnel (UAP) calls the nurse and states, “The client in room 218 is reporting shortness of breath.” Which response by the nurse is appropriate? 1. “Call the respiratory therapist and request an arterial blood gas be performed.” 2. “Ask the client when the shortness of breath started.” 3. 4. “Listen to the client’s lung sounds and notify me if you hear wheezing or crackles.” A client is prescribed irbesartan 300 mg by mouth twice a day. The medication is available in 150 mg tablets. Which number of tablets will the nurse provide for each dose? ( Record your answer rounding to the nearest whole number. ) Ans: 2 tabs The nurse provides care for a client who had a transurethral resection of the prostate (TURP). The client has a three-way urinary catheter connected by gravity with continuous bladder irrigation (CBI) of normal saline. Which observations require the nurse to intervene? ( Select all that apply. ) 1. 2. 3. Fluid leak 4. Blood pressure of 112/76 mm Hg. 5. 6. Client reports pressure in the pelvis. The nurse provides care for a client who just passed a renal calculus. The nurse sends the specimen to the laboratory. Which specimen analysis will assist the nurse to plan care? 1. Type of infection. 2. Size and number of calculi. 3. Antibodies. 4. A client in the psychiatric unit continually states to the nurse, "My stomach is missing." Which response by the nurse is appropriate? 1. “Well then, you should not have any trouble losing weight.” 2. “Where did your stomach go?” 3. 4. “I am here to help you, okay?” The nurse assesses the client who has a distended bladder. Because the client is unable to void, the health care provider prescribes catheterization. Which action does the nurse perform immediately after the catheter is inserted? 1. 2. Keeps the client in a prone position. 3. Asks the client to take deep breaths. 4. Asks if client has had the problem before. Study The nurse provides care for an older adult client after a left total hip replacement. Which finding will the nurse be most concerned about? 1. The client is positioned with a pillow between the legs. 2. The client moves slowly when getting out of bed. 3. 4. The client uses an incentive spirometer every 2 hours. The school nurse performs scoliosis health screening with a group of middle school students. For which student will the nurse be the most concerned? 1. Child reports a painful right knee. 2. Child’s feet turn inward. 3. Child shifts weight from the right foot to the left foot. 4. The nurse receives report on a client admitted to the unit with a new diagnosis of abdominal aortic aneurysm (AAA). When teaching the client measures to reduce the risk of complications associated with AAA, which instruction does the nurse include? 1. Elevate the lower extremities above the level of the heart. 2. Encourage the increase of fluid intake and dietary fiber. 3. techniques. Utilize proper lifting 4. Avoid wearing a seatbelt while driving. A nurse in the pediatric clinic discusses the potential of lead exposure with the parents of preschoolers. It is important for the nurse to follow up on which statement made by a parent? 1. “I use water from the cold water tap for cooking.” 2. “My child likes to finger paint.” 3. 4. “My child is very good about eating regular meals.” The nurse admits an older adult client diagnosed in the early stage of Alzheimer disease. Which factor causes the nurse to place the client on fall precautions? 1. Increased muscle tone and rigidity. 2. 3. Extension of the head and neck. 4. Shuffling gait. The nurse teaches a client who is newly diagnosed with type 1 diabetes mellitus. Which information does the nurse include in the client’s discharge teaching? (Select all that apply.) 1. 2. 3. Reduction 4. Symptoms and treatment of hypoglycemia. of physical activity. 5. Elimination of carbohydrates from diet. During a pregnant client’s nonstress test (NST), the nurse observes several late fetal heart rate decelerations. Which nursing action is most appropriate? 1. Reposition the client on the right side. 2. 3. 4. Stop the oxytocin immediately. The health care provider prescribes vancomycin 40 mg/kg daily for a pediatric client weighing 90 pounds (40. kg). The medication is administered orally in four equally divided doses. The vancomycin is available as a 250 mg/5 mL concentration. How much medication does the nurse administer per dose? (Do not round. Record your answer using one decimal place.) Ans: 8.1 mL The nurse assesses a client in the emergency department. Which symptoms cause the nurse to suspect that the client is experiencing a panic attack? 1. 2. Decreased blood pressure, chest pain, choking feeling. 3. Increased blood pressure, bradycardia, shortness of breath. 4. Increased respiratory rate, increased perceptual field, increased concentration ability. The client takes beclomethasone by metered dose inhaler (MDI). Which statement made by the client indicates that teaching is successful? 1."I know it is time to have the prescription refilled when the canister floats in water." 2. 3. "I will be sure not to shake the canister before I use it." 4. "If the dose does not help, I will take extra and let the health care provider know the results." The nurse prepares to complete a health history with a client seeking treatment at the medical clinic for diabetes mellitus. Which question will best provide information about the client’s reason for seeking medical care? 1. “Has your diabetes been under control?” 2. 3. “How has your health been lately?” 4. “Describe to me how you are feeling”. The nurse supervises a novice nurse providing care to a client with new symptoms of a cerebrovascular accident (CVA). Which actions by the novice nurse cause the seasoned nurse to intervene? ( Select all that apply. ) 1. 2. Prepares the client for a CT scan. 3. 4. Assigns the client a 0 score on the National Institute of Health stroke scale screen. Measures the client’s blood pressure. 5. Compiles a list of the client’s home medications. 6. Reassures the client that all symptoms will resolve. The nurse provides care for a client diagnosed with a detached retina. Which post-operative medication prescription does the nurse question? ( Select all that apply. ) 1. Droperidol. 2. Polyethylene glycol 3350. 3. 4. Benzonatate. 5. Hydromorphone . 6. Clonidine . The nurse assumes care for a client from the post-anesthesia care unit (PACU). In which order does the nurse provide care for this client? (Please arrange in order. All options must be used.) • 1. Perform a focused assessment of the client, including vital signs. • 2. Observe incision or dressing and drainage tubes. • 3. Review health care provider's postoperative prescriptions. • 4. Develop a plan of care based on findings and the individual's risk factors. • 5. Develop and implement individualized client education. Individual Study 2 The nurse provides care for the client diagnosed with heart failure and who takes digoxin 0.25 mg and furosemide 20 mg daily. Which assessment findings indicate the need for the nurse to intervene based on the current diagnosis and treatment regimen? (Select all that apply.) 1. . 2. Intestinal colic. 3. 4. 5. 6. Alopecia. The spouse of a client diagnosed with a phobia is concerned by the client's sudden fear of elevators. The spouse asks the nurse what to do when the client becomes frightened. Which action does the nurse encourage the spouse to take first? 1. Ride the elevator with the client. 2. Encourage the client to get into the elevator. 3. 4. Encourage the client to discuss the fear. The nurse provides cares for a client reporting pain at the intravenous (IV) access site. Upon assessment, the nurse notes tenderness and redness at the site and redness proximally along the vein. It is most important for the nurse to take which action? 1. Slow the infusion rate and monitor the client’s response. 2. Stop the infusion and notify the health care provider. 3. Remove the IV and apply a pressure dressing. 4. The nurse administers carbamazepine to a client for trigeminal neuralgia. Which therapeutic effect does the nurse expect after administering this medication? 1. Relieve accompanying depression. 2. Reduce the possibility of tonic-clonic seizures. 3. 4. Provide sedation. 1 er Test (ella ) The nurse provides care for clients in the diabetic clinic. Which client does the nurse assess first? 1. The client with sunken eyeballs and a fruity breath odor. The nurse provides care for a client diagnosed 2. The client reporting pain in both calves when exercising. with a cerebral vascular 3. The client drinking copious water with constant hunger. 4. The client with difficulty sleeping and frequent crying. accident (CVA) who is being treated with heparin. The nurse is concerned by which observations? ( Select all that apply. ) 1. Petechiae on chest. 2. Partial thromboplastin time (PTT) 250 sec (control 38 sec). 3. Hematuria. 4. Platelet count of 150,000/mm 3 (150,000 ×10 9/L). 5. Reddish striae on thighs. 6. Hematocrit (Hct) 32% (0.32 proportion of 1.0). The school nurse assists with planning activities for a class of 10-year-old students. Which activity is appropriate for the nurse to encourage? 1. Using finger paints to create a painting. 2. Playacting a nurse-and-client scenario. 3. Solving math problems. 4. Writing a memoir. The nurse visits the home of a client diagnosed with gout. Which client comment causes the nurse concern during the assessment process? 1. “I am losing three pounds per week.” 2. “I drink eight glasses of liquid per day.” 3. “I am eating more whole grains and fresh fruits.” 4. “I do not drink alcoholic beverages anymore.” The client is prescribed carvedilol 12.5 mg orally twice daily. The pharmacy sends carvedilol 6.25 mg tablets to the unit. How many tablets does the nurse administer for each dose? (Do not round. Record your answer using a whole number.) Ans: 2 tabs The community health nurse provides care for a client who is taking multiple medications for constipation. Which medication causes the nurse the least concern? 1. Psyllium hydrophilic mucilloid. 2. Docusate sodium. 3. Magnesium hydroxide. 4. Bisacodyl. The nurse observes an unlicensed assistive personnel (UAP) preparing to lift an object. Which principle of body mechanics does the nurse recommend to the UAP? 1. “Bend at the waist when you lift objects.” 2. “Carry objects close to your body or above your head.” 3. “Bend your knees when you lif t objects.” 4. “Lean forward when you lift objects.” The nurse provides care for a client diagnosed with a closed head injury. The client begins to vomit. Which additional finding, if occurring with the noted emesis, does the nurse report to the health care provider (HCP)? 1. Increased lethargy. 2. Heart rate of 80 beats/min. 3. Sodium of 145 mEq/L (145 mmol/L). 4. Facial symmetry. The nurse manager on the unit is fiscally responsible for meeting goals related to personnel and supply expenses. To meet budget expectations, it is important for the nurse manager to take which action? 1. Share budget expectations with the personnel on the unit. 2. Designate a staff nurse to assist with budget planning. 3. Post the budget on the bulletin board. 4. Ensure that provider needs are met. A client on the psychiatric unit begins to pace and continuously wring hands, and the nurse notes the client’s voice is becoming louder and angrier. Which action does the nurse take? 1. Utilize an organized team to place the client in seclusion. 2. Allow time in the client’s private assigned room for reflection. 3. Redirect the client to a quiet activity such as journaling. 4. Assist the client to express feelings of anger and frustration. The nurse provides care for a client with a complete heart block (CHB). The nurse questions which prescription from the health care provider? 1. 2. Prepare and administer epinephrine 2 to 10 mcg/min, titrating based on response. 3. Anticipate scheduling the client for a temporary pacemaker if the pulse continues to decrease. 4. Mix and administer 10 mL of 1:5000 solution of isoproterenol in 500 mL Dsustained bradycardia below 30 beats/min. 5W for The nurse notes that the fetal position of a client at 38 week's gestation is left occiput anterior (LOA). Which location will the nurse find the point of maximum intensity of the fetal heart tones? When assessing a client admitted to rule out a myocardial infarction, the nurse determines a history of alcoholism. Which question is a priority for the nurse to ask the client? 1. “What over-the-counter medications do you take? ” 2. “How much alcohol do you consume each day? ” 3. “When did you have your last drink? ” 4. “Have you ever had symptoms of withdrawal? ” The nurse provides care for a 3-month-old infant diagnosed with developmental dysplasia of the left hip. The health care provider prescribes a Pavlik harness. The nurse instructs the parent about how to care for the infant in the harness. Which statement by the parent indicates to the nurse that additional teaching is necessary? ( Select all that apply. ) 1. “I need to place a shirt under the chest straps.” 2. “I should check for reddened areas under the straps.” 3. “I should place my baby’s diaper over the straps.” 4. “I will adjust the harness every couple of weeks.” 5. “I will avoid swaddling my baby’s legs.” 6. “I will place knee socks on my baby.” The nurse provides care to a client diagnosed with sinus arrhythmia. The nurse uses which site to assess the client's pulse? 1. Apical. 2. Radial. 3. Femoral. 4. Carotid. The community health nurse reviews recent laboratory tests for the caseload. Which client should the nurse see first based on the laboratory results? 1. Client with granular casts found in the urinalysis. 2. Client with urine specific gravity of 1.025. 3. Client with blood urea nitrogen of 16 mg/dL (5.7 mmol/L). 4. Client with serum creatinine of 1.0 mg/dL (88.4 µmol/L). The nurse observes children playing at a community picnic. Which situation is the most important for the nurse to intervene? 1. School-aged child picking at a scab located on the knee. 2. Preschooler running with a lollipop in the mouth. 3. Toddler lying on the ground kicking and screaming with the parents close by. 4. Infant lying on the back, head to the right side with the left arm and leg bent. The nurse provides care for a client who is scheduled for a kidney transplant. The transplant will come from a living donor. Which preoperative assessment is most important for the nurse to complete? 1. Support system and grasp of required lifestyle changes. 2. Urine output. 3. Signs of graft rejection. 4. Signs and symptoms of rejection. The nurse assesses a client’s hearing by performing the Weber test. The nurse notes that the sound lateralizes to the client’s right ear. Which interpretation does the nurse make? 1. Nystagmus will require further evaluation. 2. Conductive hearing loss in the left ear. 3. This is a normal finding to document. 4. Sensorineural hearing loss in the left ear. The nurse on the burn unit orients new staff to infection control issues. Which measure is most important to emphasize for this particular type of unit? 1. Wear gowns, gloves, masks, as well as shoe and hair cover. 2. Ensure that no equipment is shared between clients. Assign clients diagnosed with infection to private rooms with negative-pressure 3. air flow. 4. Wash hands using a thorough and consistent approach.F The nurse provides care for a client who has been taking fluoxetine for 4 weeks. Which observation most concerns the nurse? 1. The client frequently uses sarcasm. 2. The client has been giving away some possessions. 3. The client has been sleeping 9 hours each night. 4. The client has started waking up at 0600 every morning. The nurse provides care for a pregnant client. The client comes for a second prenatal visit at 15 weeks' gestation. The client’s blood pressure is 120/72 mm Hg. The client’s first blood pressure at 12 weeks' gestation was 124/80 mm Hg. Which action does the nurse implement based on this information? 1. Document the blood pressure. 2. Retake the blood pressure with the client in a side-lying position. 3. Review nutrition with the client to determine iron intake. 4. Notify the health care provider. The home health nurse visits a client who has been diagnosed with human immunodeficiency virus (HIV) and lives alone in an apartment. Which observation of the home environment most concerns the nurse? The client has a cat, two birds, and a tropical fish tank, and the client says, “I 1. 2. There is a covered pitcher of water in the refrigerator, and the client says, “I know it is important for me to drink fluids, so I always keep water handy.” There are silk houseplants and flowers throughout the apartment, and the client 3. says, “I’m not much of a gardener but I love nature, so I pretend all these are real.” The dishwasher is broken and the apartment water pressure is low, and the 4. client says, “Getting the maintenance person to make any repairs is almost impossible.” The nurse on the psychiatric unit finds a client crying. As the nurse approaches the client, the client states, “What do you want? Go away. I hate you, and I hate myself.” Which response by the nurse is appropriate? 1. “Why is it that you don’t like me or you?” 2. “I will come back later when you are in a better mood.” 3. “It is difficult for me to communicate with you when you talk this way.” 4. “You seem to be in pain, so I will stay with you.” The nurse completes an admission for a client diagnosed with depression to the psychiatric unit. It is important for the nurse to take which action? 1. Give the client a brief orientation to the unit. 2. Explain the activities available to the client. 3. Introduce the client to the nursing staff. 4. Ask the client to choose activities in which to participate. The parent of a newborn prepares for discharge home. Which statement, if made by the parent to the birthing center nurse, indicates that further teaching is necessary? 1. “I will only bathe my baby two or three times a week.” 2. “After my baby eats, I will put my baby on the right side.” 3. “For the first couple of months, I will keep the baby in bed with me at night.” “If my baby has less than eight to 10 wet diapers a day, I will feed my baby 4. more often.” An infant who is prescribed digoxin 0.02 mg/kg by mouth in divided doses is sleeping and has a regular heart rate of 80 beats/min. Which action does the nurse take? 1. Stimulate the sole of the infant’s foot to recheck heart rate. 2. record. Give the medication as prescribed and document the heart rate in the medical 3. Withhold the medication and immediately notify the health care provider. 4. Ask another nurse to recheck the infant’s heart rate. The nurse prepares to complete an initial assessment for a client who has an indwelling urinary catheter. Which observation indicates to the nurse a need for intervention? 1. The client’s urinary drainage bag contains amber-colored urine. 2. The client’s urinary drainage tubing does not contain a dependent loop. 3. The client’s urinary drainage system is positioned below the level of the bladder. 4. The client’s urinary drainage bag is secured to the client’s sheet. The nurse admits a client diagnosed with major depression. The client has been experiencing difficulty falling asleep for about 6 months. Which response by the nurse is best? 1. “Tell me about your nighttime routine.” 2. “Why do you think you have trouble sleeping?” 3. “Six hours of sleep is all you need to function.” 4. “Drink hot milk 1 hour before bedtime.” The nurse instructs a client about Kegel exercises to manage urinary stress incontinence. Which statement by the client indicates to the nurse that the teaching is effective? 1. “I will do the exercises for longer periods than required.” 2. “When it is time to do the exercises, I will sit down.” 3. “I will hold my breath as I am tightening my muscles.” 4. “When I do the contractions, I will pretend I am trying to stop passing gas.” The nurse provides care to an intrapartum client on the labor-and-delivery unit. Which observation requires follow up? (Select all that apply.) 1. The partner answers questions that are directed toward the the client. 2. The client screams and uses obscenities during the delivery. 3. The partner refuses to leave the client's side when asked to do so. 4. The client reports excitement about the birth experience. 5. Fetal heart rate varies from 130 bpm and 150 bpm. 6. Each contraction lasts longer than 90 seconds. The nurse provides care for an antepartum client. Which factors, identified by the nurse on assessment, increase the risk of thrombosis? ( Select all that apply. ) 1. Vaginal birth. 2. Obesity. 3. Maternal age greater than 27 years. 4. Varicose veins. 5. Forceps use during delivery. The nurse provides cares for a client who sustained a T5 spinal cord injury four weeks ago. The nurse observes that the client is diaphoretic, nauseated, and reports a severe headache. Which action does the nurse take first? 1. Place the client in a sitting position. 2. Assist the client to empty the bladder. 3. Examine the client's rectum. 4. Administer hydralazine as prescribed. The home health nurse visits a client diagnosed with dementia. The client lives with an adult child and family. The nurse identifies which stressor as most critical to the family? 1. The client is unwilling to eat with the family. 2. The client does not recognize family members. 3. The family is not aware of community resources available to them. 4. The client is continent. The nurse performs discharge teaching for a client treated for cervical cancer with a cesium 137 implant. The nurse learns that the client works 40 hours per week in a factory and has a toddler and preschooler at home. Which client statement indicates that further teaching is needed? 1. “I will call the health care provider if I am still bleeding after a couple of days.” 2. “I will abstain from sexual intercourse and not use tampons for 2 weeks.” 3. “I cannot lift either of my children for 2 months.” 4. “I will take showers for the next 2 weeks.” The nurse prepares to administer hydroxyzine to a client. For which reason does the nurse use the Z-track method when administering this medication? 1. Slows the rate of absorption. 2. Is the safest and least painful way to give the injection. 3. Reduces irritation to the subcutaneous and skin tissues. 4. Prevents the medication from seeping into the venous circulation. The nurse makes rounds on clients on the medical-surgical unit. It is important for the nurse to intervene for which observation? 1. A client 10 hours post-tonsillectomy sits in a bedside recliner watching television. 2. 3. A client 3 days post–below knee amputation (BKA) lies prone in bed. 4. A client admitted yesterday with COPD sits with the head of the bed elevated 45degrees. A preschool-age client is recovering from a tonsillectomy and adenoidectomy. The client is discharged home with the parents. Which instruction will the nurse give to the parents? ( Select all that apply. ) 1. Monitor the child for continuous swallowing. 2. Encourage the child to deep breathe and cough every 2 hours. 3. Administer pain medication, such as acetaminophen, as needed. 4. Administer codeine elixir routinely for pain. 5. Monitor the child for restlessness and difficulty breathing. The nurse provides care for a client diagnosed with cholelithiasis. Which assessment findings will the nurse identify as risk factors to the development of the cholelithiasis? (Select all that apply.) 1. A vegan diet. 2. A body mass index of 46. 3. Having five children. 4. Taking 81 mg aspirin daily. 5. Age. The nurse provides care to a client diagnosed with a hearing impairment. Which approach will the nurse use to facilitate communication with the client? 1. Use a normal tone. 2. Speak directly into the impaired ear. 3. Talk louder. 4. Talk faster. The nurse finds a client restless, cyanotic, and clutching the throat between the thumb and fingers. Which action is appropriate for the nurse to implement? ( Select all that apply. ) 1. Slap the client on the back. 2. Call for help. 3. Insert a nasopharyngeal airway. 4. Deliver abdominal thrusts. 5. Ask if the client can speak. The nurse provides care to a client with stage 1 Lyme disease. Which finding will the nurse expect when assessing this client? 1. Flu-like symptoms. 2. Arthralgias. 3. Signs of neurological disorders. 4. Enlarged and inflamed joints. The nurse presents a program at the community center about risk factors for colorectal cancer. Which client does the nurse identify as being at risk for colorectal cancer? 1. An 18-year-old client who exercises five times weekly. 2. A 54-year-old client who eats a diet high in fat. 3. A 35-year-old client whose cousin was diagnosed with colorectal cancer at age 32. 4. A 45-year-old client who had an appendectomy during the teen years. The nurse of a client in a long-term care facility talks with the client’s spouse. The spouse reports seeing a red haze within visual fields for the past several days. Which response by the nurse is most appropriate? 1. “Have you been getting enough sleep?” 2. “How long have you had this problem?” 3. “I am concerned about how this may affect your driving.” 4. ologist?” An unlicensed assistive personnel (UAP) was injured in an automobile accident. After rehabilitation, the UAP walks with a limp and a slow, unstable gait. The UAP returns to work on an acute care surgical unit. Which action by the nurse manager is best? 1. Survey other units for more suitable positions for the UAP. 2. Recommend the UAP apply for disability benefits. 3. Transfer the UAP to a less demanding shift on the unit. 4. Transfer a portion of the UAP’s duties to other staff. The clinic nurse assesses an adult client who presents for a routine visit. Which finding concerns the nurse? 1. Weight of 142 lb (64 kg) and height of 5 feet, 7 inches. 2. Extremities warm to the touch. 3. Skin fails to tent when pinched and released. 4. Hair thin, dull, and dry. A client receives isoniazid, rifampin, ethambutol, and pyrazinamide. Which statement made by the client most concerns the nurse? 1. "I seem to be becoming color blind. I can’t see green." 2. "My urine and sweat are a reddish-orange color." 3. "Sometimes I wonder what I did to deserve all this." 4. "My big toe has started hurting so I can hardly walk." The nurse provides care for a client prescribed negative pressure wound therapy for a wound on the left lower extremity. Which is the most important action for the nurse to take prior to initiation of the therapy? 1. Check serum protein levels. 2. Check serum calcium level. 3. Assess capillary refill of the upper extremities. 4. Check white blood cell count. A client seeks emergency care for blood draining from the right ear after being in a motor vehicle crash (MVC). Which action will the nurse take first? 1. Notify the health care provider that the client ’s condition could become critical. 2. Examine external ear for injuries. 3. Ask if the ear hurts. 4. Complete appropriate forms. The nurse provides care for a young adult female client diagnosed with type 1 diabetes mellitus (DM). When teaching the client about measures to prevent long-term complications, which instruction does the nurse include? “Use a vaginal douche after each menstrual 1. period.” 2. “Wear cotton undergarments.” 3. “Limit your fluid intake to 2 liters per day.” 4. “Empty your bladder every 6 hours.” The nurse provides care for a client diagnosed with atherosclerosis. Which client statements about clopidogrel require follow-up by the nurse? ( Select all that apply. ) 1. “This medication may cause my blood pressure to be low. ” 2. “I play racquetball three times each week for exercise. ” 3. “I need to go back to the health care provider next year. ” 4. “I take my medications at the same time each day. ” 5. “I take this medication, so I don ’t have a stroke. ” 6. “I will notify my health care provider if I notice bruises. ” The nurse observes a client move up and down in the bed. Which type of therapeutic exercise is this client performing? 1. Passive. 2. Active-assistive. 3. Active. 4. Resistive. A client is admitted to the psychiatric unit with a diagnosis of major depression. The client describes to the nurse suicidal thoughts that have occurred for the past 3 days. Which client statement causes the nurse to institute a one-to-one observation of the client? 1. “This is not the first time I felt this way.” 2. “I will not sign a no-suicide contract.” 3. “This is my fifth hospitalization for depression.” 4. “My mother attempted suicide at age 40.” A client with cancer asks the nurse about late effects of chemotherapy and radiation treatments. Which late effect will the nurse include when responding to this client? 1. Nausea and vomiting. 2. Third space syndrome. 3. Secondary malignancies. 4. Continuing myelosuppression. The nurse provides care to a client with suspected influenza. To promote infection control, the nurse ensures implementation of which precautions? ( Select all that apply. ) 1. Standard precautions. 2. Neutropenic precautions. 3. Contact precautions. 4. Droplet precautions. 5. Airborne precautions. The nurse provides care to a client 4 weeks after a kidney transplant. Which client statements require immediate follow-up by the nurse? ( Select all that apply. ) 1. “I take an antacid after meals, which helps with my indigestion.” 2. “My family was disappointed when I told them I would stay home from vacation this year.” 3. “I found that a little wine in the evening helps me sleep better.” 4. “My feet were so itchy until my adult child told me to start using lotion twice a day.” 5. “I worry that my new kidney will quit working.” 6. “I saw that my blood pressure was up a little. I think I get nervous when I come to the office.” The nurse provides care for a client during a wellness visit. The client reports constipation. Which self-care measures will the nurse discuss with this client? ( Select all that apply. ) 1. Eat low-fiber foods. 2. Use enemas daily to promote elimination. 3. Establish a bowel routine one hour after meals, if needed. 4. Drink two to four glasses of water per day. 5. Follow a regular exercise program. The nurse provides care for a client who is near death. Which statement supports the importance of spiritual care at the end of life? 1. It is necessary to periodically assess the client’s spiritual needs. 2. Interventions related to spiritual needs require a health care provider’s prescription. 3. Nurses may refer spiritual needs to a social worker. 4. The nurse should consult with the health care provider before calling a clergy. The nurse assigns a client who is receiving oxygen via a Venturi mask to the unlicensed assistive personnel (UAP). Which task can be delegated by the nurse to the UAP? ( Select all that apply.) 1. Attach the client to the finger pulse oximeter. 2. Take the client’s vital signs and record the results. 3. Report changes in the oxygen saturation to the nurse. 4. Place the call button within reach of the client. 5. Adjust the oxygen flow rate based on the client’s need. The nurse provides instruction for a client receiving furosemide. Which potassium-rich food selections by the client indicate to the nurse that the teaching was effective? (Select all that apply.) 1. One medium baked potato. 2. One slice of white bread. The nurse on the surgical unit is aware that protein-calorie malnutrition contributes to postoperative infections. Which 3. One medium apple. observation indicates that the client's protein intake is 4. One scrambled egg. adequate? 5. 1 1/4 cups of corn flakes. 6. 1 cup of cantaloupe.1. The client eats 1/2–3/4 of the food on each meal tray. 2. The client consumes 5 g of protein at each meal. 3. The client requests grilled chicken, greek yogurt, and milk for lunch. 4. The client's serum albumin is 4.0 g/dL (40 g/L). The nurse assesses a client diagnosed with a perforated duodenal ulcer. Which initial symptom will the nurse expect to observe upon assessment? 1. Emesis. 2. Pain. 3. Diarrhea. 4. Fever. The nurse provides care for a client receiving carbidopa/levodopa. Which statement, if made by the client ’s spouse to the nurse, indicates the medication is effective? 1. “My husband has gained two pounds in the last month. ” 2. “My husband gets fewer upper respiratory infections. ” 3. “My husband ’s tremors have disappeared completely. ” 4. “My husband is better able to walk around in the yard. ” The nurse provides care for a client receiving 40 drops per minute of 0.9% sodium chloride. The IV set delivers 10 drops per mL. If the nurse begins infusing 1000 mL of IV fluid at 1200, how many milliliters of fluid will be remaining at 1530? (Record your answer rounding to the nearest whole number.) Ans: 160 mL A neonate is treated in the newborn nursery for hyperbilirubinemia using phototherapy lights. Which situation requires immediate intervention by the nurse? 1. The parent turns off the phototherapy lights and removes the newborn ’s eye patches in preparation for feeding. The parent is worried because the newborn experiences frequent loose, greenish 2. stools and increased urine output. 3. A laboratory technician turns off the phototherapy lights to draw the newborn's blood. The jaundice observed around the newborn ’s eyes and nose has begun to 4. disappear. The nurse instructs the parent of a young child about how to check the capillary refill on the child ’s casted left foot. Which statement, made by the parent, indicates that further teaching is necessary? “The color of the nailbed should be pink within 3 seconds after I release the 1. pressure. ” 2. “The nailbed will be white when I press on it. ” 3. “This should not be painful to my son. ” 4. “There should be no change in color when I press on the nailbed. ” The nurse observes a student nurse assess neonates in the nursery. Which student nurse action requires intervention by the nurse? 1. Documenting a negative red-light reflex in a neonate who is two days old. 2. Testing the tonic neck reflex by lying the neonate supine and turning the head to one side. 3. Testing the rooting reflex by stroking the corner of the neonate's mouth. 4. Documenting a positive Babinski reflex in a neonate who is one day old. The nurse observes a client with type 1 diabetes mellitus prepare an injection of 32 units of intermediate-acting insulin and 8 units of short-acting insulin. Which client action requires intervention by the nurse? 1. After drawing up 8 units of short-acting insulin, the client adds intermediate-acting insulin to the syringe for a total of 40 units. The client draws up 32 units of the intermediate-acting insulin followed by 8 2. units of short-acting insulin for a total of 40 units. 3. Initially, the client injects air into the intermediate-acting insulin vial without drawing up any insulin. The client injects air into each bottle of insulin equal to the amount of insulin to 4. be withdrawn. The nurse provides care for four clients on a medical surgical unit. The nurse knows that which client is at risk for wound dehiscence and evisceration? 1. A client diagnosed with Parkinson disease who is 5 feet 8 inches (172.7 cm) tall ,weighs 150 lb (68 kg), and had a stereotactic pallidotomy two days ago. 2. A client with history of mitral stenosis who is 5 feet 2 inches (157.5 cm) tall, 3. weighs 130 lb (60 kg), and had open-heart surgery for mitral valve reconstruction three days ago. A client with a fractured femur who is 6 feet 1 inch (185.4 cm) tall, weighs 170 4. lb (77.1 kg), and had open reduction and internal fixation surgery four days ago. The nurse provides nutrition teaching to the parent of a client with deep partial thickness burns on the legs. Which meal does the nurse suggest? 1. Chicken leg, broccoli, ice pop, and lemonade. 2. Cheeseburger, fruit-flavored yogurt, carrots, and milk. 3. Cottage cheese, canned peaches, crackers, and apple juice. 4. Scrambled eggs, hash brown potatoes, banana, and orange juice. The nurse provides care for a client 18 hours after a left below-the-knee amputation. Which nursing action is most important? 1. Notify the health care provider (HCP) of increased drainage. 2. Elevate the residual limb on a pillow or other soft surface. 3. Encourage the client to lie in a prone position. 4. Perform active range-of-motion (ROM) exercises on the right leg daily. The nurse provides care for several clients. Which client does the nurse assess first? 1. A middle-age female adult client reporting fatigue, severe nausea, and jaw pain. 2. An older adult male client reporting abdominal pain, vomiting, and diarrhea. 3. A middle-age female adult client reporting productive cough and shortness of breath. 4. An older adult male client reporting urinary hesitancy and weak urinary stream. A client recovering from electroshock therapy (ECT) is upset by an inability to remember what was eaten for dinner the evening before the treatment. Which response by the nurse is best? 1. “Have you had problems with your memory before?” 2. “It isn’t important for you to remember those details.” 3. “Try to concentrate and it will come back to you.” 4. “This is a result of the treatments you are undergoing.” A parent of a toddler reports a gardening hobby to the clinic nurse and discloses the possession of many house plants. The parent states that the toddler is, “into everything all the time and drives me to distraction! ” Which response by the nurse is best? 1. “What kind of plants do you have? ” 2. “Who is available to care for your child when you need a break? ” 3. “Were you like this at the same age? ” 4. “It must be hard balancing work and children. ” A client diagnosed with schizophrenia consistently neglects to take prescribed medication. Which prescription will the nurse expect from the health care provider? 1. Fluphenazine decanoate 25 mg intramuscular injection. 2. Lithium carbonate 300 mg by mouth. 3. Lorazepam 2 mg by mouth. 4. Pemoline 75 mg by mouth. The nurse provides care for a client admitted with a diagnosis of acute myocardial infarction. The client’s spouse tells the nurse about an anxiety disorder that the client has been selfmedicating with alcohol. It is most important for the nurse to assess for which symptoms? 1. Heart palpitations, shortness of breath, and nausea. 2. Fatigue, decreased appetite, and generalized pruritis. 3. Tachycardia, generalized tremors, and hypertension. 4. Dry mouth, diaphoresis, and upper extremity tingling. The nurse provides care for a client after electroconvulsive therapy (ECT). Which observation is of concern to the nurse? 1. The client reports a headache. 2. The client reports memory difficulty. 3. The client appears confused. 4. The client reports a backache. The nurse prepares to discharge a client who had a laryngectomy. Which information will the nurse include in the discharge instructions regarding stoma and laryngectomy care? ( Select all that apply. ) 1. Avoid swimming. 2. Use a home dehumidifier. 3. Avoid direct exposure to cold air. 4. Restrict fluid intake to 500 mL per day. 5. Get a medical identification bracelet. The nurse performs a physical assessment on a client. Which location would the nurse palpate the client’s brachial pulse? The nurse teaches parents of school-age children about car safety. Which parental statement indicates to the nurse a need for further teaching? 1. “My child, who is 4 feet 2 inches tall, can sit in a booster seat with only a lap belt.” 2. “My child does not ride in the front seat of a vehicle with an airbag.” 3. “My child can use the vehicle seat belt if it lays over the hip bones and across the shoulders.” 4. “When my child grows to 4 feet 9 inches or taller, a booster seat is not needed.” The home care nurse instructs a client diagnosed with Bell palsy. Which client statement indicates to the nurse that further teaching is necessary? 1. “I should place an eye shield over the affected eye at bedtime.” 2. “I should avoid sudden movement when bending over.” 3. “I should not go out when there is a cold wind.” 4. “I should use heat on the affected side of my face.” The nurse provides care for the client receiving intravenous normal saline (NS) solution at 100 mL/hr. Throughout the day, the client drinks 12 oz of water and 8 oz of milk. The client voids 1100 mL and has 380 mL liquid stool. Calculate and record the client's net 24-hour intake in mL. ( Record your answer rounding to the nearest w