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Elevated Temperature
A nurse is caring for a client who was Rationale: The content of this question emphasizes the concept of client-centered care
admitted for acute alcohol delirium through identifying findings associated with a client's diagnosis. Client-centered care
withdrawal 2 days ago. Which of the focuses on the client and emphasizes the client's cultural, ethnic, and social values.
following findings is associated with this The identification of expected and unexpected findings associated with a client's
diagnosis? diagnosis assists the nurse to distinguish possible unrelated complications the client
might be experiencing, which indicates the need for further investigation. The specific
A. Increased appetite focus on the client enhances the provision of safe, quality nursing care. An elevated
B. Elevated Temperature temperature is a finding associated with acute alcohol delirium.
C. Bradycardia
D. Drowsiness
" Let's discuss some strategies you can use when this happens again."
Rationale: This response by the nurse offers to provide information, which can reduce
anxiety and enhance decision making. This response creates a safe environment,
fosters trust and respect, and is appropriate.
A nurse working in a hospice facility is
talking to a client's son who is distressed
because his mother cries frequently and
says she wants to die. Which of the following
responses by the nurse is appropriate?
A. "I know this must be difficult, but your
mother will calm down soon."
B. "Lets discuss some strategies you can
use when this happens again."
C. Individuals near death are ready to let go
toward the end."
D. "Have you determined why she is crying
and saying she is ready to die?"
Lethargy
A nurse is caring for a client who had rationale: Lethargy occurs when pressure is placed on the reticular activating system
cerebrovascular accident 2 days ago. Which within the brainstem. Along with other indicators of a change in level of consciousness,
of the following is the first sign of increased such as restlessness, irritability, and disorientation. Lethargy is the first sign of
intracranial pressure (ICP)? increased ICP.
A. pupil dilation
B. Ataxia
C. Lethargy
D Bradycardia
Facial edema
A nurse working in a provider's office is rationale: facial edema is an indication of pregnancy-induced hypertension and should
reinforcing teaching with a client who is 14 be reported immediately to the provider.
weeks of gestation. The nurse should
instruct the client to immediately notify the
provider if she experiences which of the
following?
A. facial edema
b. urinary frequency
c. acid indigestion
d. breast leakage
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Stop the infusion
Rationale: This prevents further damage to vessel and minimizes any additional harm
A nurse is caring for a client who is receiving to the client
parenteral nutrition through a nontunneled
central venous catheter and reports hearing
a gurgling sound on the side of the catheter.
The nurse suspects the catheter has
migrated to the jugular vein. Which of the
following actions should the nurse take first?
A. Notify the provider
B. Obtain a chest x-ray
C. Flush the catheter.
D. Stop the infusion.
Cue the client by providing picture cards that portray common needs.
Rationale: Using picture cards enhances communication. The nurse should include this
A nurse is reinforcing teaching with a communication strategy in the teaching.
caregiver who has aphasia. The nurse
should include which of the following
communication strategies in the teaching?
A. Cue the client by providing picture cards
that portray common needs.
B. Increase the volume of the voice when
speaking to a client.
C. Encourage the client to limit hand
gestures when communicating.
D. Vary the use of phrases and terminology
in discussions.
Determine respiratory status
Rationale: The client is experiencing angioedema indicating a possible anaphylactic
A nurse is caring for a client who has a
reaction, which is life-threatening; therefore, the nurse should first determine the
urinary tract infection and is prescribed
client's respiratory status.
ciprofloxacin (Cipro). The client exhibits
urticaria and angioedema following
administration of the medication. Which of
the following is the first action the nurse
should take?
A. Administer epinephrine (Adrenaline)
B. Elevate the lower extremities
C. Determine respiratory status
D. Apply oxygen via non-rebreather mask.
Excessive vomiting
A nurse is caring for a client who has an rationale: Metabolic alkalosis is a potential complication of excessive vomiting because
acid-base imbalance. For which of the of loss of acid from the body.
following manifestations is metabolic
alkalosis a possible complications?
A. Hyperkalemia
B. Severe diarrhea
C. Atelectasis
D. Excessive vomiting
hypoglycemia
rationale: Betamethasone is a glucocorticoid used in the prevention of respiratory
A nurse is caring for neonate who was distress syndrome in premature infants. Betamethasone causes hyperglycemia in the
delivered at 30 weeks of gestation after his mother, which predisposes the neonate to hypoglycemia in the first hours after delivery.
mother received two injections of
betamethasone (Celestone). because of
administration of betamethasone to the
client's mother, the nurse should monitor the
neonate for which of the following effects?
A. Tachycardia
B. Sternal retractions
C. Hypoglycemia
D. Hypothermia
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" It is the responsibility of the provider to obtain express consent"
rationale: Nurses frequently obtain express consent by witnessing a client sign a
A nurse is reinforcing teaching about client consent form after ensuring the client has received and understands necessary
consent to treatment with a group of newly information regarding the procedure. This is not an appropriate statement by a newly
licensed nurses. Which of the following licensed nurse and requires further teaching.
statements by a newly licensed nurse
indicates a need for further teaching?
A. "It is necessary to have written consent
for invasive procedures"
B. "Implied consent is appropriate for some
aspects of nursing care"
C. It is the responsibility of the provider to
obtain express consent"
D. "Informed consent should be obtained
separately for each surgical procedure"
discuss the risks associated with leaving with the client
rationale: Discussing risks associated with leaving is priority concern. The client should
A nurse is caring for an adult client who has be made aware of potential negative outcomes that could occur if he chooses to leave
attempted suicide. The client tells the nurse the facility prior to physician prescribed discharge.
he is calling his family to come pick him up.
Which of the following actions by the nurse
is appropriate when the client insists on
leaving the facility against medical advice?
A. assign a security guard to stay at the
client's door.
B. request a prescription from the provider
for soft restraints.
C. discuss the risks associated with leaving
with the client
D. remove the telephone from the client's
room
Reduced bleeding time
A nurse is caring for a child who has rationale: Platelets are responsible for triggering the process of blood clotting. Clients
leukemia and is prescribed a transfusion of who have leukemia are prone to bleeding because of low platelet counts and should
platelets. Which of the following should the experience a reduced bleeding time as a result of a transfusion of platelets.
client experience as a result of the
transfusion?
A. reduced bleeding time
B. decreased plasma globulins
C. improved activity tolerance
D. increased immune functioning
" I will have my husband wear a condom during intercourse"
rationale: The client who has experienced a premature rupture of membranes should
A nurse working in a provider's office is not engage in sexual activity or insert anything in the vagina because of increased risk
reinforcing teaching with a client who is 36 for infection.
weeks of gestation and has experienced a
premature rupture of membranes. Which of
the following statements by the client
indicates a need for additional teaching?
A. "I will have my husband wear a condom
during intercourse."
B. " I will check my temperature every 4
hours."
C. I will wipe rom front to back after bowel
movements"
D. "I will notify my doctor if my baby moves
fewer than 4 times in the 2 hour following
each meal."
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Elevated Temperature
A nurse is caring for a client who was Rationale: The content of this question emphasizes the concept of client-centered care
admitted for acute alcohol delirium through identifying findings associated with a client's diagnosis. Client-centered care
withdrawal 2 days ago. Which of the focuses on the client and emphasizes the client's cultural, ethnic, and social values.
following findings is associated with this The identification of expected and unexpected findings associated with a client's
diagnosis? diagnosis assists the nurse to distinguish possible unrelated complications the client
might be experiencing, which indicates the need for further investigation. The specific
A. Increased appetite focus on the client enhances the provision of safe, quality nursing care. An elevated
B. Elevated Temperature temperature is a finding associated with acute alcohol delirium.
C. Bradycardia
D. Drowsiness
" Let's discuss some strategies you can use when this happens again."
Rationale: This response by the nurse offers to provide information, which can reduce
anxiety and enhance decision making. This response creates a safe environment,
fosters trust and respect, and is appropriate.
A nurse working in a hospice facility is
talking to a client's son who is distressed
because his mother cries frequently and
says she wants to die. Which of the following
responses by the nurse is appropriate?
A. "I know this must be difficult, but your
mother will calm down soon."
B. "Lets discuss some strategies you can
use when this happens again."
C. Individuals near death are ready to let go
toward the end."
D. "Have you determined why she is crying
and saying she is ready to die?"
Lethargy
A nurse is caring for a client who had rationale: Lethargy occurs when pressure is placed on the reticular activating system
cerebrovascular accident 2 days ago. Which within the brainstem. Along with other indicators of a change in level of consciousness,
of the following is the first sign of increased such as restlessness, irritability, and disorientation. Lethargy is the first sign of
intracranial pressure (ICP)? increased ICP.
A. pupil dilation
B. Ataxia
C. Lethargy
D Bradycardia
Facial edema
A nurse working in a provider's office is rationale: facial edema is an indication of pregnancy-induced hypertension and should
reinforcing teaching with a client who is 14 be reported immediately to the provider.
weeks of gestation. The nurse should
instruct the client to immediately notify the
provider if she experiences which of the
following?
A. facial edema
b. urinary frequency
c. acid indigestion
d. breast leakage
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Stop the infusion
Rationale: This prevents further damage to vessel and minimizes any additional harm
A nurse is caring for a client who is receiving to the client
parenteral nutrition through a nontunneled
central venous catheter and reports hearing
a gurgling sound on the side of the catheter.
The nurse suspects the catheter has
migrated to the jugular vein. Which of the
following actions should the nurse take first?
A. Notify the provider
B. Obtain a chest x-ray
C. Flush the catheter.
D. Stop the infusion.
Cue the client by providing picture cards that portray common needs.
Rationale: Using picture cards enhances communication. The nurse should include this
A nurse is reinforcing teaching with a communication strategy in the teaching.
caregiver who has aphasia. The nurse
should include which of the following
communication strategies in the teaching?
A. Cue the client by providing picture cards
that portray common needs.
B. Increase the volume of the voice when
speaking to a client.
C. Encourage the client to limit hand
gestures when communicating.
D. Vary the use of phrases and terminology
in discussions.
Determine respiratory status
Rationale: The client is experiencing angioedema indicating a possible anaphylactic
A nurse is caring for a client who has a
reaction, which is life-threatening; therefore, the nurse should first determine the
urinary tract infection and is prescribed
client's respiratory status.
ciprofloxacin (Cipro). The client exhibits
urticaria and angioedema following
administration of the medication. Which of
the following is the first action the nurse
should take?
A. Administer epinephrine (Adrenaline)
B. Elevate the lower extremities
C. Determine respiratory status
D. Apply oxygen via non-rebreather mask.
Excessive vomiting
A nurse is caring for a client who has an rationale: Metabolic alkalosis is a potential complication of excessive vomiting because
acid-base imbalance. For which of the of loss of acid from the body.
following manifestations is metabolic
alkalosis a possible complications?
A. Hyperkalemia
B. Severe diarrhea
C. Atelectasis
D. Excessive vomiting
hypoglycemia
rationale: Betamethasone is a glucocorticoid used in the prevention of respiratory
A nurse is caring for neonate who was distress syndrome in premature infants. Betamethasone causes hyperglycemia in the
delivered at 30 weeks of gestation after his mother, which predisposes the neonate to hypoglycemia in the first hours after delivery.
mother received two injections of
betamethasone (Celestone). because of
administration of betamethasone to the
client's mother, the nurse should monitor the
neonate for which of the following effects?
A. Tachycardia
B. Sternal retractions
C. Hypoglycemia
D. Hypothermia
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" It is the responsibility of the provider to obtain express consent"
rationale: Nurses frequently obtain express consent by witnessing a client sign a
A nurse is reinforcing teaching about client consent form after ensuring the client has received and understands necessary
consent to treatment with a group of newly information regarding the procedure. This is not an appropriate statement by a newly
licensed nurses. Which of the following licensed nurse and requires further teaching.
statements by a newly licensed nurse
indicates a need for further teaching?
A. "It is necessary to have written consent
for invasive procedures"
B. "Implied consent is appropriate for some
aspects of nursing care"
C. It is the responsibility of the provider to
obtain express consent"
D. "Informed consent should be obtained
separately for each surgical procedure"
discuss the risks associated with leaving with the client
rationale: Discussing risks associated with leaving is priority concern. The client should
A nurse is caring for an adult client who has be made aware of potential negative outcomes that could occur if he chooses to leave
attempted suicide. The client tells the nurse the facility prior to physician prescribed discharge.
he is calling his family to come pick him up.
Which of the following actions by the nurse
is appropriate when the client insists on
leaving the facility against medical advice?
A. assign a security guard to stay at the
client's door.
B. request a prescription from the provider
for soft restraints.
C. discuss the risks associated with leaving
with the client
D. remove the telephone from the client's
room
Reduced bleeding time
A nurse is caring for a child who has rationale: Platelets are responsible for triggering the process of blood clotting. Clients
leukemia and is prescribed a transfusion of who have leukemia are prone to bleeding because of low platelet counts and should
platelets. Which of the following should the experience a reduced bleeding time as a result of a transfusion of platelets.
client experience as a result of the
transfusion?
A. reduced bleeding time
B. decreased plasma globulins
C. improved activity tolerance
D. increased immune functioning
" I will have my husband wear a condom during intercourse"
rationale: The client who has experienced a premature rupture of membranes should
A nurse working in a provider's office is not engage in sexual activity or insert anything in the vagina because of increased risk
reinforcing teaching with a client who is 36 for infection.
weeks of gestation and has experienced a
premature rupture of membranes. Which of
the following statements by the client
indicates a need for additional teaching?
A. "I will have my husband wear a condom
during intercourse."
B. " I will check my temperature every 4
hours."
C. I will wipe rom front to back after bowel
movements"
D. "I will notify my doctor if my baby moves
fewer than 4 times in the 2 hour following
each meal."
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