Pearson Exam Cram NCLEX RN Test #1 med surg 311 Questions with Verified Answers,100% CORRECT

Pearson Exam Cram NCLEX RN Test #1 med surg 311 Questions with Verified Answers The client is admitted to the emergency room with shortness of breath, anxiety, and tachycardia. His ECG reveals atrial fibrillation with a ventricular response rate of 130 beats per minute. The doctor orders quinidine sulfate. While he is receiving quinidine, the nurse should monitor his ECG for: a Peaked P wave b Elevated ST segment c Inverted T wave d Prolonged QT interval - CORRECT ANSWER d Prolonged QT interval Quinidine can cause widened Q-T intervals and heart block. A client with ascites is scheduled for a paracentesis. Which instruction should be given to the client before the procedure? a "You will need to lay flat during the procedure." b. "You need to empty your bladder before the procedure." c. "You will be asleep during the procedure." d. "The doctor will inject a medication during the procedure." - CORRECT ANSWER b. "You need to empty your bladder before the procedure." A client's lab values reveal Hgb 12.6, WBC , K+ 1.9, uric acid 7.0, Na+ 136, and platelets 178,. The nurse evaluates that the client is experiencing which of the following? Hypernatremia b Hypokalemia Myelosuppression Leukopenia - CORRECT ANSWER b Hypokalemia Due to a high census, it has been necessary for a number of clients to be transferred to other units within the hospital. Which client should be transferred to the postpartum unit? a A 66-year-old female with gastroenteritis b A 40-year-old female with a hysterectomy c A 27-year-old male with severe depression d A 28-year-old male with ulcerative colitis - CORRECT ANSWER b A 40-year-old female with a hysterectomy Before administering Theo-Dur (theophylline), the nurse should check the patient's: a output b Blood pressure c Pulse d Temperature - CORRECT ANSWER c Pulse Which information should be given to the patient undergoing radiation therapy for breast cancer? a Avoid exposing radiation areas to sunlight during treatment time and for a year after completion of therapy b Moisturize the radiation site with oil-based lotion to prevent blistering c Use bath oil when tub bathing to prevent drying and peeling d Report redness and soreness of the area to the physician - CORRECT ANSWER a Avoid exposing radiation areas to sunlight during treatment time and for a year after completion of therapy The charge nurse is making assignments for the day. After accepting the assignment to care for a client with leukemia, the nurse tells the charge nurse that her child has chickenpox. Which initial action should the charge nurse take? a Change the nurse's assignment to another client. b Explain to the nurse that there is no risk to the client. c Ask the nurse if the chickenpox have crusted. d Ask the nurse if she has ever had the chickenpox. - CORRECT ANSWER d Ask the nurse if she has ever had the chickenpox. Which statement is true regarding therapy with Levemir (insulin detemir)? a The onset is 1-2 hours. b It may be mixed with regular insulin. c It peaks in 2-3 hours. d The duration is 24 hours. - CORRECT ANSWER d The duration is 24 hours. Which client should be assigned to the nursing assistant? a The 18-year-old with a fracture to two cervical vertebrae b The infant with meningitis with a temperature of 101°F c The elderly client with a thyroidectomy four days ago d The client with a thoracotomy two days ago - CORRECT ANSWER c The elderly client with a thyroidectomy four days ago The physician has ordered the Schilling test for a patient with suspected pernicious anemia. What other vitamin level is often assessed at the same time as the B12 level? a Folic acid b Pyridoxine c Ascorbic acid d Thiamine - CORRECT ANSWER a Folic acid A 25-year-old client arrives in the emergency room with a possible fracture of the right femur. The nurse should anticipate an order for: a Bryant's traction b Ice to the entire extremity c Buck's traction d An abduction pillow - CORRECT ANSWER c Buck's traction Which statement should be included in the teaching session of a client scheduled for a renal biopsy? a "You will be placed in a sitting position for the biopsy." b "You may experience a feeling of pressure or discomfort during aspiration of the biopsy." c "You will be asleep during the procedure." d "You will not be able to drink fluids for 24 hours following the study." - CORRECT ANSWER b "You may experience a feeling of pressure or discomfort during aspiration of the biopsy." The nurse is caring for the client who has been in a coma for two months. He has signed a donor card, but the wife is opposed to the idea of organ donation. How should the nurse handle the topic of organ donation with the wife? a Tell the wife that the hospital will honor her wishes regarding organ donation, but contact the organ-retrieval staff. b Tell her that because her husband signed a donor card, the hospital has the right to take the organs upon the death of her husband. c Explain that it is necessary for her to donate her husband's organs because he signed the permit. d Refrain from talking about the subject until after the death of her husband. - CORRECT ANSWER a Tell the wife that the hospital will honor her wishes regarding organ donation, but contact the organ-retrieval staff. The client is admitted with chronic obstructive pulmonary disease. Blood gases reveal pH 7.36, CO2 45, O2 84, bicarb 28. The nurse would assess the client to be in: a Uncompensated acidosis b Compensated alkalosis c Compensated metabolic acidosis d Uncompensated metabolic acidosis - CORRECT ANSWER c Compensated metabolic acidosis Before administering intravenous chemotherapy to the patient being treated, the nurse should: a Administer a bolus of IV fluid. b Administer pain medication. c Administer an antiemetic. d Allow the patient a chance to eat. - CORRECT ANSWER c Administer an antiemetic. Which one of the following statements is correct when measuring the client for crutches? a A distance of five fingerbreadths should exist between the top of the crutch and the axilla. b The nurse should measure three inches between the top of the crutch and the axilla. c The client's elbows should be flexed at a 10°angle. d The crutches should be extended 8 to 10 inches from the side of the foot. - CORRECT ANSWER b The nurse should measure three inches between the top of the crutch and the axilla. A patient of Greek descent has been prescribed Bactrim (sulfamethoxazole-trimethoprim) for treatment of a urinary tract infection. Before beginning the medication, the patient should be assessed for which of the following disorders? a G6PD deficiency b β-thalassemia c Sickle cell anemia d Von Willebrand disease - CORRECT ANSWER a G6PD deficiency The physician has ordered Coumadin (sodium warfarin) for a client with thrombophlebitis. The order should be entered to administer the medication at: a 0900 b 1200 c 1700 d 2100 - CORRECT ANSWER c 1700 Which medication is often used to treat the client with N.gonorrhea? a Sitavig (acyclovir) b Vibramycin (doxycycline) c Retrovir (zidovudine) d Aldara (imiquimod) - CORRECT ANSWER b Vibramycin (doxycycline) The nurse is caring for a client with cerebral palsy. The nurse should provide frequent rest periods because: a Grimacing and writhing movements decrease with relaxation and rest. b Hypoactive deep tendon reflexes become more active with rest. c Stretch reflexes are increased with rest. d Fine motor movements are improved by rest. - CORRECT ANSWER a Grimacing and writhing movements decrease with relaxation and rest. The nurse is assisting in the care of a patient who is two days post-operative from a hemorrhoidectomy. The nurse would be correct in instructing the patient to: a Avoid a high-fiber diet b Continue to apply ice packs c Take a laxative daily to p revent constipation d Use a sitz bath after each bowel movement - CORRECT ANSWER d Use a sitz bath after each bowel movement A client with an abdominal aortic aneurysm is admitted in preparation for surgery. Which finding should be reported to the doctor? a A WBC of 14,000 . b Auscultation of abdominal bruit c Complaints of lower back pain d A platelet count of 175,000 . - CORRECT ANSWER a A WBC of 14,000 . The nurse is performing an assessment on a client with possible pernicious anemia. Which finding is specific to pernicious anemia? a A weight loss of 10 pounds in six months b Fatigue c Glossitis d Pallor - CORRECT ANSWER c Glossitis The nurse is making assignments for the day. The staff consists of an RN, an LPN, and a nursing assistant. Which client could the nursing assistant care for? a A client with Alzheimer's disease b A client with pneumonia c A client with cirrhosis d A client with thrombophlebitis - CORRECT ANSWER a A client with Alzheimer's disease The client is diagnosed with multiple myeloma. The doctor has ordered cyclophosphamide (Cytoxan). Which instruction should be given to the client? a "Walk about a mile a day to prevent calcium loss." b "Increase the fiber in your diet." c "Report nausea to the doctor immediately." d "Drink at least eight large glasses of water a day." - CORRECT ANSWER d "Drink at least eight large glasses of water a day." While caring for an elderly patient with hypertension, the nurse notes the following vital signs: BP of 140/40, pulse 120, respirations 36. The nurse's initial action should be to: a Report the findings to the physician b Recheck the vital signs in one hour c Ask the patient if he is in pain d Compare the current vital signs with those on admission - CORRECT ANSWER a Report the findings to the physician The charge nurse overhears the patient care assistant speaking harshly to the client with dementia. The charge nurse should: a Change the nursing assistant's assignment b Explore the interaction with the nursing assistant c Discuss the matter with the client's family d Initiate a group session with the nursing assistant - CORRECT ANSWER b Explore the interaction with the nursing assistant Which action by the home health nurse indicates a knowledge of the needs of an elderly client? a Teaching regarding availability and services offered by hospice care b Speaking in a higher pitched voice tone to facilitate hearing c Encouraging fluid restriction to prevent nighttime voiding d Reinforcing teaching regarding the prevention of falls - CORRECT ANSWER d Reinforcing teaching regarding the prevention of falls A client with glomerulonephritis is placed on a low-sodium diet. Which of the following snacks is suitable for the client with sodium restriction? Peanut butter cookies Grilled cheese sandwich Cottage cheese and fruit Fresh peach - CORRECT ANSWER Fresh peach The nurse can help alleviate the discomfort the client is experiencing associated with xerostomia by: Limiting fluid intake Administering an analgesic Splinting swollen joints Providing sugarless hard candy - CORRECT ANSWER Providing sugarless hard candy dry mouth The client returns to the recovery room following repair of an abdominal aneurysm. Which finding would require further investigation? Pedal pulses regular Urinary output 20mL in the past hour Blood pressure 108/50 Oxygen saturation 97% - CORRECT ANSWER Urinary output 20mL in the past hour The nurse has an order for the administration of intravenous heparin. The medication should be administered using a/an: Metered chamber Infusion controller Intravenous filter Three-way stopcock - CORRECT ANSWER Infusion controller A patient is diagnosed with secondary syphilis. The nurse can expect the patient to have: "Copper penny" rash on the palms of the hands and soles of the feet Localized tumors in the skin, bones, and liver Chancres and lymphadenopathy General paresis - CORRECT ANSWER "Copper penny" rash on the palms of the hands and soles of the feet The nurse is aware that a common mode of transmission of clostridium difficile is: Use of unsterile surgical equipment Contamination of objects with sputum Through urinary catheterization Contamination of objects with stool - CORRECT ANSWER Contamination of objects with stool The nurse is assessing the abdomen. The nurse knows the best sequence to perform the assessment is: Inspection, auscultation, palpation Auscultation, palpation, inspection Palpation, inspection, auscultation Inspection, palpation, auscultation - CORRECT ANSWER a Inspection, auscultation, palpation A client is scheduled for surgery in the morning. Which of the following is the primary preoperative responsibility of the nurse? Making sure the vital signs are recorded Obtaining a signed permit for surgery Explaining the surgical procedure Answering questions about the surgery - CORRECT ANSWER a Making sure the vital signs are recorded A 70-year-old male who is recovering from a stroke exhibits signs of unilateral neglect. Which behavior is suggestive of unilateral neglect? The client is observed shaving only one side of his face. The client is unable to complete a range of vision without turning his head side to side. The client is unable to carry out cognitive and motor activity at the same time. - CORRECT ANSWER a The client is observed shaving only one side of his face. The nurse is performing discharge teaching on a client with diverticulitis who has been placed on a low-roughage diet. Which food would have to be eliminated from this client's diet? Roasted chicken Noodles Cooked broccoli Custard - CORRECT ANSWER c Cooked broccoli The doctor orders 2% nitroglycerin ointment in a 1-inch dose every 12 hours. Proper application of nitroglycerin ointment includes: Rotating application sites Limiting applications to the chest Rubbing it into the skin Covering it with a gauze dressing - CORRECT ANSWER a Rotating application sites The client has an order for Feosol(ferrous sulfate). To promote absorption, the nurse should administer the medication with: Milk A meal Orange juice Undiluted - CORRECT ANSWER c Orange juice Which information should be given to the client using a TENS unit? "Electrocution may occur if you use water with this unit." "Skin irritation may occur with prolonged use of the unit." "The unit can be placed anywhere on the body without fear of adverse reactions." "A cream or lotion should be applied to the skin before applying the unit." - CORRECT ANSWER b "Skin irritation may occur with prolonged use of the unit." The nurse is making initial rounds on a client with a C5 fracture stabilized by Crutchfield tongs. Which equipment should be kept at the bedside? Forceps Torque wrench Wire cutters Screwdriver - CORRECT ANSWER b Torque wrench The client with diabetes is preparing for discharge. During discharge teaching, the nurse assesses the client's ability to care for himself. Which statement made by the client would indicate a need for follow-up after discharge? "I live by myself." "I have trouble seeing." "I have a cat in the house with me." "I usually drive myself to the doctor." - CORRECT ANSWER b "I have trouble seeing." Which of the following post-operative diets is appropriate for the client who has had a hemorrhoidectomy? High fiber Lactose free Bland Clear liquid - CORRECT ANSWER Clear liquid The nurse is assessing the vital signs of a client with pancreatic cancer. In addition to routine vital signs, the nurse assesses the fifth vital sign of: Anorexia Pain Insomnia Fatigue - CORRECT ANSWER b Pain A home health nurse is planning for her daily visits. Which client should the home health nurse visit first? A client with AIDS being treated with Foscavir(foscarnet) A client with a fractured femur in a long leg cast A client with a recent laryngectomy for laryngeal cancer A client with diabetic ulcers to the left foot - CORRECT ANSWER c laryngectomy for laryngeal cancer The nurse is removing a peripherally inserted central catheter (PICC). The nurse should position the patient in which position? Fowlers Right side lying Left side lying Trendelenburg - CORRECT ANSWER d Trendelenburg The nurse is assigning staff for the day. Which client should be assigned to the nursing assistant? A five-month-old with bronchiolitis A 10-year-old who is two-day post-appendectomy A two-year-old with periorbital cellulitis A one-year-old with a fractured tibia - CORRECT ANSWER b A 10-year-old who is two-day post-appendectomy Which of the following is a late sign associated with oral cancer? Warmth Odor Pain Ulcer with flat edges - CORRECT ANSWER c Pain A client with an ileostomy is being discharged. Which teaching should be included in the plan of care? Using Karaya powder to seal the bag. Irrigating the ileostomy daily. Using Stomahesive as a skin protector Using a stool softener as needed - CORRECT ANSWER c Using Stomahesive as a skin protector The nurse discovers a patient care assistant looking through the client's belongings while the client is out of the room. Which action should be taken by the nurse? Discuss the nursing assistant's behavior with the family. Report the incident to the charge nurse. Monitor the situation and note whether any items are missing. Ignore the situation until items are reported missing. - CORRECT ANSWER b Report the incident to the charge nurse. The physician has prescribed Zyvox (linezolid) for a patient with VRE. The concurrent use of which of medication may result in serotonin syndrome? Nexium (esomeprazole) Zoloft (sertraline) Lipitor (atorvastatin) Zyrtec (cetirizine) - CORRECT ANSWER b Zoloft (sertraline) The doctor has ordered antithrombotic stockings to be applied to the legs of a client with peripheral vascular disease. The nurse knows antithrombotic stockings should be applied: Before the client arises in the morning With the client in a standing position After the client has bathed and applied lotion to the legs Before the client retires in the evening - CORRECT ANSWER a Before the client arises in the morning The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available? The client with Cushing's disease The client with diabetes The client with acromegaly The client with myxedema - CORRECT ANSWER a The client with Cushing's disease condition makes him more susceptible to infection. The physician has ordered atropine sulfate 0.4milligrams IM before surgery. The medication is supplied in 0.8 milligrams per milliliter. How much medication should the nurse prepare to administer? 0.25mL 0.5mL 1.0mL 1.25mL - CORRECT ANSWER b 0.5mL A client is scheduled to have a cardiac CTA with contrast. Before the procedure, the nurse should assess the patient for: Allergies to shellfish or iodine allergies The ability to lie prone for 30minutes A history of reaction to nitrates The presence of body tattoos - CORRECT ANSWER a Allergies to shellfish or iodine allergies Which statement made by the student nurse indicates the need for further teaching regarding the administration of heparin? "I will administer the medication 1-2 inches away from the umbilicus." "I will not massage the injection site after administering the heparin." "I will check the PTT before administering the heparin." "I will need to gently aspirate when I give the heparin." - CORRECT ANSWER a "I will need to gently aspirate when I give the heparin." The nurse is caring for a client with β-thalassemia major. Which therapy is used to treat β-thalassemia major? IV fluids Frequent blood transfusions Oxygen therapy Iron therapy - CORRECT ANSWER b Frequent blood transfusions The client with a recent liver transplant asks the nurse how long he will have to take an immunosuppressant. Which response is correct? One year Five years 10 years Life - CORRECT ANSWER d Life The nurse is caring for a patient following a thyroidectomy. Which of the following is an early symptom of hypocalcemia? Positive Chvostek's sign 3+ deep tendon reflexes Numbness or tingling of the toes and extremities Prolonged ST and QT intervals - CORRECT ANSWER c Numbness or tingling of the toes and extremities Which of the following is the best indication of resolution of a paralytic ileus? Passage of stool Eructation Presence of bowel sounds Decreasing abdominal girth - CORRECT ANSWER a Passage of stool The nurse is caring for a client with a diagnosis of cirrhosis who is experiencing pruritis. Which of the following is an appropriate nursing intervention? Suggesting that the client take warm showers twice daily Applying a lotion containing menthol or camphor to the skin after bathing Applying powder to the client's skin Placing warm compresses on the affected areas - CORRECT ANSWER b Applying a lotion containing menthol or camphor to the skin after bathing The nurse is caring for a client with a recent laparoscopic hemicolectomy. Which finding should be reported to the physician? Sluggish bowel sounds Pain and tenderness at the umbilicus Passage of small amount of liquid stool Increasing abdominal girth - CORRECT ANSWER d Increasing abdominal girth The client presents to the emergency room with a hyphema. Which action by the nurse would be appropriate? Elevate the head of the bed and apply ice to the eye. Place the client in a supine position and apply heat to the knee. Insert a Foley catheter and measure the intake and output. Perform a vaginal exam and check for a discharge. - CORRECT ANSWER a Elevate the head of the bed and apply ice to the eye. The patient is prescribed metronidazole (Flagyl) for adjunct treatment for a duodenal ulcer. When teaching about this medication, the nurse would include: "This medication should be taken only until you begin to feel better." "This medication should be taken on an empty stomach to increase absorption." "While taking this medication, you do not have to be concerned about being in the sun." "While taking this medication, alcoholic beverages and products containing alcohol should be avoided." - CORRECT ANSWER d "While taking this medication, alcoholic beverages and products containing alcohol should be avoided." The nurse is evaluating the client's pulmonary artery pressure (PAP). The nurse is aware that PAP evaluates: Pressure in the left ventricle Systolic, diastolic, and mean pressure in the pulmonary artery Pressure in the pulmonary veins Pressure in the right ventricle - CORRECT ANSWER Systolic, diastolic, and mean pressure in the pulmonary artery When assessing the client's blood pressure, the nurse should use a cuff with a width that is ____% of the circumference of the extremity. (Fill in the blank.) 40 30 20 10 - CORRECT ANSWER a 40 A client is admitted to the hospital in chronic renal failure. A low protein diet is ordered. The rationale for a low protein diet is that: A low protein diet helps reduce blood urea nitrogen and other wastes excreted by the kidneys. A low protein diet increases the sodium and potassium levels. A low protein diet increases albumin production. A low protein diet increases the calcium and phosphorous levels. - CORRECT ANSWER a A low protein diet helps reduce blood urea nitrogen and other wastes excreted by the kidneys. Before administering eye drops, the nurse should recognize that it is essential to consider which of the following? The eye should be cleansed with warm water to remove any exudate, before instilling the eye drops. The patient will be more comfortable if allowed to instill his own eye drops. Eye drops should be instilled with the patient looking down. Eye drops should always be warmed before instilling in the patient's eyes. - CORRECT ANSWER a The eye should be cleansed with warm water to remove any exudate, before instilling the eye drops. A client with cirrhosis is receiving Cephulac (lactulose). The nurse is aware that Cephulac is given to lower: Blood glucose Uric acid Ammonia Creatinine - CORRECT ANSWER c Ammonia The physician prescribes captopril (Capoten) 25mg PO bid for the client with hypertension. Which of the following adverse reactions can occur with administration of Capoten? Tinnitus Persistent cough Muscle weakness Diarrhea - CORRECT ANSWER b Persistent cough The home health nurse is planning for the day's visits. Which client should be seen first? The client with renal insufficiency The client with Alzheimer's disease The client with diabetes who has a decubitus ulcer The client with multiple sclerosis who is being treated with IV cortisone - CORRECT ANSWER d The client with multiple sclerosis who is being treated with IV cortisone In planning care for the patient with ulcerative colitis, the nurse identifies which nursing diagnosis as a priority? Anxiety Impaired skin integrity Fluid volume deficit Nutrition altered, less than body requirements - CORRECT ANSWER c Fluid volume deficit A nurse indicates that she is licensed in her new state of residence even though reciprocity has not been granted. The nurse's action can result in a charge of: Fraud Tort Malpractice Negligence - CORRECT ANSWER a Fraud Which complaint is frequently expressed by a client with macular degeneration? Problems with activities requiring focused vision such as sewing Severe eye and face pain accompanied by nausea and vomiting Seeing halos around lights Veil-like loss of vision - CORRECT ANSWER a Problems with activities requiring focused vision such as sewing When assessing deep tendon reflexes, the nurse grades the client's patellar reflex as a 3+. This reading indicates that the assessed reflex is: Stronger than normal Hypoactive Normal Hyperactive - CORRECT ANSWER a Stronger than normal A client with a femoral popliteal bypass graft is assigned to a semiprivate room. The most suitable roommate for this client is the client with: Hypothyroidism Diabetic ulcers Gastroenteritis Bacterial pneumonia - CORRECT ANSWER a Hypothyroidism The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 68/34, pulse rate 130, and respirations 18. Which is the client's most appropriate priority nursing diagnosis? Alteration in cerebral tissue perfusion Fluid volume deficit Ineffective airway clearance Alteration in sensory perception - CORRECT ANSWER b Fluid volume deficit The nurse identifies ventricular tachycardia on the cardiac monitor. The patient has a pulse rate of 160 with a regular rhythm. The nurse should give priority to: Administering atropine sulfate Requesting a stat potassium level Administering amiodarone Defibrillating at 360 joules - CORRECT ANSWER Administering amiodarone The nurse is discharging a client with a prescription of eyedrops. Which observation by the nurse would indicate a need for further client teaching? Shaking of the suspension to mix the medication Administering a second eyedrop medication immediately after the first one was instilled Washing the hands before and after the administration of the drops Holding the lower lid down without pressing the eyeball to instill the drops - CORRECT ANSWER b Administering a second eyedrop medication immediately after the first one was instilled The physician has prescribed NovoLog (as part) insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the onset of the insulin occurs? "I will make sure I eat breakfast within 10 minutes of taking my insulin." "I will need to carry candy or some form of sugar with me all the time." "I will eat a snack around three o'clock each afternoon." "I can save my dessert from supper for a bedtime snack." - CORRECT ANSWER a "I will make sure I eat breakfast within 10 minutes of taking my insulin." The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is: Measuring the urinary output Checking the vital signs Encouraging increased fluid intake Weighing the client - CORRECT ANSWER b Checking the vital signs The nurse is providing dietary teaching for a client with elevated cholesterol levels. Which cooking oil is not suggested for the client on a low-cholesterol diet? Safflower oil Sunflower oil Coconut oil Canola oil - CORRECT ANSWER c Coconut oil The nurse is teaching a client with peritoneal dialysis how to manage exchanges at home. The nurse should tell the client to notify the doctor immediately if: The dialysate returns become cloudy in appearance. The return of the dialysate is slower than usual. A "tugging" sensation is noted as the dialysate drains. A feeling of fullness is felt when the dialysate is instilled. - CORRECT ANSWER a The dialysate returns become cloudy in appearance. indicates infection and impending peritonitis The nurse is caring for a client with diabetes mellitus. Which instruction should be given to the client? Tell the client to avoid stairs Tell the client to decrease her intake of sodium Instruct the client to weigh daily Tell the client to report numbness and tingling in her feet and toes - CORRECT ANSWER d Tell the client to report numbness and tingling in her feet and toes diabetic neuropathy. A client with myasthenia gravis is admitted in a cholinergic crisis. Signs of cholinergic crisis include: Decreased blood pressure and constricted pupils Increased heart rate and increased respirations Increased respirations and increased blood pressure Anoxia and absence of the cough reflex - CORRECT ANSWER a Decreased blood pressure and constricted pupils overmedication with anticholinesterase inhibitors. The nurse caring for a client with a head injury would recognize which assessment finding as the most indicative of increas-ed ICP? Vomiting Headache Dizziness Papilledema - CORRECT ANSWER Papilledema causes the part of the optic nerve inside the eye to swell. vision, headache, vomiting, On the second post-operative day after a subtotal thyroidectomy, the client tells the nurse, "I feel numbness and my face is twitching." What is the nurse's best initial action? Offer mouth care. Loosen the neck dressing. Notify the physician. Document the finding as the only action. - CORRECT ANSWER c Notify the physician. hypocalcemia and symptoms of tetany Which statement is true regarding a patient with a Sengstaken-Blakemore tube? The smaller balloon will provide direct pressure to control bleeding from the esophagus. The tube has four lumens, one of which drains esophageal secretions. The esophageal balloon should be inflated to a pressure between 30-35 mmHg. Scissors should be kept at the patient's bedside. - CORRECT ANSWER Scissors should be kept at the patient's bedside. to deflate balloons and remove the tube rapidly The nurse is assessing a trauma client in the emergency room when she notes a penetrating abdominal wound with exposed viscera. The nurse should: Apply a clean dressing to protect the wound. Cover the exposed viscera with a sterile saline gauze. Gently replace the abdominal contents. Cover the area with a petroleum gauze. - CORRECT ANSWER Cover the exposed viscera with a sterile saline gauze. Which medication should be avoided by the client with acute pancreatitis? Demerol (meperidine) Pepcid (famotidine) Zantac (ranitidine) Duramorph (morphine sulfate) - CORRECT ANSWER Duramorph (morphine sulfate) causes spasms of the sphincter of Oddi The nurse is changing the ties of the client with a tracheostomy. The safest method of changing the tracheostomy ties is to: Apply the new tie before removing the old one Have a helper present in case assistance is needed Hold the tracheostomy tie with the nondominant hand while removing the old tie Ask the client to hold the tracheostomy in place as the ties are changed - CORRECT ANSWER a. Apply the new tie before removing the old one A client is to receive Dilantin (phenytoin) via a nasogastric (NG) tube. When giving the medication, the nurse should: Flush the NG tube with 2-4mL of water before giving the medication Administer the medication, flush with 5mL of water, and clamp the NG tube Flush the NG tube with 5mL of normal saline and administer the medication Flush the NG tube with 2-4oz of water before and after giving the medication - CORRECT ANSWER d Flush the NG tube with 2-4oz of water before and after giving the medication A client having a colonoscopy is medicated with Versed (midazolam). The nurse recognizes that the client: Will be able to remember the procedure within 2-3 hours Will not be able to remember having the procedure done Will be able to remember the procedure within 2-3 days Will not be able to remember what occurred before the procedure - CORRECT ANSWER Will not be able to remember having the procedure done Versed produces conscious sedation The nurse is planning care for a client with adrenal insufficiency. The nurse should give priority to: Monitoring the client for signs of dehydration Promoting sleep and rest Providing high-calorie snacks Promoting a healthy body image - CORRECT ANSWER a Monitoring the client for signs of dehydration frequently suffers from fluid volume deficit and acidosis The nurse is assessing a client who had a colon resection two days ago. The client states, "I feel like my stitches have burst loose." Upon further assessment, dehiscence of the wound is noted. Which action should the nurse take? Immediately place the client in the prone position. Apply a sterile, saline-moistened dressing to the wound. Administer atropine to decrease abdominal secretions. Wrap the abdomen with an ACE bandage. - CORRECT ANSWER b Apply a sterile, saline-moistened dressing to the wound. The nurse is caring for a client admitted to the emergency room after a fall. X-rays reveal that the client has several fractured bones in the foot. Which treatment should the nurse anticipate for the fractured foot? Application of a walking boot Stabilization with a cast Surgery with Kirschner wire implantation Application of spica cast - CORRECT ANSWER b Stabilization with a cast The nurse is preparing a client with gastroesophageal reflux disease (GERD) for discharge. The nurse should tell the client to: Eat a small snack before bedtime Sleep on his right side Avoid carbonated beverages Increase his intake of citrus fruits - CORRECT ANSWER c Avoid carbonated beverages The nurse is performing discharge teaching on a client with ulcerative colitis who has been placed on a low-residue diet. Which food would need to be eliminated from this client's diet? Roasted chicken Noodles Cooked broccoli Roast beef - CORRECT ANSWER c Cooked broccoli While caring for a client with cervical cancer, the nurse notes that the radioactive implant is lying in the bed. The nurse should: Place the implant in a biohazard bag and return it to the lab. Give the client a pair of gloves and ask her to reinsert the implant. Use tongs to pick up the implant and return it to a lead-lined container. Discard the implant in the commode and double-flush. - CORRECT ANSWER c Use tongs to pick up the implant and return it to a lead-lined container. A client with Parkinson's disease is scheduled for stereotactic surgery. Which finding indicates that the surgery had its intended effect? The client no longer has intractable tremors. The client has sufficient production of dopamine. The client no longer requires any medication. The client will have increased production of serotonin. - CORRECT ANSWER a The client no longer has intractable tremors. The physician has ordered a homocysteine blood level on a client. The nurse recognizes that the results will be increased in a client with a deficiency in which of the following: Vitamin B12 Vitamin C Vitamin A Vitamin E - CORRECT ANSWER a Vitamin B12 increased when a client has B12 deficiency Which obstetrical client is most likely to have an infant with respiratory distress syndrome? A 28-year-old with a history of alcohol use during the pregnancy A 24-year-old with a history of diabetes mellitus A 30-year-old with a history of smoking during the pregnancy A 32-year-old with a history of pregnancy-induced hypertension - CORRECT ANSWER b A 24-year-old with a history of diabetes mellitus A client with a C4 spinal cord injury has been placed in traction with cervical tongs. Nursing care should include: Releasing the traction for five minutes each shift Loosening the pins if the client complains of headache Elevating the head of the bed 90° Performing sterile pin care as ordered - CORRECT ANSWER d Performing sterile pin care as ordered The nurse has been teaching the role of diet in regulating blood pressure to a client with hypertension. Which meal selection indicates the client understands his new diet? Cornflakes, whole milk, banana, and coffee Scrambled eggs, bacon, toast, and coffee Oatmeal, apple juice, dry toast, and coffee Pancakes, ham, tomato juice, and coffee - CORRECT ANSWER c Oatmeal, apple juice, dry toast, and coffee The nurse is caring for a child in a plaster-of-Paris hip spica cast. To facilitate drying, the nurse should: Use a small hand-held hair dryer set on medium heat. Place a small heater near the child's bed. Turn the child at least every two hours. Allow one side to dry before changing positions. - CORRECT ANSWER c Turn the child at least every two hours. A client is admitted with kidney disease. Which type of intravenous fluid is likely to be ordered for this client? Hypertonic Isotonic Colloid Hypotonic - CORRECT ANSWER b Isotonic Isotonic solutions such as 0.9% sodium chloride and Lactated Ringer's Which of the following statements is true regarding management of the client with multiple sclerosis? Taking a hot bath will decrease stiffness and spasticity. A schedule of strenuous exercise will improve muscle strength. Rest periods should be scheduled throughout the day. Visual disturbances can be corrected with prescription glasses - CORRECT ANSWER c Rest periods should be scheduled throughout the day. The nurse is preparing to administer regular insulin by continuous IV infusion to a client with diabetic ketoacidosis. The nurse should: Mix the insulin with Dextrose 5% in water. Flush the IV tubing with the insulin solution and discard the first 50mL. Avoid using a pump or controller with the infusion. Mix the insulin with Ringer's lactate. - CORRECT ANSWER Flush the IV tubing with the insulin solution and discard the first 50mL. Insulin molecules adhere to glass and plastic The nurse is caring for a client with possible cervical cancer. What clinical data would the nurse most likely find in the client's history? Post-coital vaginal bleeding Nausea and vomiting Foul-smelling vaginal discharge Elevated temperature levels - CORRECT ANSWER a. Post-coital vaginal bleeding spotting is a common symptom of cervical cancer The nurse is caring for a client with amyotrophic lateral sclerosis (ALS, Lou Gehrig's disease). The nurse should give priority to: Assessing the client's respiratory status Providing an alternate means of communication Referring the client and family to community support groups Instituting a routine of active range-of-motion exercises - CORRECT ANSWER a Assessing the client's respiratory status The physician has prescribed nitroglycerin sublingual tablets as needed for a client with angina. The nurse should tell the client to take the medication: After engaging in strenuous activity Every four hours to prevent chest pain As soon as he notices signs of chest pain At bedtime to prevent nocturnal angina - CORRECT ANSWER c As soon as he notices signs of chest pain A client is admitted to the emergency department with a loss of consciousness with unknown etiology. The nurse expects to perform which laboratory test to assist in determining etiology? Total cholesterol Alkaline phosphatese Serum glucose Urinalysis - CORRECT ANSWER c Serum glucose assists in determining the cause of the loss of consciousness The home health nurse is visiting a 30-year-old with sickle cell disease. Assessment findings include spleenomegaly. What information obtained on the visit would cause the most concern? The client: Eats fast food daily for lunch Drinks a beer occasionally Sometimes feels fatigued Works as a furniture mover - CORRECT ANSWER d Works as a furniture mover The nurse is caring for a client with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the nurse's best action? Notify the physician Record the reading as the only action. Turn the client and recheck the reading. Place the client supine. - CORRECT ANSWER a Notify the physician Normal ICP is 10-20. A reading of 66 is high The nurse is completing the preoperative checklist on a client scheduled for surgery and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action? Call the surgeon and ask him to come see the client to clarify the information. Explain the procedure and complications to the client. Check in the physician's progress notes to see if understanding has been documented. Check with the client's family to see if they understand the procedure fully. - CORRECT ANSWER a Call the surgeon and ask him to come see the client to clarify the information. Four clients are to receive medication. Which client should receive medication first? A client with an apical pulse of 72 receiving Lanoxin (digoxin) PO daily A client with abdominal surgery receiving Phenergan (promethazine) IM every four hours PRN for nausea and vomiting A client with labored respirations receiving a stat dose of IV Lasix (furosemide) A client with pneumonia receiving Polycillin (ampicillin) IVPB every six hours - CORRECT ANSWER c A client with labored respirations receiving a stat dose of IV Lasix (furosemide) The nurse is planning the diet of a client who is recovering from acute pancreatitis. The nurse should select foods that are High in carbohydrate and protein Low in sodium but high fat High in protein and sodium Low in fat and low protein - CORRECT ANSWER d Low in fat and low protein A client with congestive heart failure has been receiving digoxin (Laxoxin). Which finding indicates that the medication is having a desired effect? Increased urinary output Stabilized weight Improved appetite Increased pedal edema - CORRECT ANSWER a Increased urinary output Lanoxin slows and strengthens the contraction of the heart. The physician has ordered two units of whole blood for a client following surgery. To provide for client safety, the nurse should: Obtain a signed permit for each unit of blood. Use a new administration set for each unit transfused. Administer the blood using a Y connector. Check the blood type and Rh factor three times before initiating the transfusion. - CORRECT ANSWER d Check the blood type and Rh factor three times before initiating the transfusion. During the change of shift report, a nurse writes in her notes that she suspects illegal drug use by a client assigned to her care. During the shift, the notes are found by the client's daughter. The nurse could be sued for: Libel Slander Malpractice Negligence - CORRECT ANSWER a Libel The registered nurse is making shift assignments. Which client should be assigned to the licensed practical nurse (LPN)? A client who is a diabetic with a foot ulcer A client with a deep vein thrombosis receiving intravenous heparin A client being weaned from a tracheostomy A post-operative cholecystectomy with a T-tube - CORRECT ANSWER a A client who is a diabetic with a foot ulcer A client is admitted with sickle cell crises and sequestration. Upon assessing the client, the nurse would expect to find: Decreased blood pressure Moist mucus membranes Decreased respirations Increased blood pressure - CORRECT ANSWER a Decreased blood pressure will have signs of hypovolemia, including decreased blood pressure The nurse knows that a client with right-sided hemiplegia understands teaching regarding ambulation with a cane if she states: "I will hold the cane in my right hand." "I will advance my cane and my right leg at the same time." "I will be able to walk only by using a walker." "I will hold the cane in my left hand." - CORRECT ANSWER d "I will hold the cane in my left hand." The nurse is conducting a physical assessment on a client with mild anemia. Which of the following would the nurse expect to observe? Heart murmur Increased respiratory rate Activity intolerance Frequent respiratory infections - CORRECT ANSWER b Increased respiratory rate A client with angina is experiencing migraine headaches. The physician has prescribed Sumatriptan succinate (Imitrex). Which nursing action is most appropriate? Call the physician to question the prescription order. Try to obtain samples for the client to take home. Perform discharge teaching regarding this drug. Consult social services for financial assistance with obtaining the drug. - CORRECT ANSWER Call the physician to question the prescription order. Imitrex results in cranial vasoconstriction to reduce pain, but it can also cause vasoconstri effects systemically Contraindicated in pts w/angina The nurse is assessing a client hospitalized with a duodenal ulcer. Which finding should be reported to the doctor immediately? BP 82/60, pulse 120 Pulse 68, respirations 24 BP 110/88, pulse 56 Pulse 82, respirations 16 - CORRECT ANSWER a BP 82/60, pulse 120 Decreased BP & increased pulse are associated w/bleeding and shock Which statement made by the family member caring for the client with a percutaneous gastrostomy tube indicates understanding of the nurse's teaching? "I must flush the tube with water after feedings and clamp the tube." "I must check placement four times per day." "I will report to the doctor any signs of indigestion." "If my father is unable to swallow, I will discontinue the feeding and call the clinic." - CORRECT ANSWER a "I must flush the tube with water after feedings and clamp the tube." The nurse is caring for a client following the reimplantation of the thumb and index finger. Which finding should be reported to the physician immediately? Temperature of 100°F Coolness and discoloration of the digits Complaints of pain Difficulty moving the digits - CORRECT ANSWER Coolness and discoloration of the digits The nurse is caring for a client with full thickness burns to the lower half of the torso and lower extremities. During the emergent phase of injury, the primary nursing diagnosis would focus on: Imbalanced nutrition less than body requirements related to hypermetabolic state Risk for infection related to altered skin integrity Risk for fluid volume imbalance related to intracompartmental fluid shift Acute pain related to burn injury - CORRECT ANSWER c Risk for fluid volume imbalan related to intracompartmental fluid shift Emergent phase A client with rheumatoid arthritis is receiving injections of Myochrysine (gold sodium thiomalate). Before administering the client's medication, the nurse should: Check the lab work. Administer an antiemetic. Obtain the blood pressure. Administer a sedative. - CORRECT ANSWER a Check the lab work. gold salts are toxic to the kidneys and the bone marrow Which finding is associated with secondary syphilis? Painless, papular lesions on the perineum, fingers, and eyelids Absence of lesions Deep asymmetrical granulomatous lesions Well-defined generalized lesions on the palms, soles, and perineum - CORRECT ANSWER d Well-defined generalized lesions on the palms, soles, and perineum The nurse is caring for a client with Lyme's disease. The nurse should carefully monitor the client for signs of neurological complications, which include: Complaints of a "drawing" sensation and paralysis on one side of the face Presence of an unsteady gait, intention tremor, and facial weakness Complaints of excruciating facial pain brought on by talking, smiling, or eating Presence of fatigue when talking, dysphagia, and involuntary facial twitching - CORRECT ANSWER a Complaints of a "drawing" sensation and paralysis on one side of the face The client has surgery for removal of a prolactinoma. Which of the following interventions would be appropriate for this client? Place the client in Trendelenburg position for postural drainage. Encourage coughing and deep breathing every two hours. Elevate the head of the bed 30°. Encourage the client to gently blow the nose every two hours to remove secretions. - CORRECT ANSWER c Elevate the head of the bed 30°. A prolactinoma is a type of pituitary tumor. 30° decreases the ICP and reduces risk of CSF leaks A client is hospitalized with signs of transplant rejection following a recent renal transplant. Assessment of the client would be expected to reveal: A weight loss of two pounds in one day A serum creatinine 1.25mg/dL Urinary output of 50mL/hr Rising blood pressure - CORRECT ANSWER d Rising blood pressure Increased BP following renal transplant is an early sign of transplant failure. A client with diabetes insipidus is receiving DDAVP (desmopressin acetate). Which lab finding indicates that the medication is having its intended effect? Blood glucose 92mg/dL Urine specific gravity 1.020 White blood count of 7,500 Glycosylated hemoglobin 3.5mg/dL - CORRECT ANSWER Urine specific gravity 1.020 The nurse would identify which one of the following assessment findings as a normal response in a craniotomy client post-operatively? A decrease in responsiveness the third post-op day Sluggish pupil reaction the first 24-48 hours Dressing changes three to four times a day for the first three days Temperature range of 98.8°F to 99.6°F the first 2-3 days - CORRECT ANSWER d Temperature range of 98.8°F to 99.6°F the first 2-3 days The physician has ordered intubation and mechanical ventilation for a client with periods of apnea following a closed head injury. Arterial blood gases reveal a pH of 7.47, PCO2 of 28, and HCO3 of 23. These findings indicate that the client has: Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis - CORRECT ANSWER b Respiratory alkalosis Which one of the following symptoms is common in the client with duodenal ulcers? Vomiting shortly after eating Epigastric pain following meals Frequent bouts of diarrhea Presence of blood in the stools - CORRECT ANSWER Presence of blood in the stools A nurse is working in an endoscopy recovery area. Many of the clients are administered midazolam (Versed) to provide conscious sedation. Which medication is important to have available as an antidote for Versed? Diazepam (Valium) Naloxone (Narcan) Flumazenil (Romazicon) Florinef (Fludrocortisone) - CORRECT ANSWER Flumazenil (Romazicon) The nurse has just received the change of shift report. Which client should the nurse assess first? A client with a supratentorial tumor awaiting surgery A client admitted with a suspected subdural hematoma A client recently diagnosed with akinetic seizures A client transferring to the neuro rehabilitation unit - CORRECT ANSWER b A client admitted with a suspected subdural hematoma The nurse caring for a client in shock recognizes that the glomerular filtration rate of the kidneys will fail if the client's mean arterial pressure falls below which of the following levels? 140 120 100 80 - CORRECT ANSWER d 80 The nurse is caring for a patient hospitalized with leukopenia. Which of the following assessments should be reported to the physician immediately? The blood pressure is 110/62. The apical pulse is 90. The temperature has increased from 98.6°F to 99.8°F. The respiratory rate is 24. - CORRECT ANSWER c The temperature has increased from 98.6°F to 99.8°F. A client with chronic obstructive pulmonary disease (COPD) is admitted to the respiratory unit. Which physician prescription should the nurse question? O2 at 5L/min by nasal cannula Solu Medrol 125mg IV push every six hours Ceftriaxone (Rocephin) 1gram IVPB daily Darvocet N 100 po prn pain - CORRECT ANSWER a O2 at 5L/min by nasal cannula A client with cystic fibrosis is taking pancreatic enzymes. The nurse should administer this medication: Once per day in the morning Three times per day with meals Once per day at bedtime Four times per day - CORRECT ANSWER b Three times per day with meals The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery, the nurse should give priority to assessing the: Serum collection (Davol) drain Client's pain Nutritional status Immobilizer - CORRECT ANSWER a Serum collection (Davol) drain A client hospitalized with MRSA is placed on contact precautions. Which statement is true regarding precautions for infections spread by contact? The client should be placed in a room with negative pressure. Infection requires close contact; therefore, the door may remain open. Transmission is highly likely, so the client should wear a mask at all times. Infection requires skin-to-skin contact and is prevented by hand washing, gloves, and a gown. - CORRECT ANSWER d Infection requires skin-to-skin contact and is prevented by hand washing, gloves, and a gown. The nurse is caring for a client following a laryngectomy. The nurse can best help the client with communication by: Providing a pad and pencil Checking on him every 30 minutes Telling him to use the call light Teaching the client simple sign language - CORRECT ANSWER a Providing a pad and pencil The nurse is preparing a client for discharge following the removal of a cataract. The nurse should tell the client to: Take aspirin for discomfort Avoid bending over to put on his shoes Remove the eye shield before going to sleep Continue showering as usual - CORRECT ANSWER b Avoid bending over to put on his shoes Which of the following is not a step in primary assessment of a client presenting to the emergency department after being involved in a motor vehicle accident? Assessing and maintaining a patent airway Obtaining vital signs Using the Glasgow Coma Scale to check responsiveness Controlling bleeding - CORRECT ANSWER Obtaining vital signs VS are part of the secondary assessment. The others are part of the Primary Assess A client is admitted to the intensive care unit after falling on an icy sidewalk and striking the right side of the head. An MRI revealed a right-sided epidural hematoma. Which physical force explains the location of the client's injury? Coup Contrecoup Deceleration Acceleration - CORRECT ANSWER a Coup A coup type of injury occurs when the brain damage is directly under the site of impact. The nurse is assessing the heart sounds of a client with mitral stenosis following a history of rheumatic fever. To hear a mitral murmur, the nurse should place the stethoscope at: The third intercostal space right of the sternum The third intercostal space left of the sternum The fourth intercostal space beneath the sternum The fourth intercostal space mid-clavicular line - CORRECT ANSWER d The fourth intercostal space mid-clavicular line A client is admitted with symptoms of vertigo and syncope. Diagnostic tests indicate left subclavian artery obstruction. What additional findings would the nurse expect? Memory loss and disorientation Numbness in the face, mouth, and tongue Radial pulse differences over 10bpm Frontal headache with associated nausea or emesis - CORRECT ANSWER c Radial pulse differences over 10bpm An elderly female is admitted with a fractured right femoral neck. Which clinical manifestation would the nurse expect to find? Free movement of the right leg Abduction of the right leg Internal rotation of the right hip Shortening of the right leg - CORRECT ANSWER d Shortening of the right leg A client hospitalized with renal calculi complains of severe pain in the right flank. In addition to complaints of pain, the nurse can expect to see changes in the client's vital signs that include: Decreased pulse rate Increased blood pressure Decreased respiratory rate Increased temperature - CORRECT ANSWER c Increased blood pressure The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client? Roast beef sandwich, potato chips, pickle spear, iced tea Split pea soup, mashed potatoes, pudding, milk Tomato soup, cheese toast, gelatin, coffee Hamburger, baked beans, fruit cup, iced tea - CORRECT ANSWER b Split pea soup, mashed potatoes, pudding, milk The physician has ordered Zyvox (linezolid) for a patient diagnosed with vancomycin resistant enterococcus. Which food should be avoided? Wheat bread Honey Oranges Aged cheese - CORRECT ANSWER d Aged cheese The nurse is preparing a client for surgery. Which lab finding should be reported to the physician? Potassium 2.5mEq/L Hemoglobin 14.5g/dL Blood glucose 75mg/dL White cell count 8,000mm3 - CORRECT ANSWER a Potassium 2.5mEq/L A patient refuses to take his dose of oral medication. The nurse tells the patient that if he does not take the medication that she will administer it by injection. The nurse's comments can result in a charge of: Malpractice Assault Negligence Battery - CORRECT ANSWER b Assault The primary cause of anemia in a client with chronic renal failure is: Poor iron absorption Destruction of red blood cells Lack of intrinsic factor Insufficient erythropoietin - CORRECT ANSWER Insufficient erythropoietin A client with tuberculosis who has been on combined therapy with Rifadin (rifampin) and INH (isoniazid) asks the nurse how long he will have to take medication. The nurse should tell the client that: Medication is rarely needed after two weeks. He will need to take medication the rest of his life. The course of combined therapy is usually six months. - CORRECT ANSWER c The course of combined therapy is usually six months. A client with severe anemia is to receive a unit of packed red blood cells. In the event of a transfusion reaction, the first action by the nurse should be to: Notify the physician and the nursing supervisor. Stop the transfusion and maintain an IV of normal saline. Call the lab for verification of type and cross match. Prepare an injection of Benadryl (diphenhydramine). - CORRECT ANSWER b Stop the transfusion and maintain an IV of normal saline. The nurse is caring for the client receiving Amphotericin B. Which of the following indicates that the client has experienced toxicity to this drug? Changes in vision Nausea Urinary frequency Changes in skin color - CORRECT ANSWER d Changes in skin color liver toxicity in the client taking Abelcet (amphotericin B) Nimodipine (Nimotop) is ordered for the client with a ruptured cerebral aneurysm. What does the nurse recognize as a desired effect of this drug? Prevent the influx of calcium into cells. Restore a normal blood pressure reading. Prevent the inflammatory process. Dissolve the clot that has formed. - CORRECT ANSWER a Prevent the influx of calcium into cells. calcium channel blocker and is used to prevent calcium influx A client hospitalized with AIDS tells the nurse that he has been exposed to measles. The nurse should contact the physician regarding an order for: An antibiotic Immune globulin An antiviral Airborne isolation - CORRECT ANSWER Immune globulin A burn client is in the acute phase of burn care. The nurse assesses jugular vein distention, edema, urine output of 20 mLin two hours, and crackles on auscultation. Which order would the nurse anticipate from the physician? Furosemide (Lasix) 40 mg IV push Irrigate the Foley catheter Increase the IV fluids to 200mL/hr Place the client in Trendelenburg position - CORRECT ANSWER Furosemide (Lasix) 40 mg IV push suspect CHF and anticipate an order for a diuretic to remove excess fluid. The nurse is caring for a client with a radium implant for the treatment of cervical cancer. While caring for the client with a radioactive implant, the nurse should: Provide emotional support by spending additional time with the client. Stand at the foot of the bed when talking to the client. Avoid handling items used by the client. Wear a badge to monitor the amount of time spent in the client's room. - CORRECT ANSWER d Wear a badge to monitor the amount of time spent in the client's room. The physician is preparing to remove a central line. The nurse should tell the client to: Breathe normally Take slow, deep breaths Take a deep breath and hold it Breathe as quickly as possible - CORRECT ANSWER c Take a deep breath and hold it A client who uses a respiratory inhaler asks the nurse to explain how he can know when half his medication is empty so that he can refill his prescription. The nurse should tell the client to: Shake the inhaler and listen for the contents. Drop the inhaler in water to see if it floats. Check for a hissing sound as the inhaler is used. Press the inhaler and watch for the mist. - CORRECT ANSWER b Drop the inhaler in water to see if it floats. A client is admitted with a ruptured spleen following a four-wheeler accident. In preparation for surgery, the nurse suspects that the client is in the compensatory stage of shock because of which clinical manifestation? Blood pressure 120/70, confusion, heart rate 120 Crackles on chest auscultation, mottled skin, lethargy Jaundice, urine output less than 30mL in the past hour, heart rate 170 Rapid shallow respirations, unconscious, petechiae anterior chest - CORRECT ANSWER a Blood pressure 120/70, confusion, heart rate 120 Compensatory stage of shock BP remains normal A nurse is caring for a client with a myocardial infarction. The nurse recognizes that the most common complication in the client following a myocardial infarction is: Right ventricular hypertrophy Cardiac dysrhythmia Left ventricular hypertrophy Hyperkalemia - CORRECT ANSWER b Cardiac dysrhythmia Which of the following statements best explains the rationale for placing the client in Trendelenburg position during the insertion of a central line catheter? It will facilitate catheter insertion. It will make the client more comfortable during the insertion. It will prevent the occurrence of ventricular tachycardia. It will prevent the development of pulmonary embolus. - CORRECT ANSWER a It will facilitate catheter insertion. A client is admitted to the emergency department with complaints of crushing chest pain that radiates to the left jaw. After obtaining a stat electrocardiogram the nurse should: Obtain a history of prior cardiac problems Begin an IV using a large-bore catheter Administer oxygen at 2L per minute via nasal cannula Perform pupil checks for size and reaction to light - CORRECT ANSWER c Administer oxygen at 2L per minute via nasal cannula The nurse is caring for a client following a myocardial infarction. Which of the following enzymes are specific to cardiac damage? SGOT and LDH SGOT and CK BB LDH and CK MB LDH and CK BB - CORRECT ANSWER c LDH and CK MB specific for diagnosing cardiac damage A burn client's care plan reveals an expected outcome of no localized or systemic infection. Which assessment by the nurse supports this outcome? Wound culture results showing minimal bacteria Cloudy, foul-smelling urine White blood cell count of 14,000/mm3 Temperature elevation of 101°F - CORRECT ANSWER a Wound culture results showing minimal bacteria The home health nurse is visiting a client with an exacerbation of rheumatoid arthritis. To prevent deformities of the knee joints, the nurse should: Tell the client to walk without bending the knees. Encourage movement within the limits of pain. Instruct the client to sit only in a recliner. Tell the client to remain in bed as long as the joints are painful. - CORRECT ANSWER b Encourage movement within the limits of pain. The nurse is caring for a client with cancer of the pancreas. Which finding indicates involvement of the bile ducts? Dark urine Petechiae Dark stools Steatorrhea - CORRECT ANSWER a Dark urine Dark urine, clay-colored stools, jaundice, & pruritis indicate involvemnt of bile ducts in the client w/pancreatic cancer After attending a company picnic, several clients are admitted to th