NURSING 706 Review Questions and Answers 2022

NURSING 706 Review Questions and Answers 2022 A man had a permanent pacemaker implanted one year ago. He returns to the outpatient clinic because he thinks the pacemaker battery is malfunctioning. It is MOST important for the nurse to assess which of the following? 1. Abdominal pain, nausea, and vomiting 2. Wheezing on exertion, cyanosis, and orthopnea 3. Peripheral edema, shortness of breath, and dizziness 4. Chest pain radiating to the right arm, headache, and diaphoresis 3. Peripheral edema, shortness of breath, and dizziness A woman with type 1 diabetes is returned to the recovery room one hour after an uneventful delivery of a 9lb., 8oz., baby boy. The nurse would expect the woman's blood sugar to do which of the following? 1. Change from 220 to 180 mg/dL 2. Change from 110 to 80 mg/dL 3. Change from 90 to 120 mg/dL 4. Change from 100 to 140 mg/dL 2. Change from 110 to 80 mg/dL 00:0201:27 Which of the following assignments by the RN would be appropriate for an LPN/LVN? 1. A 34-year old woman with low back pain scheduled for a myelogram in the afternoon 2. A 41-year old woman in traction with a fractured femur 3. A 43-year old woman in newly diagnosed with type 1 diabetes mellitus 4. A 56-year old male with emphysema scheduled to be discharged later today 2. A 41-year old woman in traction with a fractured femur After receiving a report from the night nurse, which of the following clients should the nurse see FIRST? 1. A 31 year-old woman refusing sucralfate before breakfast 2. A 40 year-old man with left-sided weakness asking for assistance to the commode 3. A 52-year-old woman reporting chills who is scheduled for a cholecystectomy 4. A 65-year-old man with a nasogastric tube who had a bowel resection yesterday 3. A 52-year-old woman reporting chills who is scheduled for a cholecystectomy The physician orders tobramycin sulfate 3mg/kg IV every 8 hours for a 3-year-old boy. The nurse enters the client's room to administer the medication and discovers that the boy does not have an identification bracelet. Which of the following should the nurse do? 1. Ask the parents at the child's bedside to state their child's name 2. Ask the child to say his first name and last name 3. Have a coworker identify the child before giving the medication. 4. Hold the medication until an identification bracelet can be obtained 1. Ask the parents at the child's bedside to state their child's name A 21-year-old woman in active labor is admitted to the labor suite. An hour later, the membranes rupture spontaneously. The nurse observes a glistening white cord protruding from the vagina. Which of the following actions should the nurse take FIRST? 1. Return to the nurses' station and place an emergency call to the physician 2. Administer oxygen by mask at 10-12 L/min and assess the mother's vital signs 3. Place a clean towel over the cord and wet it with sterile normal saline 4. Apply manual pressure to the presenting part and have the mother assume a knee-chest position 4. Apply manual pressure to the presenting part and have the mother assume a knee-chest position A 50-year-old male client comes to the nurses' station and asks the nurse if he can go to the cafeteria to get something to eat. When told that his privileges do not include visiting the cafeteria, the client becomes verbally abusive. Which of the following approaches by the nurse would be MOST effective? 1. Tell the client to lower his voice, because he is disturbing the other clients 2. Ask the client what he wants from the cafeteria and have it delivered to his room 3. Calmly but firmly escort the client back to his room 4. Assign the nursing assistive personnel (NAP) to accompany the client to the cafeteria. 3. Calmly but firmly escort the client back to his room A cast is applied to a 9 month old girl for the treatment of talipes equinovarus. Which of the following instructions is MOST essential for the nurse to give to the child's mother regarding her care? 1. Offer appropriate toys for her age 2. Make frequent clinic visits for cast adjustment 3. Provide an analgesic as needed 4. Do circulatory checks of the casted extremity 4. Do circulatory checks of the casted extremity The home health nurse is going to start an IV with 5% dextrose in water (D5W) for a 76 year old woman. To perform the venipuncture, the nurse should start the IV with which of the following? 1. The vein's of the client's wrist on the nondominant side 2. The veins of the leg so it will not interfere with the client's ability to feed herself 3. The dorsal veins of the client's forearm on the nondominant side 4. The dorsal surface of the client's hand on the nondominant side 3. The dorsal veins of the client's forearm on the nondominant side A 7 year old girl with type 1 insulin-dependent diabetes mellitus (IDDM) has been home sick for several days and is brought to the ED by her parents. If the child is experiencing ketoacidosis, the nurse would expect to see which of the following lab results? 1. Serum glucose 140 mg/dL 2. Serum creatinine 5.2 mg/dL 3. Blood pH 7.28 4. Hematocrit 38% 3. Blood pH 7.28 The nurse delivers external cardiac compressions to a client while performing cardiopulmonary resuscitation (CPR). Which of the following actions by the nurse is BEST? 1. Maintain a position close the client's side with the nurse's knees apart 2. Maintain vertical pressure on the client's chest through the heel of the nurse's hand 3. Re-check the nurse's hand position after every 10 chest compressions 4. Check for a return of the client's pulse after every 8 breaths by the nurse 2. Maintain vertical pressure on the client's chest through the heel of the nurse's hand The nurse obtains a health history form a client admitted with acute glomerulonephritis that is associated with beta- hemolytic Streptococcus., The nurse expects which of the following to be significant in the health history? 1. The client had a sore throat 3 weeks earlier 2. There is a family history of glomerulonephritis 3. The client had a renal calculus 2 year earlier 4. The client had an accident involving renal trauma several years ago 1. The client had a sore throat 3 weeks earlier 00:0201:27 The nurse plans care for a client diagnosed with an acute myocardial infarction (MI). An appropriate nursing diagnosis is decreased cardiac output secondary to which of the following? 1. Ventricular dysrhythmias 2. Congestive heart failure 3. Recurrent myocardial infarction 4. Hypertensive crisis 1. Ventricular dysrhythmias A client comes to the ER reporting nausea, vomiting, and severe right upper quadrant pain. His temperature is 101.3, and an abdominal x-ray reveals an enlarged gallbladder. He is scheduled for surgery. Which of the following actions should the nurse take FIRST? 1. Assess the client's need for dietary teaching 2. Evaluate the client's fluid and electrolyte status 3. Examine the client's health history for allergies to antibiotics 4. Determine whether the client has signed consent for surgery 2. Evaluate the client's fluid and electrolyte status A client is being treated in the burn unit for second- and third-degree burns over 45% of his body. The physician's orders include the application of silver sulfadiazine cream. The BEST way for the nurse to apply this medication is to use which of the following? 1. Sterile 4x4 dressings soaked in saline 2. Sterile tongue depressor 3. Sterile gloved hand 4. Sterile cotton-tipped applicator 3. Sterile gloved hand When caring for a client with anorexia nervosa, which of the following observations indicates to the nurse that the client's condition is improving? 1. The client eats all the food on her meal tray 2. The client asks friends to bring her special foods 3. The client weighs herself daily 4. The client's weight has increased 4. The client's weight has increased Which of the following symptoms observed by the nurse during the first 24 hrs after a percutaneous liver biopsy would indicate a complication from the procedure? 1. Anorexia, nausea, and vomiting 2. Abdominal distention and discomfort 3. Pulse 112, blood pressure 100/60, respirations 20 4. Pain at the biopsy site 3. Pulse 112, blood pressure 100/60, respirations 20 The nurse is caring for a 56-year-old man receiving haloperidol (Haldol) 2 mg PO bid. The nurse assists the client to choose which of the following menus? 1. 3 oz. roast beef, baked potatoes, salad with dressing, dill pickle, baked apple pie, and milk 2. 3 oz. baked chicken, green beans, steamed rice, 1 slice of bread, banana, and milk 3. Cheeseburger on a bun, french fries with catsup, chocolate chip cookie, apple, and milk 4. 3 oz. baked fish, slice of bread, broccoli, ice cream, and pineapple drink taken 30-60 min after the meal 2. 3 oz. baked chicken, green beans, steamed rice, 1 slice of bread, banana, and milk An adolescent is seen in the ER for a fracture of the left femur sustained in a sledding accident. The fracture is reduced and a cast is applied. The client is taught how to use crutches for ambulating without bearing weight on the left leg. The nurse would expect the client to learn which of the following crutch-walking gaits? 1. Two-point gait 2. Three-point gait 3. Four-point gait 4. Swing-through gait 2. Three-point gait The nurse cares for a client diagnosed with a right-sided CVA with dysphagia. Which of the following actions by the nurse reflects appropriate care for the client? Select all that apply. 1. The nurse assesses the client's ability to swallow 2. the nurse positions the client at a 45-degree angle 3. The nurse offers the client scrambled eggs 4. The nurse instructs the client to place food on the left side of the mouth 5. The nurse turns off the television 1, 3, 5 The nurse plans care for a 4 year old girl who has been sexually abused by her father. Play therapy is scheduled. The nurse knows that the PRIMARY goal of play therapy for a 4 year old is which of the following? 1. Provide her with the opportunity to express anger and hostility by playing with dolls 2. Promote communication because she may lack the emotional and intellectual capacity to express her perceptions verbally 3. Assess whether she is functioning at an age-appropriate developmental level 4. Reveal through direct observation of her at play what type of abuse has been experienced 2. Promote communication because she may lack the emotional and intellectual capacity to express her perceptions verbally A client is being treated for heart failure with diuretic therapy. Which of the following assessments BEST indicates to the nurse that the client's condition is improving? 1. The client's weight has remained stable since admission 2. The client's systolic blood pressure has decreased 3. There are fewer crackles heard when auscultating the client's lungs 4. The client's urinary output is 1,500 mL per day 3. There are fewer crackles heard when auscultating the client's lungs A preschooler with a fractured femur is brought to the ER by her parents. When asked how the injury occurred, the nurse finds old and new lesions on the child's buttocks. Which of the following statements MOST appropriately reflects how the nurse should document these findings? 1. "Six lesions noted on buttocks at various stages of healing" 2. "Multiple lesions on buttocks due to child abuse" 3. "Lesions on buttocks due to unknown causes" 4. "Several lesions on buttocks caused by cigarettes" 1. "Six lesions noted on buttocks at various stages of healing" A construction worker is admitted to the hospital for treatment of active TB. The nurse teaches the client about TB. Which of the following statements by the client indicates to the nurse that further teaching is necessary? 1. "I will have to take my medication for 6 months" 2. "I should cover my nose and mouth when coughing or sneezing" 3. "I will remain in isolation for at least 6 weeks" 4. "I will always have a positive skin test for TB" 3. "I will remain in isolation for at least 6 weeks" A woman admitted to the hospital in premature labor has been treated successfully. The client is to be sent home on an oral terbutaline. Which of the following statements by the client indicates to the nurse that the client understands the discharge teaching about the medication? 1. "As long as I take my medication, I can be sure I will not deliver prematurely" 2. "It is important that I count the fetal movements for one hour, twice a day" 3. "I may feel a rapid heartbeat and some muscle tremors while on this medication" 4. "Bed rest is necessary in order for the medication to work properly" 3. "I may feel a rapid heartbeat and some muscle tremors while on this medication" The nurse describes the procedure to a male client for collecting a clean-catch urine specimen for culture and sensitivity testing. Which of the following explanations by the nurse would be MOST accurate? 1. "The urinary meatus is cleansed with an iodine solution and then a urinary drainage catheter is inserted to obtain urine" 2. "You will be asked to empty your bladder one-half hour before the test; you will then be asked to void into a container" 3. "Before voiding, the urinary meatus is cleansed with an iodine solution and urine is voided into a sterile container; the container must not touch the penis" 4. "You must void a few drops of urine, then stop; then void the remaining urine into a clean container, which should be immediately covered" 3. "Before voiding, the urinary meatus is cleansed with an iodine solution and urine is voided into a sterile container; the container must not touch the penis" The physician orders an arterial blood gas for a client receiving oxygen at 6 L/min. Results show pH 7.37, HCO3 26 mmHg, pCO2 42 mmHg, pO2 90 mmHg. Which of the following should the nurse do FIRST? 1. Increase the rate of oxygen flow the client is receiving 2. Elevate the head of the bed 3. Document the results in the chart 4. Instruct the client to cough and deep breathe 3. Document the results in the chart A client's brought to the emergency room reporting pressure in her chest. Her blood pressure is 150/90, pulse 88, respirations 20. The nurse administers nitroglycerin 0.4 mg SL as ordered. After five minutes her blood pressure is 100/60, pulse 96, respirations 20. Which of the following should the nurse do next? 1. Notify the physician that the client has become hypotensive, and obtain an order to administer IV fluids. 2. Place the client in semi-Fowler's position, and administer O2 at 4 L. 3. Administer a second dose of nitroglycerin 4. Document the results, and continue to monitor the client. 4. Document the results, and continue to monitor the client. A client contacts his home care nurse and reports nausea and abdominal pain. He has type 1 diabetes. The nurse should advise the client to do which of the following? 1. "Hold your regular dose of insulin" 2. "Check your blood glucose level every 3-4 hrs" 3. "Increase your consumption of foods containing simple sugars" 4. "Increase your activity level" 2. "Check your blood glucose level every 3-4 hrs" A client is being treated for Addison's disease. The physician orders cortisone 25 mg PO daily. The nurse should explain to the client that adjustment of the dosage may be required in which of the following situations? 1. Dosage is increased when the blood glucose level increases 2. Dosage is increased when dietary intake is increased 3. Dosage is decreased when infection stimulates endogenous steroid secretion 4. Dosage is increased relative to an increase in the level of stress 4. Dosage is increased relative to an increase in the level of stress A client with a history of heart failure visits the clinic. He states, "I have not been feeling like my old self for about 2 weeks." It would be MOST important for the nurse to ask which of the following questions? 1. "Do your ankles swell at the end of the day" 2. "Where do you sleep at night?" 3. "How do you feel after you eat dinner?" 4. "Do you have chest pain when you inhale?" 2. "Where do you sleep at night?" The nurse is caring for a client immediately after a paracentesis. It it MOST important for the nurse to ask which of the following questions? 1. "Do your clothes still feel tight?" 2. "Do you need to void?" 3. "Are you feeling dizzy?" 4. "Do you have any pain?" 3. "Are you feeling dizzy?" On admission to the hospital, an elderly client appears disheveled and is restless and confused. During the client's second day on the unit, a nurse approaches the client to administer medications. The nurse is unable to identify the client because his armband is missing. Which of the following actions by the nurse is the BEST? 1. Have the client's roommate identify him 2. Ask the client to state his full name 3. Ask another nurse to identify the client 4. Look in the chart at the picture of the client 4. Look in the chart at the picture of the client A client is treated in the ER for acute alcohol intoxication. He has a 4 year history of alcohol abuse. He is agitated and verbally abusive. His admission orders include chlordiazepoxide 50 mg IM or PO every 4-6 hrs for agitation. The nurse should take which of the following precautions after chlordiazepoxide is administered? 1. Place the client in restraints. 2. Leave the client in a room by himself until the tranquilizer takes effect. 3. Assign a practical nurse to stay with the client and document his condition 4. Ask the security guard to stay with the client 3. Assign a practical nurse to stay with the client and document his condition A woman is admitted to the hospital and delivers a healthy 7 lb, 2 oz girl. The mother decides to bottle-feed her infant. Which of the following statements by the mother after a teaching session indicates to the nurse that the client needs further instruction? 1. "I'll pump my breasts and use warm packs to relieve breast pain" 2. "I'll use a tight bra and ice packs to relieve engorgements discomfort" 3. "I'll take the medication prescribed by the doctor for pain" 4. "I'll take the pills ordered by my doctor to help stop the production of milk" 1. "I'll pump my breasts and use warm packs to relieve breast pain" A client sustains a fractured left femur in a car accident. She is placed in balanced suspension skeletal traction using a Thomas splint and a Pearson attachment. The client tells the nurse that she has "terrible" pain in her left thigh. Which of the following should the nurse do FIRST? 1. Determine that all the weights and ropes from the traction apparatus are in line and hanging free 2. Ask the client for more information about the location and characteristics of her pain 3. Check the Thomas splint and Pearson attachment to make sure they are appropriately positioned 4. Explain to the client that the pain she is experiencing in the affected leg is a common occurrence 2. Ask the client for more information about the location and characteristics of her pain A client is admitted to the hospital with flu-like symptoms. When taking the history, the nurse learns that the client has been taking digoxin 0.125 mg PO daily and furosemide 40 mg PO daily for 3 years. Last month her physician changed the prescription for digoxin to 0.25 mg qd. The nurse would expect the physician to order which of the following laboratory tests? 1. Serum electrolytes and digoxin level 2. White blood cell count, hemoglobin, and hematocrit 3. Cardiac enzymes and an arterial blood gas 4. Blood cultures and urinalysis 1. Serum electrolytes and digoxin level The nurse plans care for a teenager admitted with fever, vomiting, and diarrhea. The nurse writes the following nursing diagnosis on the client's care plan: "fluid volume deficit." Which of the following changes in laboratory values would demonstrate an improvement in the client's condition? 1. Urine specific gravity, 1.015; hematocrit, 37% 2. Urine specific gravity, 1.020: hematocrit, 45% 3. Urine specific gravity, 1.032: hematocrit. 52% 4. Urine specific gravity, 1.025: hematocrit, 35% 2. Urine specific gravity, 1.020: hematocrit, 45% A client is hospitalized with a diagnosis of atrial fibrillation. Heparin 5,000 units is ordered every 12 hrs to be given SQ. The health care provider orders daily partial thromboplastin time (PTT). The result of the client's most recent PTT is 55. Which of the following actions should be taken by the nurse? 1. Document the results and administer the heparin 2. Withhold the heparin 3. Notify the health care provider 4. Have the test repeated 1. Document the results and administer the heparin The physician orders furosemide and spironolactone for a client. Prior to administering the medication, the nurse determines that the client's potassium, is 3.2 mEq/L. In addition to notifying the physician, the nurse should anticipate taking which of the following actions? 1. Do not administer the furosemide or spironolactone 2. Administer the spironolactone only 3. Administer the furosemide only 4. Administer the furosemide and spironolactone 2. Administer the spironolactone only A client returns to the clinic 2 weeks after being started on allopurinol 200 mg PO daily. The nurse reviews information about this medication with the client. Which of the following statements by the client indicates that the teaching was effective? 1. "I should take my medication on an empty stomach" 2. "I should take my medication with orange juice" 3. "I should increase my intake of protein" 4. "I should drink at least 8 glasses of water every day" 4. "I should drink at least 8 glasses of water every day" A client is receiving packed red blood cells. Several minutes after the infusion is started, the client reports itching and develops hives on his chest and abdomen. Which of the following actions should the nurse take FIRST? 1. Slow the rate of the transfusion 2. Call the physician for an order for an antihistamine 3. Mix IV fluid with the blood to dilute it 4. Stop the transfusion 4. Stop the transfusion Upon returning form lunch, the nurse is approached in the elevator by a hospital employee from another unit. The employee states that her close friend is a client on the nurse's unit. The employee asks how her friend is doing and if all of her tests were normal. The nurse should do which of the following? 1. Answer the employee's questions softly so other people on the elevator will not hear 2. Refuse to discuss her friend's medical condition. Suggest that she visit her friend. 3. Give the employee the name of the client's physician to call for this information 4. Tell the employee about the results of the client's tests because they were within normal limits 2. Refuse to discuss her friend's medical condition. Suggest that she visit her friend. An hour after admission to the nursery, the nurse observes a newborn baby having spontaneous jerky movements of the limbs. The infant's mother had gestational diabetes mellitus during pregnancy. Which of the following actions should the nurse take FIRST? 1. Give dextrose water 2. Call the physician immediately 3. Determine the blood glucose level 4. Observe closely for other symptoms 3. Determine the blood glucose level A woman is admitted to the hospital with a ruptured ectopic pregnancy. A laparotomy is scheduled. Preoperatively, which of the following goals is MOST important for the nurse to include on the client's plan of care? 1. Fluid replacement 2. Pain relief 3. Emotional support 4. Respiratory therapy 1. Fluid replacement The nurse obtains a diet history from a pregnancy 16 year old girl. The girls tells the nurse that her typical daily diet includes cereal and milk for breakfast, pizza and soda for lunch, and a cheeseburger, milk shake, fries, and salad for dinner. Which of the following is the MOST accurate nursing diagnosis based on this data? 1. Altered nutrition: more than body requirements related to high-fat intake 2. Knowledge deficit: nutrition in pregnancy 3. Altered nutrition: less than body requirements related to increased nutritional demands of pregnancy 4. Risk for injury: fetal malnutrition related to poor maternal diet 3. Altered nutrition: less than body requirements related to increased nutritional demands of pregnancy The nurse plans acre for a 14 year old girl admitted with an eating disorder. On admission, the girl weighs 82 lb. and is 5'4" tall. Lab tests indicate severe hypokalemia, anemia, and dehydration. The nurse should give which of the following nursing diagnosis the HIGHEST priority? 1. Body image disturbance related to weight loss 2. Self-esteem disturbance related to feelings of inadequacy 3. Altered nutrition: less than body requirements related to decreased intake 4. Decreased cardiac output related to the potential for dysrhythmias 4. Decreased cardiac output related to the potential for dysrhythmias The mother of a boy with type 1 diabetes calls the physician's office to discuss the child's self-monitoring blood glucose home reading. He is being tightly regulated with a combination of NPH and regular insulin before breakfast and supper. The past 2 morning his blood sugar readings were 220 mg/dL and 210 mg/dL. Which of the following should the nurse tell the boy's mother? 1. "Continue with his medication regimen" 2. "Check his blood sugar during the night" 3. "Give his NPH insulin later in the evening" 4. "Serve his bedtime snack earlier in the evening" 2. "Check his blood sugar during the night" A boy was riding his bike to school when he hit the curb. He fell and hurt his leg. The school nurse was called and found him alert and conscious, but in severe pain with a possible fracture of the right femur. Which of the following is the FIRST action that the nurse should take? 1. Immobilize the affected limb with a spinal split and ask him not to move 2. Make a thorough assessment of the circumstances surrounding the accident 3. Put him in semi-Fowler's position for comfort 4. Check the pedal pulse and blanching sign in both legs 1. Immobilize the affected limb with a spinal split and ask him not to move A child undergoes a tonsillectomy for treatment of chronic tonsillitis unresponsive to antibiotic therapy. After surgery, the child is brought to the recovery room. Which of the following actions should the nurse include in the child's plan of care? 1. Institute measures to minimize crying 2. Perform postural drainage every 2 hours 3. Cough and deep breathe every hour 4. Give ice cream as tolerated 1. Institute measures to minimize crying A client is receiving intravenous cimetidine. After 20 minutes of the infusion, the client reports a headache and dizziness. Which of the following actions should the nurse take FIRST? 1. Stop the infusion 2. Take the client's vital signs 3. Reposition the client 4. Call the pharmacist 1. Stop the infusion A client is admitted with a diagnosis of dementia. He attempts several times to pull out his nasogastric tubes. An order for cloth wrist restraints is received by the nurse. Which of the following actions by the nurse is MOST appropriate? 1. Attach the ties of the restraints to the bed frame 2. Perform range of motion to the restrained extremities once a shift 3. Remove the restraints when the client is up in a wheelchair 4. Explain the need for restraints only to the family because the client is confused 1. Attach the ties of the restraints to the bed frame The nurse cares for a client with a diagnosis of CVA. The nurse is feeding the client in a chair when he suddenly begins to choke. Which of the following actions should the nurse take FIRST? 1. Check for breathlessness by placing an ear over the client's mouth and observing the chest 2. Leave the client in the chair and apply vigorous abdominal or chest thrusts fro behind the client 3. Ask the client, "Are you choking?' 4. Return the client to the bed and apply vigorous abdominal chest thrusts while straddling the client's thighs 3. Ask the client, "Are you choking?' A client with a history of bipolar disorder is admitted to the psychiatric hospital. She was found by the police attempting to climb onto the wing of a plane at the airport. Her husband reports that she has not eaten or slept in 2 days, and he suspects she has stopped taking lithium. On admission, the nurse should place the HIGHEST priority on which of the following client care needs? 1. Teaching the client about the importance of taking lithium as prescribed 2. Providing the client with safe environment with few distractions 3. Arranging for food and rest for the client 4. Setting limits on the client's behavior 3. Arranging for food and rest for the client The physician orders a NG tube inserted and connected to low intermittent suction for a client with an intestinal obstruction. Two hours after insertion of the NG tube, the client vomits 200 mL. While irrigating the NG tube, the nurse notes resistance. Which of the following actions should the nurse take FIRST 1. Replace the NG tube with a larger one 2. Turn the client on his left side 3. Change the suction from intermittent to continuous 4. Continue the irrigation 2. Turn the client on his left side A child with a compound fracture of the left femur is being admitted to a pediatric unit. Which of the following actions is BEST for the nurse to take? 1. Ask the NAP to obtain the child's vital signs while the nurse obtains a history from the parents. 2. ASK the LPN/LVN to assess the peripheral pulses of the child's left leg while the nurse completes the admission forms 3. Ask the LPN/LVN to stay with the child and his parents while the nurse obtains phone orders from the physician 4. Ask the NAP to obtain equipment for the child's care while the nurse talks with the child and his parents 4. Ask the NAP to obtain equipment for the child's care while the nurse talks with the child and his parents Which of the following tasks is appropriate for the nurse to delegate to an experienced NAP? 1. Obtain a 24 hr diet recall from a client recently admitted with anorexia nervosa 2. Obtain a clean-catch urine specimen form a client suspected of having a urinary tract infection 3. Observe the amount and characteristics of the returns from a continuous bladder irrigation for a client after a transurethral resection 4. Observe a client newly diagnosed with diabetes mellitus practice injection techniques using an orange 2. Obtain a clean-catch urine specimen form a client suspected of having a urinary tract infection Which of the following clients should the nurse on a pediatric unit assign to an LPN/LVN? 1. a 3 year old admitted yesterday with laryngotracheobronchitis who has a tracheostomy 2. A 6 year old girl admitted after a gastric lavage for acetaminophen ingestion 3. A 6 year old boy admitted for a fracture of the femur, in balanced suspension traction 4. A 10 year old boy admitted for observation after an acute asthmatic attack 3. A 6 year old boy admitted for a fracture of the femur, in balanced suspension traction Immediately after a percutaneous liver biopsy, the nurse should place the client in which of the following positions? 1. Supine 2. Right side-lying 3. Left side-lying 4. Semi-Fowler's 2. Right side-lying An angiogram is scheduled for a client with decreased circulation in her right leg. After the angiogram, the nurse should place the client in which of the following positions? 1. Semi-Fowler's with right leg bent at the knee 2. Side-lying with a pillow between the knees 3. Supine with right leg extended 4. High Fowler's with right leg elevated 3. Supine with right leg extended The nurse cares for a client after a lumbar laminectomy. Which of the following statements BEST describes the method of turning a client following a lumbar laminectomy? 1. The head of the bed is elevated 30 degrees; the client locks her knees when turning 2. A pillow is placed between the client's legs; her body is turned as a unit 3. The client straightens her back and grasps the side rail on the opposite side of the bed 4. The head of the bed is flat; the client bends her knees and rolls to the side 2. A pillow is placed between the client's legs; her body is turned as a unit The nurse cares for a client after an appendectomy. The client continues to report discomfort to the nurse shortly after receiving an analgesic. Which of the following measures by the nurse would be MOST appropriate? 1. Notify the physician 2. Place the client in Fowler's position 3. Massage his abdomen 4. Provide him with reading material 2. Place the client in Fowler's position A client is admitted to the ER with a diagnosis of acute myocardial infarction. The client tells the nurse, "I'm sacred. I think I'm going to die." Which of the following responses by the nurse would be MOST appropriate? 1. "Everything is going to be fine. We'll take good care of you." 2. "I know what you mean. I thought I was having a heart attack once." 3. "I'll call your doctor so you can discuss it with him." 4. "It's normal to feel frightened. We're doing everything we can for you." 4. "It's normal to feel frightened. We're doing everything we can for you." A mother is to undergo a breast biopsy. She tells the nurse, "If I lose my breast, I know my husband will no longer find me attractive." Which of the following responses by the nurse would be MOST appropriate? 1. "You don't know if you are going to lose your breast. They are just doing the biopsy now." 2. "You should focus on your children. They are young and they need you." 3. "You seem to be concerned that your relationship with your husband might change." 4. "Why don't you wait and see what your husband's reaction is before you get upset." 3. "You seem to be concerned that your relationship with your husband might change." A client in the psychiatric unit asks the nurse, "Am I in a special radioactive shelter? When was it last checked for radioactivity?" Which of the following responses by the nurse would be MOST appropriate? 1. "This is a hospital, and we do not have a Nuclear Medicine Department here." 2. "Don't worry, you're safe. There's no radioactivity here." 3. "I'm sure your safety is of concern to you, but this is a hospital." 4. "Please share with me what makes you think there is radioactivity here." 3. "I'm sure your safety is of concern to you, but this is a hospital." A 58 year old man with head and neck cancer is admitted to the hospital and tells the nurse he does not want parenteral nutritional therapy as his cancer progresses. The nurse explains he can specify his wishes by creating an advance directive. The nurse knows that the requirement to provide clients with this type of information can be found in which of the following? 1. The Patient Self-Determination Act 2. Nursing Scope and Standards of Practice 3. The Patient Protection and Affordable Care Act 4. The Patients' Bill of Rights 1. The Patient Self-Determination Act A 14 year old girl newly diagnosed with diabetes is preparing for discharge. Which of the following activities BEST describes the nurse's role as a client advocate? 1. Arranging for a visit with a home health nurse 2. Providing written medication instructions to the client's parents 3. Instructing the client to follow up with her provider in 4 weeks 4. Teaching the client how to administer insulin rejections 4. Teaching the client how to administer insulin rejections A client is seen for an outpatient appointment and asks the nurse if he can obtain a copy of his medical record. The nurse knows the client has the right to read and copy his medical records, and that this guaranteed by virtue of which of the following? 1. The Code of Ethics for Nurses 2. The Health Insurance Portability and Accountability Act 3. The Patient Self-Determination Act 4. The Americans with Disabilities Act 2. The Health Insurance Portability and Accountability Act After receiving report at the start of the evening shift, which of the following clients should the nurse attend to FIRST? 1. A 34 year old man undergoing treatment for non-Hodgkin's lymphoma with a potassium level of 7.5 mEq/L 2. A 21 year old woman with sickle-cell anemia with pain of 6 on a scale of 1-10 3. A 55 year old woman with ovarian cancer waiting to be discharged 4. A 72 year old man with chronic obstructive pulmonary disease and a pulse oximetry of 96% on room air 1. A 34 year old man undergoing treatment for non-Hodgkin's lymphoma with a potassium level of 7.5 mEq/L A 34 year old woman who developed Stevens-Johnson syndrome while undergoing treatment with carbamazepine is being transferred in stable condition from the intensive care unit to the medical unit. There are 4 beds available. The nurse knows the BEST choice of roommates for this client is which of the following? 1. A 40 year old man with MRSA 2. A 28 year old woman diagnosed with diarrhea 3. A 72 year old man with fever of unknown origin 4. A 68 year old woman with atrial fibrillation 4. A 68 year old woman with atrial fibrillation A 72 year old man who had a stroke is being transferred from a medical unit to a rehabilitation center. The nurse case manager is assisting in the process. The nurse knows that the goals of case management include which of the following? Select all that apply. 1. Improving the coordination of care 2. Increasing referrals to local organizations 3. Reducing the fragmentation of care 4. Discharging clients quickly 1, 3 An 18 year old client with acute lymphocytic leukemia is admitted to the bone marrow transplantation unit. His family is having trouble dealing with the emotional and financial pressures of his disease. The nurse, case manager, physician, and social worker meet to discuss the plan of care. The nurse knows this type of interdisciplinary interactions is BEST referred to as which of the following? 1. Case management 2. Collaboration 3. Cooperation 4. Collegiality 2. Collaboration A pregnant woman at 15 weeks' gestation is scheduled for an amniocentesis. As the client is being prepped for the procedure, it becomes clear to the nurse that the client doesn't fully understand the risks and benefits associated with the procedure. Which of the following describe the nurse's role in obtaining informed consent? Select all that apply. 1. Explain the risks and benefits associated with the procedure 2. Describe the alternatives to the procedure 3. Witness the client's signature on the consent form 4. Advocate for the client by ensuring she is making an informed decision 3, 4 The nurse noticed and increase in the prevalence of pressure ulcers among clients in an intensive care unit. Sh documented her findings and worked with her manager to develop and implement a new policy using a pressure ulcer risk assessment scale. Which of the following BEST describes the nurse's actions? 1. Quality improvement 2. Collaboration 3. Advocacy 4. Case management 1. Quality improvement The nurse is working on a surgical unit. Which of the following tasks would be appropriate for the nurse to delegate to the nursing assistive personnel? 1. Assist a new postoperative client to the bathroom 2. Set up the clients' lunch trays 3. Change a central line dressing 4. Teach a client how to administer discharge medications 2. Set up the clients' lunch trays The nurse has been asked to administer a drug by IV push. She is uncertain whether or not this task falls within her scope of practice. The nurse knows that which of the following are the BEST sources to refer to for information related to her scope of practice in this situation? Select all that apply. 1. Hospital and unit policies and procedures 2. Nurse Practice Act 3. Ordering physician 4. Hospital pharmacist 1, 2 A 20 year old client with leukemia has consented to a blood transfusion against the wishes of his family, who are all Jehovah's Witnesses. The nurse knows that which of the following ethical principles BEST supports this decision? 1. Autonomy 2. Beneficence 3. Nonmaleficence 4. Justice 1. Autonomy The nurse wants to delegate the task of showering an elderly client in a wheelchair to the nursing assistive personnel. Before delegating a task to the NAP, the nurse should FIRST ensure which of the following is accomplished? 1. The UAP is supervised at all times 2. The UAP demonstrated competency for the task during orientation 3. The UAP has performed the task before 4. The UAP has received the assignment during report 2. The UAP demonstrated competency for the task during orientation A well-known actor has been admitted to an ambulatory surgical unit. The nurse notices a staff member who is not involved in the client's care reading his medical record. The nurse knows he should FIRST do which of the following? 1. Nothing. The staff member has a hospital ID badge and is authorized to read the medical record 2. Inform the staff member that without a legitimate need for the information, staff should not be reading the medical record 3. Tell the client his medical records have been read by an unauthorized individual 4. Page the physician and ask if it's acceptable for the staff member to access the medical records 2. Inform the staff member that without a legitimate need for the information, staff should not be reading the medical record The nurse is learning how to use the hospital's new electronic medication administration record. The nurse knows this tool has the potential to do which of the following? Select all that apply. 1. Reduce medication administration errors 2. Improve access to information at the point of care 3. Eliminate the need for the nurse to document medication administration 4. Eliminate the need for the nurse to verify dose calculations 1, 2 The nurse uses the Internet to receive electrocardiogram results from a client living in a nursing home. The nurse knows this type of information technology is BEST described as which of the following? 1. Encryption 2. Telecommunications 3. Telehealth 4. Nursing informatics 3. Telehealth The nurse is preparing to transfer a client to the operating room. She knows that adhering to the hospital policy for client handoffs BEST ensures which of the following? 1. Case management 2. Continuity of care 3. Confidentiality protection 4. Collaboration 2. Continuity of care The nurse is preparing to perform an admission assessment on a 28 year old man being admitted for Crohn's disease. The nurse know that according to the Patients' Bill of Rights, this client is responsible for which of the following? Select all that apply. 1. Consenting to treatment 2. Providing information about medications 3. Providing proof of insurance 4. Providing information about past illnesses 2, 4 The nurse is caring for a 41 year old man with a new colostomy. As part of the care planning for this client, the nurse knows a referral to which of the following will be the priority? 1. A certified wound, ostomy, and continence nurse 2. Social services 3. Physical therapy 4. Occupational therapy 1. A certified wound, ostomy, and continence nurse An RN is in charge of a team on a medical/surgical unit that includes an LPN. The RN understands that which of the following is an activity that falls within the scope of practice of an LPN? 1. Administer oral medications to a client 2. Collaborate with social services to develop a discharge plan 3. Formulate a nursing diagnosis 4. Develop a policy 1. Administer oral medications to a client The nurse in a maternity unit is caring for a client who has just delivered twins. The client voices concern about her ability to manage when she gets home. Which of the following statements BEST illustrates quality care delivery by the nurse? Select all that apply. 1. "Just focus on how lucky you are to have two healthy babies." 2. "We can arrange for follow up visits with a home health nurse." 3. "Here is some information on support groups for parents of multiples." 4. "You will find it easier to formula-feed your babies at home." 2, 3 After responding to a code, several staff nurses express concerns over their confidence levels and performance to the nurse in charge of the hospital's performance improvement program. The nurse in charge knows the BEST way to evaluate and improve performance is to implement which of the following? 1. A program that collects and analyzes performance data 2. Mock codes 3. Inservice training 4. Written competency exams 2. Mock codes A client is being treated for uncontrolled hypertension. The nurse knows that the involvement of nursing, pharmacy, cardiology, and nutritional services is an example of which of the following approaches? 1. Managed care 2. Multidisciplinary 3. Case management 4. Performance improvement 2. Multidisciplinary The nurse is caring for a client newly diagnosed with diabetes, and performs the following tasks. Place the tasks the nurse would perform in the appropriate order. All options must be used. 1. The nurse establishes a goal with the client to be able to self-administer insulin injections 2. The nurse assesses the client's level of knowledge about how to administer insulin injections 3. The nurse evaluates the client while self-administering insulin injections 4. The nurse establishes the diagnosis of knowledge deficit 2, 4, 1, 3 The nurse administers the first dose of chemotherapy to a client on an oncology unit. The nurse knows that which of the following activities is appropriate to delegate to the LPN? 1. Obtain the client's blood pressure 2. Provide teaching about the side effects of chemotherapy 3. Administer the second dose of chemotherapy 4. Flush the client's central line with heparin 1. Obtain the client's blood pressure The physician orders an MRI of the brain for an adult male client. Which of the following findings in the client's history should the nurse report tot he physician? 1. Allergy to contrast dye 2. Implanted cardiac pacemaker 3. COPD 4. Hernia repair 2. Implanted cardiac pacemaker The nurse is developing a care plan for a client with hepatitis C. The nurse knows that the primary route of transmission of this hepatitis virus is which of the following? 1. Contaminated food 2. Feces 3. Blood 4. Sputum 3. Blood The nurse is preparing to discharge a client with rheumatic heart disease who is recovering from endocarditis. Which of the following statements from the client indicates that the client understands the teaching? 1. "I'm so glad I don't need any more antibiotics now that I'm feeling better." 2. "I can restart my exercise program in a day or two." 3. "I will watch for signs of relapse the first few days after discharge." 4. "I will inform my dentist should I ever need any dental work." 4. "I will inform my dentist should I ever need any dental work." The nurse is preparing to test a client who has allergies from an unknown cause. Which of the following test should the nurse perform? 1. Tzanck test 2. Patch test 3. Rinne test 4. Stress test 2. Patch test The nurse is preparing a client with AIDS for discharge to home. Which of the following instructions should the nurse include? 1. "Avoid sharing articles such as razors and toothbrushes" 2. "Do not share eating utensils with family members" 3. "Limit the time you spend in public places" 4. "Avoid eating food from serving dishes shared with others" 1. "Avoid sharing articles such as razors and toothbrushes" The nurse is preparing to administer a tuberculin (Mantoux) skin test to a client suspected of having TB. The nurse knows that the test will reveal which of the following? 1. How long the client has been infected with TB 2. Active TB infection 3. Latent TB infection 4. Whether the client has been infected with TB bacteria 4. Whether the client has been infected with TB bacteria An older adults has been admitted with diagnosis of stroke and a history of dementia. Which of the following nursing diagnoses has the highest priority for this client? 1. Bathing/hygiene self-care deficit 2. Risk for injury 3. Impaired physical mobility 4. Disturbed thought processes 2. Risk for injury The nurse has just administered insulin to a diabetic client. In which of the following ways should the nurse dispose of the needle? 1. Re-cap the needle and discard it in the nearest puncture-resistant container 2. Re-cap the needle and discard it in the nearest biohazard container 3. Discard the needle in a puncture-resistant container 4. Break the needle and discard it in the nearest puncture-resistant container. 3. Discard the needle in a puncture-resistant container The nurse is preparing to administer packed RBCs to a client. Arrange the following steps in the order the nurse should perform them. All options must be used. 1. Explain the procedure to the client 2. Obtain the client's vital signs 3. Assess that the client has a blood bank identification armband 4. Obtain the PRBCs from the blood bank according to hospital policy and perform a visual check of the blood 5. Perform a bedside identification and blood product verification by two licensed individuals 6. Verify the physician order 7. Prime the transfusion tubing with 0.9% sodium chloride solution 6, 3, 1, 2, 7, 4, 5 The nurses are preparing to lift a client up in bed. Which of the following should the nurses do to help avoid injuring their backs? 1. Bend from the waist 2. Lift with the back, not with the legs 3. Lower the head of the bed to about 30 degrees, if the client can tolerate it 4. Make certain the bed is in a reasonably high position 4. Make certain the bed is in a reasonably high position In the emergency room, the nurse assesses a 4 year old child suspected of having measles. Which of the following kinds of precautions should the nurse initiate? 1. Contact precautions 2. Droplet precautions 3. Airborne precautions 4. Reverse isolation 3. Airborne precautions A female client comes to the ED reporting vaginal discharge, irritation of the vagina, and the need to urinate. The nurse suspects a STD, and the physician orders diagnostic testing of the vaginal discharge. Which of the following STDs does the nurse know must be reported to the DPH? 1. Genital herpes 2. HPV 3. Gonorrhea 4. Trichomoniasis 3. Gonorrhea An elderly client, who is not oriented to time, place, or person, has a total hip replacement. The client is attempting to get out of bed and pull out the IV line that is infusing antibiotics. The client has bilateral soft wrist restraints and a vest restraint. Which of the following interventions by the nurse are appropriate? Select all that apply. 1. Ask the client if he needs to use the bathroom, and provide ROM exercises every 2 hours 2. Document the type of restraint used and asses the need for continued use 3. Tie the restraint tot eh side rails of the bed 4. Obtain a new physician order for the restraint every 12 hrs 5. Observe for correct placement of restraints 6. Tie the restraints in a quick-release knot 1, 2, 5, and 6 The nurse is preparing to administer a unit of PRBCs to an anemic client. After obtaining the blood from the blood bank, the nurse must begin administering it within which of the following time periods? 1. 15 minutes 2. 30 minutes 3. 45 minutes 4. 60 minutes 2. 30 minutes The nurse is assessing an elderly client for risk for falls. Which of the following should the nurse collect? 1. The facility's restraint policy 2. Gait, balance, and visual impairment information 3. Psychosocial history 4. The facility's environmental safety plan 2. Gait, balance, and visual impairment information The nurse is administering nightly medications, which include an anticoagulant and a stool softener. Which of the following should the nurse do FIRST before administering the medications? 1. Scan the medication label and the client's wristband 2. Ask the client his or her name to properly identify this client as the one for whom the medications were ordered 3. Match the client's date of birth and name on the client's wristband with the same information on the medication order 4. Match the client's name and room number with the medication order 3. Match the client's date of birth and name on the client's wristband with the same information on the medication order The physician verbally orders a medication for a client during an emergency code. Which of the following should the nurse do? 1. Repeat the order back to the physician for confirmation and administer it 2. Retrieve the medication and administer it 3. Write the order down, retrieve the medications, and administer it 4. Read the order to another nurse, have that nurse retrieve the medication, and stay with the client 1. Repeat the order back to the physician for confirmation and administer it The client has a new order for placement of a Foley catheter due to urinary retention. Which of the following should the nurse do before starting the procedure? Select all that apply 1. The nurse should confirm the clients identity, because a procedure requires proper identification 2. The nurse should confirm the client's medical record number via the wristband and order 3. Ask the client his or her name only, because this is a procedure and not a medication administration 4. The nurse should confirm the client's name via the wristband and order 1, 2, 4 Which of the following actions by the nurse is the MOST effective means of preventing infection? 1. Washing hands after client contact 2. Washing hands after removing gloves 3. Hand hygiene between clients 4. Hand hygiene before entry to a client's room and upon exit of a client's room 4. Hand hygiene before entry to a client's room and upon exit of a client's room The client is an obese male with decubitus ulcers. Treatment of the ulcers requires frequent turning and repositioning. The nursing unit has a special lift that allows for turning of clients and placement onto a bedpan without any lifting on the part of the staff. The client urgently requests the bedpan. Because the lift apparatus takes a few minutes to set up, which of the following should the nurse do? 1. Quickly assist the client onto the bedpan without the lift because he needs to use it urgently 2. Encourage the client to try to be patient, and set up the apparatus 3. Get the assistance of an aide to help lift the client 4. Encourage the client to wear an incontinence brief 2. Encourage the client to try to be patient, and set up the apparatus The client has experienced multiple episodes of hyperglycemia not manageable by SQ insulin injections. The client has an active order for infusion of an insulin drip for glycemic management to be discontinued at bedtime, after which the client is NPO. The client's most recent blood sugar level, taken at 3pm was 60. Which of the following actions by the nurse is the MOST appropriate? 1. The nurse should follow the order and allow the insulin to infuse until bedtime 2. The nurse should recheck the client's blood sugar 3. The nurse should bring this blood sugar level to the physician's attentions and discuss stopping the infusion 4. The nurse should seek advice from other nurses 3. The nurse should bring this blood sugar level to the physician's attentions and discuss stopping the infusion The adult children of a hospice home care client inquire about whether it is safe to hug their mother, because she has had a MRSA infection in the past. Which of the following statements by the children would indicate a need for further teaching by the nurse? 1. "We should wash our hands frequently." 2. "We should use hand sanitizer.' 3. "Those of us with poor immune systems should be extra careful." 4. "We should wear gowns and gloves at all times when having contact with out mother." 4. "We should wear gowns and gloves at all times when having contact with out mother." The nurse witnesses another nurse, wearing a gown and gloves, enter a client room labeled "Airborne Precautions." Which of the following actions by the witnessing nurse is MOST appropriate? 1. Notify the nurse manager to discuss policies with the other nurse 2. Ask a physician to give a presentation on which precautions require which types of PPE 3. Remind the other nurse that she needs a mask in addition to a gown and gloves for airborne-type precautions 4. Ask the other nurse to look up the policy about precautions 3. Remind the other nurse that she needs a mask in addition to a gown and gloves for airborne-type precautions The nurse discovers a client on the floor in the client's hospital room. After examining the client and assisting him safely back to bed, which of the following should the nurse do FIRST? 1. File an incident report 2. Put the bed alarm back on 3. Institute a client observe to sit with the client and prevent further falls 4. Notify the nurse manager 2. Put the bed alarm back on The hospitalized client is receiving an infusion and the pump has malfunctioned. Which of the following actions by the nurse is MOST appropriate once the infusion has been stopped and restarted with a functioning pump? 1. Place a "Broken" sticker on the malfunctioning pump according to hospital policy, and place the pump in the designated malfunctioning equipment area 2. Place the malfunctioning pump in the utility room 3. Remove the malfunctioning pump from the client's room and place with other pumps 4. Place the malfunctioning pump to the side in the client's room 1. Place a "Broken" sticker on the malfunctioning pump according to hospital policy, and place the pump in the designated malfunctioning equipment area The nurse completes a peripherally inserted central catheter line dressing change for a home care client. When removing the PPE, the nurse should do which of the following? 1. Remove the mask and then the gloves 2. Remove the gloves and then the mask 3. Remove only the gloves; there is no need to wear a mask 4. Remove only the mask; there is no need to wear gloves 2. Remove the gloves and then the mask The client is found on the floor by the NAP. Once the client is safe, which of the following should the nurse do next? 1. Document the event in the client's medical record and file an incident report 2. File an incident report only 3. Document the event in the client's medical record and have the NAP file an incident report 4. Document the event in the client's medical record only 3. Document the event in the client's medical record and have the NAP file an incident report The nurse is making a home visit to an elderly client during the winter. The nurse notices upon arrival that the client has the oven turned on with the oven door open, and is using it as a form of heat. Which of the following actions by the nurse is MOST appropriate? 1. Take care of the client's medical needs and do not get involved in the client's private matters 2. Shut the oven off and continue with the home visit 3. Report the event to the local Fire Department 4. Have a meeting with the client and family and warn them of the fire and safety risks of using the oven for heat 4. Have a meeting with the client and family and warn them of the fire and safety risks of using the oven for heat The medical center encounters a bomb threat. The emergency response team informs the staff that the threat is legitimate and that clients should start being evacuated. Which of the following clients should the nurse begin evacuating FIRST to the safe designated area? 1. Ambulatory clients 2. Bedridden clients 3. ICU clients 4. Infant clients 1. Ambulatory clients The nurse discovers that the last dose of intravenous antibiotic administered to a client was the wrong dose. Which of the following should the nurse do? 1. Document the event in the client's medical record only 2. File an incident report, and document the event in the client's medical record 3. Document in the client's medical record that an incident report was filed 4. File an incident report, but don't document the event in the client's medical record, because information about the incident is protected 2. File an incident report, and document the event in the client's medical record A 20 year old client has just given birth. The baby looks healthy, with the exception of giving a grimace instead of a cry. Which of the following would the nurse expect the obstetrician to say? 1. "The APGAR score is 3." 2. "The APGAR score is 6." 3. "The APGAR score is 9." 4. "The APGAR score is 12." 3. "The APGAR score is 9." The outpatient client is postmenopausal. In discussing breast self-examination, which of the following should the nurse let the client know that she can do? 1. Switch to an annual schedule, because she does not have periods 2. Discontinue self-examination, because hormone changes decrease her risks 3. Wait until her mammogram shows some findings 4. Continue to palpate monthly, picking her own meaningful date 4. Continue to palpate monthly, picking her own meaningful date A client with acne has been using isotretinoin. She tells the nurse that she recently learned she is pregnant. She asks "Will my pregnancy interfere with the medication;s effectiveness?" Which of the following is the appropriate response by the nurse? 1. "The medication is contraindicated for pregnant women." 2. "You will have to change the route of administration, because you are pregnant." 3. "There is no reason you can't continue taking it." 4. "If the medication helps you look better, that will help feel better about yourself." 1. "The medication is contraindicated for pregnant women." The nurse is preparing for a women's health fair. The nurse knows that which of the following is correct when teaching about the risks and benefits of hormone replacement therapy? 1. HRT is related to a decreased risk of DVT 2. HRT is related to an increased risk for CAD 3. HRT is related to an increased risk for osteoporosis-related bone fractures 4. HRT is related to a decreased risk of breast cancer 2. HRT is related to an increased risk for CAD The nurse has been working with a 45 year old African American who bicycles to work. Lab tests show low serum lipids. The nurse knows that the client's risk factors for primary (essential) hypertension include which of the following? 1. Being under the age of 65 2. Race 3. Low serum lipids 4. Active lifestyle 2. Race The nurse is designing a diet plan for a 70 year old with poorly fitting dentures who has been recently diagnosed with type 2 diabetes. The nurse knows that which of the following is the LEAST likely risk to the client? 1. Malnutrition 2. Dehydration 3. Hyperglycemia 4. Low blood sugar 3. Hyperglycemia The nurse is providing education at a senior center. Which of the following measures will the nurse say is MOST effective in attaining normal blood sugar levels in a client with type 2 diabetes? 1. Decreasing sodium intake 2. Increasing potassium and calcium intake 3. Reaching recommended weight 4. Decreasing daily exercise 3. Reaching recommended weight A local high school is having a health fair. Which of the following main courses should the nurse recommend as most healthful for a teenager whose cholesterol level is 300 mg/dL? 1. Medium-rare hamburger with only one slice of cheese 2. Vegetaria