NR 322 nlcex questions All correct responses provided 100% correct

Question 1 See full question A 64-year-old client has just had total hip replacement surgery. The physician orders heparin 8,000 units to be administered subcutaneously. The label on the heparin vial reads: "Heparin 10,000 units/ml." How many milliliters of heparin should the nurse draw up in the syringe to administer the correct dose? Record your answer using one decimal place. Your Response:  0.8 Correct response:  0.8 Explanation: The following formula is used to calculate drug dosages: dose on hand/quantity on hand = dose desired/X. In this example, the equation is as follows: 10,000 units/ml = 8,000 units/X; X = 0.8 ml. Question 2 See full question A nurse records a client’s fnger stick blood glucose level and gives 2 units of regular insulin as ordered. At the next scheduled blood glucose assessment, the nurse realizes that he/she previously tested and administered the insulin to the wrong client. What is the nurse’s priority action related to this incident? You Selected:  Assess both clients and call the appropriate physicians to notify them of the errors. Correct response:  Assess both clients and call the appropriate physicians to notify them of the errors. Explanation: Remediation: Question 3 See full questionThe unit secretary who transcribes the health care provider’s (HCP’s) prescriptions asks the nurse to interpret an illegible prescription. The nurse should clarify the prescription with the: You Selected:  pharmacist. Correct response:  HCP. Explanation: Remediation: Question 4 See full question A parent asks the nurse about head lice (pediculosis capitis) infestation during a visit to the clinic. Which symptom should the nurse tell the parent is most common in a child infected with head lice? You Selected:  itching of the scalp Correct response:  itching of the scalp Explanation: Remediation: Question 5 See full question The nurse notes that a neonate’s Apgar score at 5 minutes was 9. The nurse interprets this as indicating which information about the neonate? You Selected:  The neonate was in stable condition. Correct response:  The neonate was in stable condition.Explanation: Remediation: Question 6 See full question The nurse tells the student nurse that they will be visiting a family that experienced a stillbirth at 38 weeks gestation. The student nurse begins to cry and says, “I can’t possibly participate in the visit. I just found out I am pregnant. I can’t deal with the thought of losing a baby in pregnancy.” What is the nurse’s most appropriate response to the student nurse? You Selected:  Tell the student nurse it is okay to cry and encourage her to talk about the way she is feeling. Correct response:  Tell the student nurse it is okay to cry and encourage her to talk about the way she is feeling. Explanation: Question 7 See full question A client with pernicious anemia asks why she must take vitamin B12 injections forever. Which is the nurse's best response? You Selected:  “The reason for your vitamin defciency is an inability to absorb the vitamin because the stomach is not producing sufcient amounts of a factor that allows the vitamin to be absorbed.” Correct response:  “The reason for your vitamin defciency is an inability to absorb the vitamin because the stomach is not producing sufcient amounts of a factor that allows the vitamin to be absorbed.” Explanation: Remediation: Question 8 See full questionA client who is being treated for nonhealing diabetic foot ulcers tells the nurse angrily, “I am so frustrated with my doctors. The wound care doctor tells me this will not heal and I need to have my toes amputated and another doctor tells me I need to keep going with the antibiotics and dressing changes so I can save my foot. I just want to go home!” After listening to the client’s concerns, the nurse should: You Selected:  contact the client’s case manager to set up a care conference. Correct response:  contact the client’s case manager to set up a care conference. Explanation: Remediation: Question 9 See full question Guaifenesin 300 mg four times a day has been prescribed as an expectorant. The dosage strength of the liquid is 200 mg/5 mL. How many milliliters should the nurse administer for each dose? Record your answer using one decimal place. Your Response:  1.5 Correct response:  7.5 Explanation: 300 mg/X = 200 mg/5 mL X = 7.5 mL. Remediation: Question 10 See full question While preparing medication for a client in labor, the observes a co-worker slipping a vial of morphine into their side pocket. The nurse should: You Selected:  notify the supervisor of the unit.Correct response:  notify the supervisor of the unit. Explanation: Question 11 See full question How should a nurse assess a neonate's rooting reflex? You Selected:  Stroke the neonate's cheek. Correct response:  Stroke the neonate's cheek. Explanation: Remediation: Question 12 See full question The physician has indicated that a client has a poor prognosis for recovery, and the family is very concerned. How would the nurse best support the family? You Selected:  Attune to their grieving, explain what is happening, and encourage involvement in the care. Correct response:  Attune to their grieving, explain what is happening, and encourage involvement in the care. Explanation: Remediation: Question 13 See full question A 6-year-old child is brought to the walk-in clinic in his/her neighborhood for onset of symptoms of a urinary tract infection (UTI). The child is reluctant to give a urine specimen or to remove his/her clothing. Which one of these reports by the mother requires further investigation?You Selected:  “My child slept over at my boyfriend’s last night while I worked the night shift.” Correct response:  “My child slept over at my boyfriend’s last night while I worked the night shift.” Explanation: Remediation: Question 14 See full question A nurse is caring for a client receiving a dopamine receptor agonist for treatment of extrapyramidal symptoms caused by antipsychotic medications. What evaluation would indicate a therapeutic response to this drug? You Selected:  Client experiences a decrease in dystonia. Correct response:  Client experiences a decrease in dystonia. Explanation: Remediation: Question 15 See full question A nurse is maintaining a problem-oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan? You Selected:  Progress note. Correct response:  Progress note. Explanation:Remediation: Question 16 See full question A client who had an exploratory laparotomy 3 days ago has a white blood cell (WBC) differential with a shift to the left. The nurse instructs unlicensed assistive personnel (UAP) to report which clinical manifestation of this laboratory report? You Selected:  elevated temperature Correct response:  elevated temperature Explanation: Remediation: Question 17 See full question Which complication is common in neonates who receive prolonged mechanical ventilation at birth? You Selected:  Bronchopulmonary dysplasia Correct response:  Bronchopulmonary dysplasia Explanation: Remediation: Question 18 See full question The nurse is caring for a client with unsuccessful laboring who is anticipating a caesarian section. What is the fnal assessment the nurse should make in the birthing room immediately before the client is transported to the operating room? You Selected:  Fetal heart tones Correct response: Fetal heart tones Explanation: Remediation: Question 19 See full question The nurse receives the preoperative blood work report for a client who is scheduled to undergo surgery. Which laboratory fnding should be reported to the surgeon and anesthesiologist? You Selected:  red blood cells, 4.5 million/mm3 (4.5 X 1012/L) Correct response:  creatinine, 2.6 mg/dL (230 µmol/L) Explanation: The nurse should call the surgeon for a serum creatinine level of 2.6 mg/dL (230 µmol/L), which is higher than the normal range of 0.1 to 0.4 mg/dL (9 to 35 µmol/L). An elevated serum creatinine value indicates that the kidneys are not fltering effectively and has important implications for the surgical client because many anesthesia and analgesia medications need to be fltered out through the renal system. The red blood cell count, hemoglobin level, and blood urea nitrogen level are within normal limits and do not need to be reported to the surgeon. Remediation: Question 20 See full question Which activity by the mother offers the most support to the child during the frst few days after surgery to repair a cleft lip? You Selected:  staying at the bedside and holding the child's hand Correct response:  holding and cuddling the child Explanation:The mother should be encouraged to hold and cuddle her child to provide needed emotional support. Such activities as helping the child play with toys, reading stories, and staying with the child would not be contraindicated but do not offer as much emotional support as holding and cuddling. Remediation: Question 21 See full question A client with cholecystitis continues to have severe right upper quadrant pain. The nurse obtains the following vital signs: temperature 101.1° F (38.4° C); pulse 114 bpm; respirations 22/min; blood pressure 142/90 mm Hg. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse recommends to the health care provider for the client to receive: You Selected:  hydromorphone IV. Correct response:  hydromorphone IV. Explanation: Remediation: Question 22 See full question A client is admitted to the facility with a suspected ectopic pregnancy. When reviewing the client's health history for risk factors for this abnormal condition, the nurse expects to fnd: You Selected:  a history of pelvic inflammatory disease. Correct response:  a history of pelvic inflammatory disease. Explanation: Remediation: Question 23 See full questionThe nurse is planning care for a client with severe postoperative pain. There is a prescription for morphine written as “10 mg MSO4” on the medical record. What should the nurse do frst? You Selected:  Contact the health care provider (HCP) who prescribed the medication. Correct response:  Contact the health care provider (HCP) who prescribed the medication. Explanation: Remediation: Question 24 See full question A nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to transfer body weight to the unaffected leg, and then: You Selected:  advance both crutches. Correct response:  advance both crutches. Explanation: Remediation: Question 25 See full question The nurse is preparing to administer propranolol to a client for control of migraine headaches. The client also has a prescription for sumatriptan as needed for a headache. The client’s pulse rate is 56 bpm. What should the nurse do next? You Selected:  Administer sumatriptan. Correct response:  Assess blood pressure.Explanation: One of the actions of propranolol, a drug used in the treatment of migraine headaches, is to inhibit arterial vasodilation. The nurse should assess the client’s blood pressure to evaluate overall circulatory response to the medication. Until the nurse determines the client’s blood pressure, there is no immediate need to contact the HCP. There is no immediate need to administer oxygen. The client has not indicated pain; it is not necessary to administer the sumatropin at this time. Remediation: Question 26 See full question After instruction of a primigravid client at 8 weeks' gestation about measures to overcome early morning nausea and vomiting, which client statement indicates the need for additional teaching? You Selected:  "I will eat two large meals daily with frequent protein snacks." Correct response:  "I will eat two large meals daily with frequent protein snacks." Explanation: Remediation: Question 27 See full question A newly admitted client, diagnosed with delirium, has a history of hypertension and anxiety. The client had been taking digoxin, furosemide, and diazepam. The nurse suspects that this client’s impairment may be the result of: You Selected:  drug intoxication. Correct response:  drug intoxication. Explanation: Remediation: Question 28 See full questionWhen prioritizing a client's care plan based on Maslow's hierarchy of needs, a nurse's frst priority would be: You Selected:  administering pain medication. Correct response:  administering pain medication. Explanation: Remediation: Question 29 See full question During the second day postpartum, the nurse notices that a client is initiating breastfeeding with her infant and changing her infant's diapers with a little assistance from her partner. According to Reva Rubin's "phases of bonding," which of the following is the appropriate phase the woman is experiencing? You Selected:  The taking-hold phase Correct response:  The taking-hold phase Explanation: Remediation: Question 30 See full question Which teaching approach for the client with chronic renal failure who has difculty concentrating due to high uremia levels would be most appropriate? You Selected:  Validate the client's understanding of the material frequently. Correct response:  Validate the client's understanding of the material frequently.Explanation: Remediation: Question 31 See full question When preparing to give a child with insulin-dependent diabetes his dose of regular insulin and isophane insulin suspension, which of the following actions is most appropriate? You Selected:  Taking the premixed insulin out of the refrigerator, then withdrawing the amount into one syringe. Correct response:  Withdrawing the regular insulin frst, then withdrawing the isophane insulin suspension into one syringe. Explanation: Using only one syringe is recommended for the child taking regular insulin along with an intermediate- or long-acting insulin. Additionally, insulin types, such as protamine zinc, globin zinc, and isophane insulin suspension, contain an additional modifying protein that slows absorption. Therefore, a vial of insulin that does not contain the protein (such as, regular insulin) should never be contaminated with insulin that does have the added protein. Premixing is rarely recommended because isophane insulin suspension does not remain stable for extended periods when mixed with regular insulin. Using two syringes is not recommended because the insulin types can be mixed. Also, using two syringes is more expensive. Insulin types, such as protamine zinc, globin zinc, and isophane insulin suspension, contain an additional modifying protein that slows absorption. A vial of insulin that does not contain the protein (i.e., regular insulin) should never be contaminated with insulin that does have the added protein. Remediation: Question 32 See full question What are important nursing responsibilities when a referral to other health team members has been made for a client? You Selected: Recommending that each member read the history and nurse’s notes to understand the client’s progress Correct response:  Sharing assessment information and information on the client’s capability and level of participation in meeting activities of daily living Explanation: Question 33 See full question A client admitted to the inpatient psychiatric unit changes clothes eight or nine times a day, wears heavy eye makeup, is intrusive with other clients, and makes inappropriate sexual advances toward staff members. Which of the following client goals would be most appropriate? You Selected:  The client will refrain from hugging other clients and change clothing only twice per day. Correct response:  The client will refrain from hugging other clients and change clothing only twice per day. Explanation: Remediation: Question 34 See full question During chemotherapy, a boy, age 10, loses his appetite. When teaching the parents about his food intake, the nurse should include which instruction? You Selected:  "Let your child eat any food he wants." Correct response:  "Let your child eat any food he wants." Explanation:Remediation: Question 35 See full question A client at 28 weeks’ gestation in premature labor was placed on nifedipine. To maintain the pregnancy, the primary health care provider orders the client to have 20 mg now, followed by 20 mg every 8 hours while contractions persist, not to exceed the maximum daily oral dose of 60 mg. At what time will the client have reached the maximum dose if she begins taking the medication at 0600? Record your answer using military time. Your Response:  8 Correct response:  2200 Explanation: If 20 mg were administered at 0600 and then 20 mg were administered at 1400, the dose at 2200 reached the maximum oral dose of 60 mg/day. Remediation: Question 36 See full question The client with a cognitive disorder tells the nurse, "Everyone is after me. They want to kill me." The nurse should respond: You Selected:  "You are frightened. This is a hospital and these people are staff members. You are safe here." Correct response:  "You are frightened. This is a hospital and these people are staff members. You are safe here." Explanation: Remediation: Question 37 See full questionThe nurse is assisting with the birth of a fetus in a frank breech presentation. Which graphic illustrates that position? You Selected:  Correct response: Explanation: Question 38 See full question During the emergent (resuscitative) phase of burn injury, which fnding indicates that the client requires additional volume with fluid resuscitation? You Selected:  serum creatinine level of 2.5 mg/dL (221 µmol/L) Correct response:  serum creatinine level of 2.5 mg/dL (221 µmol/L) Explanation:Remediation: Question 39 See full question A client has a heart rate of 170 beats/minute. The physician diagnoses ventricular tachycardia and orders lidocaine hydrochloride, an initial I.V. bolus of 50 mg followed in 5 minutes by a second 50-mg bolus, then continuous I.V. infusion at 2 mg/minute. The nurse can expect the client to begin experiencing an antiarrhythmic effect within: You Selected:  1 to 2 minutes after I.V. bolus administration. Correct response:  1 to 2 minutes after I.V. bolus administration. Explanation: Remediation: Question 40 See full question The nurse is caring for a client admitted with pyloric stenosis. A nasogastric tube placed upon admission is on low intermittent suction. Upon review of the morning's blood work, the nurse observes that the patient's potassium is below reference range. The nurse should recognize that the patient may be at risk for what imbalance? You Selected:  Metabolic alkalosis Correct response:  Metabolic alkalosis Explanation: Remediation: Question 41 See full question For a client with Graves' disease, which nursing intervention promotes comfort? You Selected: Maintaining room temperature in the low-normal range Correct response:  Maintaining room temperature in the low-normal range Explanation: Remediation: Question 42 See full question During a well-baby visit, a toddler’s mother states that she keeps all of the medications out of the toddler’s reach in the kitchen cabinet. Which of the following is an appropriate response by the nurse? You Selected:  "Medications should be kept in a locked location." Correct response:  "Medications should be kept in a locked location." Explanation: Remediation: Question 43 See full question A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should assess the client for which alteration in fluid and electrolyte balance? You Selected:  decreased serum sodium level Correct response:  decreased serum sodium level Explanation: Question 44 See full questionA school-age child is admitted to the facility with a diagnosis of acute lymphocytic leukemia (ALL). The nurse formulates a nursing diagnosis of Risk for infection. What is the most effective way for the nurse to reduce the child's risk of infection? You Selected:  Practicing thorough hand washing Correct response:  Practicing thorough hand washing Explanation: Remediation: Question 45 See full question Indicate on the illustration where the nurse would place the other electrode of the automated external defbrillator (AED) on a victim who has collapsed and does not have a pulse. You Selected:  Your selection and the correct area, market by the green box. Explanation: Remediation: Question 46 See full questionA nurse determines that a client is in false labor. After obtaining discharge orders, the nurse provides discharge teaching to the client. Which instruction is most appropriate at this time? You Selected:  "Return to the facility if fever occurs." Correct response:  "Return to the facility if fever occurs." Explanation: Remediation: Question 47 See full question A client who has started therapy for drug-resistant tuberculosis demonstrates understanding of tuberculosis transmission when the client says: You Selected:  "I'll stop being contagious when I have a negative acid-fast bacilli test." Correct response:  "I'll stop being contagious when I have a negative acid-fast bacilli test." Explanation: Remediation: Question 48 See full question The nurse is developing a teaching plan for a client with stress incontinence. Which instruction should be included? You Selected:  Avoid activities that are stressful and upsetting. Correct response:  Avoid caffeine and alcohol. Explanation:Clients with stress incontinence are encouraged to avoid substances that are bladder irritants, such as caffeine and alcohol. Emotional stressors do not cause stress incontinence. It is most commonly caused by relaxed pelvic musculature. Wearing girdles is not contraindicated. Although clients may want to limit physical exertion to avoid incontinence episodes, they should be encouraged to seek treatment instead of limiting their activities. Remediation: Question 49 See full question A nurse inadvertently gives a client a double dose of an ordered medication. After discovering the error, whom should the nurse notify frst? You Selected:  The prescriber Correct response:  The prescriber Explanation: Remediation: Question 50 See full question A 34-year-old primigravid client at 39 weeks' gestation admitted to the hospital in active labor has type B Rh-negative blood. The nurse should instruct the client that if the neonate is Rh positive, the client will receive an Rh immune globulin (RHIG) injection for what reason? You Selected:  to prevent Rh-positive sensitization with the next pregnancy Correct response:  to prevent Rh-positive sensitization with the next pregnancy Explanation: Remediation: Question 51 See full questionA new nurse on orientation asks for an example of a collaborative health care team. Which members would be included on this team? Select all that apply. You Selected:  Case manager  Primary nurse  Primary care provider Correct response:  Case manager  Primary care provider  Primary nurse Explanation: Question 52 See full question A client comes to the emergency department with severe back pain. The client states he has taken several pain pills he had at home but cannot remember how many he has taken and provides the nurse with an empty bottle of acetaminophen with codeine. Which laboratory value should the nurse address? You Selected:  Serum aminotransferase level (AST) of 256 u/L and international normalized ratio (INR) of 3.0 Correct response:  Serum aminotransferase level (AST) of 256 u/L and international normalized ratio (INR) of 3.0 Explanation: Remediation: Question 53 See full questionA nurse who provides care on a post-surgical unit is performing discharge teaching as a component of her effort to ensure continuity of care. Which of the following is the primary goal of continuity of care? You Selected:  Ensuring a smooth and safe transition between different healthcare settings. Correct response:  Ensuring a smooth and safe transition between different healthcare settings. Explanation: Remediation: Question 54 See full question A nurse is caring for a client who had a stroke. Which nursing intervention promotes urinary continence? You Selected:  Encouraging intake of at least 2 L of fluid daily Correct response:  Encouraging intake of at least 2 L of fluid daily Explanation: Remediation: Question 55 See full question A 17-year-old male client is being admitted to the adolescent psychiatric unit. He was brought in by the police after beating up two male peers. The client says, "They said I was gay because I had sex with an older neighbor when I was 8 years old. I am not gay!" Which nursing interventions would be appropriate? Select all that apply. You Selected:  Ask the client if he would like to attend a support group.  Assist the client in processing his feelings about the sexual abuse. Help the client express anger safely.  Monitor the client's level of anger and potential aggression. Correct response:  Monitor the client's level of anger and potential aggression.  Help the client express anger safely.  Assist the client in processing his feelings about the sexual abuse.  Ask the client if he would like to attend a support group. Explanation: Remediation: Question 56 See full question A woman with preeclampsia is receiving magnesium sulfate via infusion pump at 1 gram/hour. The nurse’s assessment includes: temperature 36.7° C; pulse 78; respirations 12/minute; B/P 128/82; urinary output 90 mLs in last 4 hours via Foley catheter; patellar-tendon reflex absent; ankle clonus absent; fetal heart rate 120 beats per minute; cervix 4 cm dilated, 80% effaced, station –1. You Selected:  Discontinue the magnesium sulfate infusion and notify the health care provider (HCP). Correct response:  Discontinue the magnesium sulfate infusion and notify the health care provider (HCP). Explanation: Remediation: Question 57 See full question A staff member says she's really busy and asks the charge nurse to double-check a dose of insulin she has drawn up. The nurse holds up a bottle of Lente insulin, but the charge nurse notices a bottle of Lantus insulin on the medication cart. Thisnurse has made multiple medication errors and the charge nurse is concerned that she isn't safe. What should the charge nurse do? You Selected:  Tell the nurse that she'd like to start at the beginning to be on the safe side. Correct response:  Tell the nurse that she'd like to start at the beginning to be on the safe side. Explanation: Remediation: Question 58 See full question A nurse is helping a client move up in the bed. Which action maintains good body mechanics? You Selected:  Having the client help himself as much as possible Correct response:  Having the client help himself as much as possible Explanation: Remediation: Question 59 See full question A client who is scheduled for an open cholecystectomy has been smoking a pack of cigarettes a day for 20 years. For which postoperative complication is the client most at risk? You Selected:  atelectasis Correct response:  atelectasis Explanation:Remediation: Question 60 See full question A physician has ordered hydrochlorothiazide for a client diagnosed with Ménière's disease. Which instruction should the nurse include in the teaching session? You Selected:  "Increase your fluid intake." Correct response:  "Increase your intake of bananas, tomatoes, and oranges." Explanation: Remediation: Question 61 See full question The nurse is instructing a Hindu client to increase protein in the diet. Which foods are appropriate to include in this client's diet? Select all that apply. You Selected:  broiled fsh sandwich  lentil soup Correct response:  lentil soup  broiled fsh sandwich Explanation: Question 62 See full question A registered nurse is mentoring a new graduate nurse. Which action by the new graduate demonstrates a need for further teaching? You Selected:  Administers lidocaine to a client experiencing frequent premature ventricular contractions (PVCs).Correct response:  Turns the defbrillator to synchronize before defbrillating a client with ventricular fbrillation. Explanation: Question 63 See full question Which moral principle is a nurse applying when she decides what is best for a client and acting without consulting the individual? You Selected:  Paternalism Correct response:  Paternalism Explanation: Question 64 See full question A nurse working on the postpartum unit is asked to participate in the unit Client Safety Committee. The nurse wants to know what type of projects would be conducted for the unit. Select all that apply. You Selected:  safe medication administration  prevention of infant abduction  maternal/infant identifcation system  proper restraints during procedures Correct response:  prevention of infant abduction  safe medication administration  proper restraints during procedures maternal/infant identifcation system Explanation: Remediation: Question 65 See full question The mother tells the nurse that the diagnosis of colic upsets her because she knows her infant will continue to have colicky pain. Which response by the nurse would be most appropriate? You Selected:  "It can be difcult to listen to your baby cry so loud and so long, so try to make sure that you get some free time." Correct response:  "It can be difcult to listen to your baby cry so loud and so long, so try to make sure that you get some free time." Explanation: Question 66 See full question The nurse assigned to telephone triage returns a call from a parent whose teenager experienced a hard tackle last night. The parent reports, "He seemed dazed after it happened and the coach had him sit out the rest of the game, but he is fne now." What is the most appropriate instruction for the nurse to give? You Selected:  "Take him immediately to the emergency department." Correct response:  "He cannot return to play until he has been evaluated by a health care provider." Explanation: Remediation: Question 67 See full questionA client who is postmenopausal with an intact uterus asks the nurse why her hormone medicine has two drugs, estrogen and progesterone. Which statement by the nurse provides the client with accurate information? You Selected:  "The progesterone will help prevent breast cancer." Correct response:  "The progesterone will help prevent endometrial cancer." Explanation: Remediation: Question 68 See full question A client has been hospitalized with myxedema coma. What acid–base imbalance would be expected in this client? You Selected:  Respiratory acidosis Correct response:  Respiratory acidosis Explanation: Remediation: Question 69 See full question A nurse is caring for a full-term neonate who is 24 hours old. Assessment fndings include axillary temperature of 96.8° F (36° C), apical heart rate of 188 beats/minute, and respiratory rate of 48 breaths/minute. The mother reports that the neonate is lethargic when she tries to breast-feed and looks "like a rag doll." The mother also has a low-grade fever. Pulse oximetry reveals saturation of 89% on room air, and the neonate has dusky mucous membranes. What are the most appropriate nursing interventions? Select all that apply. You Selected:  Provide blow-by oxygen and monitor the neonate's respiratory status. Observe the neonate carefully, contact the physician, and explain her suspicions of early neonatal sepsis.  Inform the parents that she wants to monitor the neonate closely. Correct response:  Observe the neonate carefully, contact the physician, and explain her suspicions of early neonatal sepsis.  Provide blow-by oxygen and monitor the neonate's respiratory status.  Inform the parents that she wants to monitor the neonate closely. Explanation: Remediation: Question 70 See full question The nurse is teaching a client with diabetes insipidus about using desmopressin nasal spray. The therapeutic effects of desmopressin nasal spray are obtained when the client no longer has: You Selected:  headache. Correct response:  polydipsia. Explanation: The therapeutic effects of desmopressin nasal spray are relief from polydipsia and control of polyuria and nocturia in the client with diabetes insipidus. Side effects include nasal congestion and headache. Blurred vision is not related to desmopressin. Remediation: Question 71 See full question A child with sickle cell anemia is being discharged after treatment for a crisis. Which instructions for avoiding future crises would the nurse provide to the child and family? Select all that apply.You Selected:  Drink plenty of fluids.  Report a sore throat to an adult immediately.  Wash hands before meals and after playing. Correct response:  Drink plenty of fluids.  Report a sore throat to an adult immediately.  Wash hands before meals and after playing. Explanation: Remediation: Question 72 See full question A client is receiving vincristine. Client teaching by the nurse should include instructions on: You Selected:  low fber, bland diet. Correct response:  bowel regimen. Explanation: Remediation: Question 73 See full question A nurse is teaching a client about metformin therapy. The nurse warns the client that metformin commonly causes hypoglycemia when combined with which other medications? You Selected:  ACE inhibitorsCorrect response:  ACE inhibitors Explanation: Remediation: Question 74 See full question A mother brings her 2-year-old adopted Korean child to the clinic for an initial checkup. The child has been living with the adopted family for several weeks. The nurse notes an irregular area of deep blue pigment on the child’s buttocks extending into the sacral area. The nurse should: You Selected:  do nothing concerning this fnding. Correct response:  do nothing concerning this fnding. Explanation: Remediation: Question 75 See full question The nurse is performing Leopold's maneuvers on a woman who is in her eighth month of pregnancy. The nurse is palpating the uterus as shown above. Which maneuver is the nurse performing? You Selected:  third maneuver Correct response:  third maneuver Explanation: Question 76 See full question A nurse is planning care for a client who experienced a stroke in the right hemisphere of his brain. What should the nurse do?You Selected:  Provide close supervision because of the client's impulsiveness and poor judgment. Correct response:  Provide close supervision because of the client's impulsiveness and poor judgment. Explanation: Remediation: Question 77 See full question During periods of extreme stress a client may experience elevated blood pressure, dilated pupils, and increased respirations. These unconscious responses originate in which part of the brain? You Selected:  Hypothalamus Correct response:  Hypothalamus Explanation: Question 78 See full question A toddler is hospitalized for evaluation and management of congenital heart disease (CHD). During discharge preparation, the nurse should discuss which topic with the parents? You Selected:  The importance of restricting the child's fat intake Correct response:  When to administer prophylactic antibiotics Explanation: Remediation:Question 79 See full question A client with idiopathic thrombocytopenic purpura (ITP), an autoimmune disorder, is admitted to an acute care facility. Concerned about hemorrhage, the nurse monitors the client's platelet count and observes closely for signs and symptoms of bleeding. The client is at greatest risk for cerebral hemorrhage when the platelet count falls below: You Selected:  10,000/?l. Correct response:  10,000/?l. Explanation: Remediation: Question 80 See full question A nurse is assigned to a client with polymyositis. Which expected outcome in the care plan relates to a potential problem associated with polymyositis? You Selected:  "Client will exhibit no signs or symptoms of aspiration." Correct response:  "Client will exhibit no signs or symptoms of aspiration." Explanation: Question 81 See full question A nurse notices that a severely depressed client is crying and asks what's wrong. The client responds, "Well, it looks like my suspicions are about to be confrmed." When asked what he means, the client says he can't talk about the matter. The nurse later notices a letter from the client's spouse lying on the floor near the bed. The client is in session with the psychiatrist and the nurse believes the contents of the letter could offer clues about the client's depression. What is the nurse's best course of action? You Selected: Pick up the letter and place it on the client's bedside table. Correct response:  Pick up the letter and place it on the client's bedside table. Explanation: Remediation: Question 82 See full question Using Abraham Maslow's hierarchy of human needs, the nurse assigns highest priority to which client need? You Selected:  Inserting a Foley catheter Correct response:  Inserting a Foley catheter Explanation: Remediation: Question 83 See full question A nurse is assigning the care of a client admitted with appendicitis. The nurse should assign this client's care to: You Selected:  a registered nurse with geriatric experience. Correct response:  a registered nurse pulled from the cardiac unit. Explanation: According to the National Council of State Boards of Nursing, delegation encompasses fve rights — the right task, right circumstance, right person, right direction and communication, and right supervision and evaluation. This client requires frequent assessment and monitoring. The nurse should assign the client's care to a registered nurse because the client may need immediate nursing action ifthe appendix ruptures. The client does not require the specialized knowledge of a clinical nurse specialist. It is not appropriate to delegate the licensed practical nurse. Since appendicitis is uncommon in the elderly population, the cardiac nurse would be a better choice. Remediation: Question 84 See full question A client with third-degree atrioventricular heart block with a rate of 28 is admitted to the coronary care unit. Which intervention takes priority? You Selected:  Applying an apnea monitor Correct response:  Teaching the client about a temporary pacemaker Explanation: Third degree A-V heart block is manifested by profound bradycardia and may be accompanied by confusion, dizziness, and syncope. This type of heart block will require pacemaker insertion. Applying an apnea monitor is not appropriate for this client. Reviewing advanced directive are not necessary at this time. Teaching the client to take his pulse is important but also not necessary. Remediation: Question 85 See full question A 13-month-old client is admitted to the pediatric unit with gastroenteritis. The toddler has experienced vomiting and diarrhea for the past 3 days, and laboratory tests reveal dehydration. Which nursing interventions are correct to prevent further dehydration? Select all that apply. You Selected:  Monitor the intravenous (IV) solution per the physician's order.  Give clear liquids in small amounts.  Encourage the child to eat non-salty soups and broth. Correct response: Give clear liquids in small amounts.  Encourage the child to eat non-salty soups and broth.  Monitor the intravenous (IV) solution per the physician's order. Explanation: Remediation: Question 86 See full question A client with acute respiratory distress syndrome (ARDS) has fne crackles at lung bases, and the respirations are shallow at a rate of 28 breaths/min. The client is restless and anxious. In addition to monitoring the arterial blood gas results, what should the nurse do? Select all that apply. You Selected:  Auscultate the lungs.  Monitor serum creatinine and blood urea nitrogen levels.  Administer humidifed oxygen. Correct response:  Monitor serum creatinine and blood urea nitrogen levels.  Administer humidifed oxygen.  Auscultate the lungs. Explanation: Remediation: Question 87 See full question A child is admitted with a diagnosis of possible appendicitis. The child is in acute pain. Which nursing intervention would be appropriate prior to surgery to decrease pain? Select all that apply. You Selected:  Offer an ice pack. Request a prescription for a cathartic.  Encourage the child to assume a position of comfort.  Limit the child's activity. Correct response:  Offer an ice pack.  Encourage the child to assume a position of comfort.  Limit the child's activity. Explanation: Remediation: Question 88 See full question A client with obsessive-compulsive disorder must brush the hair back from the forehead 15 times before performing any other activity. The nurse notices that the client's hair is thinning and that the skin on the forehead is irritated. What is the nurse's highest priority in planning care for this client? You Selected:  Setting consistent limits on the ritualistic behavior if it harms the client or others Correct response:  Setting consistent limits on the ritualistic behavior if it harms the client or others Explanation: Remediation: Question 89 See full question A refugee family from the Middle East arrives with enough food and supplies to have a party for their mother, who was admitted for depression. The nurse recognizes that which factors are in play? (Select all that apply.)You Selected:  Refugees who are not yet fully integrated into American culture are mistrustful and do not eat foods prepared by strangers.  It is the practice in some Middle Eastern countries for families to supply food and linens for their hospitalized family member.  Often, immigrant families cannot tolerate hospital food, or otherwise may prefer ethnic foods brought in from home. Correct response:  It is the practice in some Middle Eastern countries for families to supply food and linens for their hospitalized family member.  Often, immigrant families cannot tolerate hospital food, or otherwise may prefer ethnic foods brought in from home. Explanation: Remediation: Question 90 See full question A charge nurse is making arrangements for an elderly client newly admitted from the emergency department for treatment of suspected pyelonephritis. The charge nurse notes that the client has been assigned to a semiprivate room with another client who has the same last name. What should the nurse do frst? You Selected:  Ask the admissions department to assign the elderly client to a new room. Correct response:  Ask the admissions department to assign the elderly client to a new room. Explanation: Question 91 See full question The client who routinely takes sertraline presents to the emergency department reporting muscle rigidity and tremors. The client also states that they had a coughlast week that was treated with dextromethorphan. What is the appropriate nursing intervention? You Selected:  Administer intravenous diazepam Correct response:  Administer intravenous diazepam Explanation: Remediation: Question 92 See full question When preparing the teaching plan for a client who is to start clozapine, which information is crucial to include? You Selected:  an emphasis on the need for weekly blood tests Correct response:  an emphasis on the need for weekly blood tests Explanation: Remediation: Question 93 See full question A nurse is assisting in the discharge planning for a client with alcoholism. Which actions should be included in the discharge plan? Select all that apply. You Selected:  Provide nutritional information and counseling.  Strongly encourage participation in Alcoholics Anonymous (AA).  Discuss relapse prevention. Correct response: Strongly encourage participation in Alcoholics Anonymous (AA).  Provide nutritional information and counseling.  Establish an exercise program.  Discuss relapse prevention. Explanation: Remediation: Question 94 See full question A usually reliable interpreter called by the nurse to help communicate with a mother of a child who does not speak English and has brought her child in for a routine visit has yet to arrive in the clinic. The nurse has paged the interpreter several times. What should the nurse do next? You Selected:  Reschedule the infant's appointment for later in the week. Correct response:  Reschedule the infant's appointment for later in the week. Explanation: Question 95 See full question The client is diagnosed with diverticular disease. Which of the following foods would the nurse include in the teaching to prevent complications? You Selected:  Wheat bread Correct response:  Wheat bread Explanation:Wheat bread is high in fber. The client managing diverticulosis should maintain a high-fber diet. Eggs, cooked fsh, and white rice are low in fber and would not be helpful in preventing complications. Remediation: Question 96 See full question A 9-year-old is given morphine for postoperative pain. As the nurse is assessing the client for pain 4 hours later, his parent leaves the room and the child begins to cry. The nurse's initial assessment of the child's pain is that he is: You Selected:  less tolerant of pain because he is upset. Correct response:  less tolerant of pain because he is upset. Explanation: Remediation: Question 97 See full question A nurse should begin screening for lead poisoning when a child reaches which age? You Selected:  18 months Correct response:  12 months Explanation: The nurse should start screening a child for lead poisoning at age 12 months and perform repeat screenings at 24 months. High-risk infants, such as premature infants and formula-fed infants not receiving iron supplementation, should be screened for iron defciency anemia at age 6 months. Regular dental visits should begin at age 24 months. Remediation: Question 98 See full questionA nurse is preparing a client for an exercise stress test the following morning. Which client statement indicates a need for additional teaching? You Selected:  "I won't eat or drink anything after midnight tonight." Correct response:  "I won't eat or drink anything after midnight tonight." Explanation: Remediation: Question 99 See full question A nurse is assessing a client who recently experienced a stroke. The client has a left facial droop, hemiparesis of the upper left extremity, and diplopia. Which nursing intervention is most appropriate for this client? You Selected:  Match visual tasks with a verbal statement. Correct response:  Consistently place client care items in the same location. Explanation: Clients with diplopia see two of the same object. Consistently placing items in the same location assists the client in locating the item. Based on the clinical presentation, the client most likely had a stroke located in the right middle cerebral artery. The speech center, Broca’s area, is located in the left hemisphere of the brain and therefore, the client may have some slurred speech due to the facial droop, but not experience aphasia. The vagus nerve, which controls swallowing, is located in the brainstem. The client has double vision, therefore writing or observing visual cues would be difcult. Remediation: Question 100 See full question When performing a physical assessment on a postterm neonate, the nurse expects to fnd:You Selected:  patchy fne hair distribution. Correct response:  abundant subcutaneous fat. Explanation: Typical assessment fndings for a postterm neonate include abundant subcutaneous fat; long, silky hair; absent vernix caseosa; dry, cracked skin; and long nails. Absent plantar creases, abundant lanugo, and patchy fne hair distribution are typical assessment fndings for a preterm neonate Question 1 See full question A pregnant woman does not have funds to purchase adequate, nutritious food. She works part time at a low-wage job and has two other children. The nurse can refer the client to which type of assistance? You Selected:  food bank Correct response:  food bank Explanation: Remediation: Question 2 See full question A client has a serum calcium level of 7.2 mg/dl (1.8 mmol/L). During the physical examination, the nurse expects to assess: You Selected:  Trousseau's sign. Correct response:  Trousseau's sign. Explanation:Remediation: Question 3 See full question A physician orders corticosteroids for a child with systemic lupus erythematosus (SLE). The nurse knows that the purpose of corticosteroid therapy for this child is to: You Selected:  combat inflammation. Correct response:  combat inflammation. Explanation: Remediation: Question 4 See full question A nurse in the emergency department is caring for a client with acute heart failure. Which laboratory value is most important for the nurse to check before administering medications to treat heart failure? You Selected:  Potassium Correct response:  Potassium Explanation: Remediation: Question 5 See full question The client’s identifcation armband was cut and removed to start an IV line as a part of the preoperative preparation. The transport team has arrived to transport the client to the operating room. The nurse notices that the client’s identifcation band is not on either wrist. What should the nurse do? You Selected:  Place a new identifcation armband on the client's wrist before transport.Correct response:  Place a new identifcation armband on the client's wrist before transport. Explanation: Remediation: Question 6 See full question A client with Parkinson's disease is prescribed levodopa (L-dopa) therapy. Improvement in which area indicates effective therapy? You Selected:  muscle rigidity Correct response:  muscle rigidity Explanation: Remediation: Question 7 See full question An adult client who is alert and oriented requires surgery. The client cannot read. Which of the following nursing interventions is the best? You Selected:  Read the consent form to the client and have the client verbalize understanding Correct response:  Read the consent form to the client and have the client verbalize understanding Explanation: Remediation: Question 8 See full questionA nurse obtained a client’s fasting blood sugar (FBS) at 0700, which was 144 mg/dL (8 mmol/L). The client has an order for regular insulin 8 units every morning. What should the nurse do next? You Selected:  Administer the insulin as ordered. Correct response:  Administer the insulin as ordered. Explanation: Remediation: Question 9 See full question A charge nurse is making client care assignments. Which client is most appropriate for a licensed practical nurse? You Selected:  A newly admitted 15-year-old child with diabetic ketoacidosis Correct response:  A stable 6-month-old infant with pneumonia admitted 2 days ago Explanation: Question 10 See full question A client, hospitalized for pulmonary embolism, is being discharged on warfarin therapy. The client asks the nurse to explain how warfarin works. What is the nurse’s best response? You Selected:  It inhibits the formation of blood clots. Correct response:  It inhibits the formation of blood clots. Explanation:Remediation: Question 11 See full question When caring for a multiparous client who is human immunodefciency virus (HIV)– positive and asking to breastfeed her neonate as soon as possible, which information about breast milk should the nurse include in the teaching plan? You Selected:  It has been found to contain the retrovirus HIV. Correct response:  It has been found to contain the retrovirus HIV. Explanation: Remediation: Question 12 See full question A nurse on the gynecologic surgery unit observes a respiratory therapist (RT) take a medication cup with pills that was sitting in the medication room. What course of action should the nurse take? You Selected:  Report the situation to the nursing supervisor. Correct response:  Report the situation to the nursing supervisor. Explanation: Question 13 See full question The nurse is receiving results of a blood glucose level from the laboratory over the telephone. The nurse should: You Selected:  write down the results, read back the results to the caller from the laboratory, and receive confrmation from the caller. Correct response: write down the results, read back the results to the caller from the laboratory, and receive confrmation from the caller. Explanation: Question 14 See full question Because of religious beliefs, a client, who is an Orthodox Jew, refuses to eat hospital food. Hospital policy discourages food from outside the hospital. The nurse should next: You Selected:  explain alternatives to food such as intravenous fluids that can provide nutrition during hospitalization. Correct response:  discuss the situation and possible courses of action with the dietitian and the client. Explanation: Remediation: Question 15 See full question A nurse is caring for a client receiving warfarin therapy following a mechanical valve replacement. The nurse completed the client's prothrombin time and International Normalized Ratio (INR) at 7 a.m. (0700), before the morning meal. The client had an INR reading of 4. The nurse's frst priority should be to: You Selected:  assess the client for bleeding around the gums or in the stool and notify the physician of the laboratory results and most recent administration of warfarin. Correct response:  assess the client for bleeding around the gums or in the stool and notify the physician of the laboratory results and most recent administration of warfarin. Explanation:Remediation: Question 16 See full question Which is a priority goal for the client with chronic obstructive pulmonary disease (COPD)? You Selected:  maintaining functional ability Correct response:  maintaining functional ability Explanation: Remediation: Question 17 See full question After an eye examination, a client is diagnosed with open-angle glaucoma. The physician orders pilocarpine ophthalmic solution, 0.25% gtt i, OU q.i.d. Based on this prescription, the nurse should teach the client or a family member to administer the drug by: You Selected:  instilling one drop of pilocarpine 0.25% into both eyes four times daily. Correct response:  instilling one drop of pilocarpine 0.25% into both eyes four times daily. Explanation: Remediation: Question 18 See full question A nurse is reviewing a client's arterial blood gas (ABG) report. Which ABG value reflects the acid concentration in the client's blood? You Selected:  pH Correct response: pH Explanation: Remediation: Question 19 See full question A child with diabetes insipidus receives desmopressin acetate. When evaluating for therapeutic effectiveness, the nurse should interpret which fnding as a positive response to this drug? You Selected:  Decreased urine output Correct response:  Decreased urine output Explanation: Remediation: Question 20 See full question While auscultating the heart sounds of a client with heart failure, the nurse hears an extra heart sound immediately after the second heart sound (S2). The nurse should document this as: You Selected:  a third heart sound (S3). Correct response:  a third heart sound (S3). Explanation: Remediation: Question 21 See full question A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most benefcial in determining the potential cause of the episode?You Selected:  Compliance with the prescribed medication regimen Correct response:  Compliance with the prescribed medication regimen Explanation: Remediation: Question 22 See full question A client is admitted with a diagnosis of schizotypal personality disorder. Which signs would this client exhibit during social situations? You Selected:  Paranoid thoughts Correct response:  Paranoid thoughts Explanation: Question 23 See full question A staff nurse is caring for a client who is a potential heart donor. The client's family is concerned that the recipient will have access to personal donor information. Which response by the nurse demonstrates knowledge of the organ donation process? You Selected:  "I will have the transplant coordinator speak with you to answer your questions." Correct response:  "I will have the transplant coordinator speak with you to answer your questions." Explanation: Remediation:Question 24 See full question A child's parents state that they childproofed their home for their 2-year-old. During a home visit, the nurse discovers some situations that show the parents don't fully understand the developmental abilities of their toddler. Which situation displays misunderstanding by the parents? You Selected:  Toy chest in front of a second-story, locked window Correct response:  Toy chest in front of a second-story, locked window Explanation: Question 25 See full question A nurse is assessing a client with right flank pain, fever, and chills. A urine culture is obtained, and a diagnosis of suspected right pyelonephritis is documented. When instructing the client on the diagnosis, the nurse uses a diagram of the urinary structures. Identify the area associated with the diagnosis. You Selected: Your selection and the correct area, market by the green box. Explanation: Remediation: Question 26 See full questionAssessment of a primigravid client reveals cervical dilation at 8 cm and complete effacement. The client has severe back pain during this phase of labor. The nurse explains that the client’s severe back pain is most likely caused by the fetal occiput being in which position? You Selected:  posterior Correct response:  posterior Explanation: Remediation: Question 27 See full question A nurse is providing discharge teaching for a client who had a laryngectomy. Which instruction should the nurse include in her teaching? You Selected:  "Cover the stoma with a loose plastic cloth whenever you shower or bathe." Correct response:  "Cover the stoma with a loose plastic cloth whenever you shower or bathe." Explanation: Remediation: Question 28 See full question A client who is receiving chemotherapy develops stomatitis. What should the nurse instruct the client to do? You Selected:  Rinse the mouth with full-strength hydrogen peroxide every 4 hours. Correct response:  Use a soft-bristled toothbrush after each meal.Explanation: Remediation: Question 29 See full question The nurse should explain that the most common cause for the unhappiness some children experience when frst entering school is due to which factor? You Selected:  feelings of insecurity Correct response:  feelings of insecurity Explanation: Remediation: Question 30 See full question When a client has a tearing of tissue with irregular wound edges, the nurse should document this as: You Selected:  laceration. Correct response:  laceration. Explanation: Remediation: Question 31 See full question Thirty people are injured in a train derailment. Which client should be transported to the hospital frst? You Selected:  a 25-year-old with a sucking chest wound Correct response: a 25-year-old with a sucking chest wound Explanation: Remediation: Question 32 See full question What is the most important nursing intervention when caring for a child with a newly applied wet hip-spica cast? You Selected:  Reposition the child every 1 to 2 hours Correct response:  Reposition the child every 1 to 2 hours Explanation: Remediation: Question 33 See full question The nurse is preparing a client for a paracentesis. The nurse should: You Selected:  have the client void immediately before the procedure. Correct response:  have the client void immediately before the procedure. Explanation: Remediation: Question 34 See full question A client with newly diagnosed type 1 diabetes is scheduled to receive regular insulin 10 units and NPH insulin 20 units every morning. When should the nurse schedule the administration of these medications? You Selected:  NPH 1 hour before and regular 0.5 hours before breakfastCorrect response:  both insulins 0.5 hours before breakfast Explanation: Remediation: Question 35 See full question A nurse is caring for a client in addisonian crisis. Which medication order should the nurse question? You Selected:  Potassium chloride Correct response:  Potassium chloride Explanation: Remediation: Question 36 See full question At 0300 the mother of a 3-year-old child calls the emergency department nurse and reports the child has a temperature of 101° F (38° C), a runny nose, and a barky cough that “gets going and will not stop.” The mother states that she just gave the child acetaminophen. What should the nurse recommend next? You Selected:  Sit with the child in a steamy, warm bathroom. Correct response:  Sit with the child in a steamy, warm bathroom. Explanation: Remediation: Question 37 See full question A client moves in with her family after her boyfriend of 4 weeks told her to leave. She is admitted to the subacute unit after reporting feeling empty and lonely, beingunable to sleep, and eating very little for the last week. Her arms are scarred from frequent self-mutilation. What should the nurse do in order of priority from frst to last? All options must be used. You Selected:  Monitor for suicide and self-mutilation.  Monitor sleeping and eating behaviors.  Discuss the issues of loneliness and emptiness.  Discuss her housing options for after discharge. Correct response:  Monitor for suicide and self-mutilation.  Monitor sleeping and eating behaviors.  Discuss the issues of loneliness and emptiness.  Discuss her housing options for after discharge. Explanation: Remediation: Question 38 See full question A chronically ventilated client requests that care be withdrawn. The client is competent and understands the consequences of his/her decisions. The client is not depressed, but is certain that he/she does not want to live as he/she has been living. What should the nurse consider in this situation? Select all that apply. You Selected:  The client has the right to refuse medical treatment.  The physician must be notifed of the request.  The client's chart must be checked for a healthcare power of attorney. Correct response: The client has the right to refuse medical treatment.  The client's chart must be checked for a healthcare power of attorney.  The physician must be notifed of the request. Explanation: Remediation: Question 39 See full question A client is diagnosed with myocardial infarction. Which data collection fndings indicate that the client has developed left-sided heart failure? Select all that apply. You Selected:  Orthopnea  Crackles  Cough Correct response:  Orthopnea  Cough  Crackles Explanation: Remediation: Question 40 See full question Which statement made by a client who is taking misoprostol, indicates a therapeutic outcome of therapy? You Selected:  “My stom