NCLEX FINAL EXAM GRADE A GUARANTEED. 300 assorted MCQs with correct answers

This document contains many random questions exhibiting professional standards that will ensure you are set for any awkwardness or questions that need special perspectives. Great tool to prepare for exams 1. Which of the following actions, if performed by the nurse, would be considered negligence? A. The nurse obtains a Guthrie blood test on a 4-day-old infant. B. The nurse massages lotion on the abdomen of a 3-year-old diagnosed with Wilm’s tumor. C. The nurse instructs a 5-year-old asthmatic to blow on a pinwheel. D. The nurse plays kickball with a 10-year-old with juvenile arthritis (JA). 2. A nurse is reviewing a patient's medication during shift change. Which of the following medication would be contraindicated if the patient were pregnant? A: Coumadin B: Finasteride C: Celebrex D: Catapress E: Habitrol F: Clofazimine 3. A nurse is reviewing a patient's PMH. The history indicates photosensitive reactions to medications. Which of the following drugs has not been associated with photosensitive reactions? A: Cipro B: Sulfonamide C: Noroxin D: Bactrim E: Accutane F: Nitrodur 4. A patient tells you that her urine is starting to look discolored. If you believe this change is due to medication, which of the following patient's medication does not cause urine discoloration? A: Sulfasalazine B: Levodopa C: Phenolphthalein D: Aspirin 5. You are responsible for reviewing the nursing unit's refrigerator. If you found the following drug in the refrigerator it should be removed from the refrigerator's contents? A: Corgard B: Humulin (injection) C: Urokinase D: Epogen (injection) 6. A 34 year old female has recently been diagnosed with an autoimmune disease. She has also recently discovered that she is pregnant. Which of the following is the onlyimmunoglobulin that will provide protection to the fetus in the womb? A: IgA B: IgD C: IgE D: IgG 7. A second year nursing student has just suffered a needlestick while working with a patient that is positive for AIDS. Which of the following is the most important action that nursing student should take? A: Immediately see a social worker B: Start prophylactic AZT treatment C: Start prophylactic Pentamide treatment D: Seek counseling 8. A thirty five year old male has been an insulin-dependent diabetic for five years and now is unable to urinate. Which of the following would you most likely suspect? A: Atherosclerosis B: Diabetic nephropathy C: Autonomic neuropathy D: Somatic neuropathy 9. You are taking the history of a 14 year old girl who has a (BMI) of 18. The girl reports inability to eat, induced vomiting and severe constipation. Which of the following would you most likely suspect? A: Multiple sclerosis B: Anorexia nervosa C: Bulimia D: Systemic sclerosis 10. A 24 year old female is admitted to the ER for confusion. This patient has a history of a myeloma diagnosis, constipation, intense abdominal pain, and polyuria. Which of the following would you most likely suspect? A: Diverticulosis B: Hypercalcaemia C: Hypocalcaemia D: Irritable bowel syndrome 11. Rho gam is most often used to treat____ mothers that have a ____ infant. A: RH positive, RH positive B: RH positive, RH negative C: RH negative, RH positive D: RH negative, RH negative 12. A new mother has some questions about (PKU). Which of the following statements made by a nurse is not correct regarding PKU? A: A Guthrie test can check the necessary lab values.B: The urine has a high concentration of phenylpyruvic acid C: Mental deficits are often present with PKU. D: The effects of PKU are reversible. 13. A patient has taken an overdose of aspirin. Which of the following should a nurse most closely monitor for during acute management of this patient? A: Onset of pulmonary edema B: Metabolic alkalosis C: Respiratory alkalosis D: Parkinson's disease type symptoms 14. A fifty-year-old blind and deaf patient has been admitted to your floor. As the charge nurse your primary responsibility for this patient is? A: Let others know about the patient's deficits B: Communicate with your supervisor your concerns about the patient's deficits. C: Continuously update the patient on the social environment. D: Provide a secure environment for the patient. 15.A patient is getting discharged from a SNF facility. The patient has a history of severe COPD and PVD. The patient is primarily concerned about their ability to breath easily. Which of the following would be the best instruction for this patient? A: Deep breathing techniques to increase O2 levels. B: Cough regularly and deeply to clear airway passages. C: Cough following bronchodilator utilization D: Decrease CO2 levels by increase oxygen take output during meals. 16. A nurse is caring for an infant that has recently been diagnosed with a congenital heart defect. Which of the following clinical signs would most likely be present? A: Slow pulse rate B: Weight gain C: Decreased systolic pressure D: Irregular WBC lab values 17.A mother has recently been informed that her child has Down's syndrome. You will be assigned to care for the child at shift change. Which of the following characteristics is not associated with Down's syndrome? A: Simian crease B: Brachycephaly C: Oily skin D: Hypotonicity 18. A patient has recently experienced a (MI) within the last 4 hours. Which of the following medications would most like be administered? A: Streptokinase B: AtropineC: Acetaminophen D: Coumadin 19. A patient asks a nurse, "My doctor recommended I increase my intake of folic acid. What type of foods contain folic acids?" A: Green vegetables and liver B: Yellow vegetables and red meat C: Carrots D: Milk 20. A nurse is putting together a presentation on meningitis. Which of the following microorganisms has noted been linked to meningitis in humans? A: S. pneumonia B: H. influenza C: N. meningitis D: Cl. difficile 21.A nurse is administering blood to a patient who has a low hemoglobin count. The patient asks how long to RBC's last in my body? The correct response is. A: The life span of RBC is 45 days. B: The life span of RBC is 60 days. C: The life span of RBC is 90 days. D: The life span of RBC is 120 days. 22.A 65 year old man has been admitted to the hospital for spinal stenosis surgery. When does the discharge training and planning begin for this patient? A: Following surgery B: Upon admit C: Within 48 hours of discharge D: Preoperative discussion 23. A child is 5 years old and has been recently admitted into the hospital. According to Erickson which of the following stages is the child in? A: Trust vs. mistrust B: Initiative vs. guilt C: Autonomy vs. shame D: Intimacy vs. isolation 24. A is 16 months old and has been recently admitted into the hospital. According to Erickson which of the following stages is the toddler in? A: Trust vs. mistrust toddler B: Initiative vs. guilt C: Autonomy vs. shame D: Intimacy vs. isolation25. A young adult is 20 years old and has been recently admitted into the hospital. According to Erickson which of the following stages is the adult in? A: Trust vs. mistrust B: Initiative vs. guilt C: Autonomy vs. shame D: Intimacy vs. isolation 26. A nurse is making rounds taking vital signs. Which of the following vital signs is abnormal? A: 11 year old male - 90 b.p.m, 22 resp/min. , 100/70 mm Hg B: 13 year old female - 105 b.p.m., 22 resp/min., 105/60 mm Hg C: 5 year old male- 102 b.p.m, 24 resp/min., 90/65 mm Hg D: 6 year old female- 100 b.p.m., 26 resp/min., 90/70mm Hg 27.When you are taking a patient's history, she tells you she has been depressed and is dealing with an anxiety disorder. Which of the following medications would the patient most likely be taking? A: Elavil B: Calcitonin C: Pergolide D: Verapamil 28. Which of the following conditions would a nurse not administer erythromycin? A: Campylobacterial infection B: Legionnaire's disease C: Pneumonia D: Multiple Sclerosis 29. A patient's chart indicates a history of hyperkalemia. Which of the following would you not expect to see with this patient if this condition were acute? A: Decreased HR B: Paresthesias C: Muscle weakness of the extremities D: Migranes 30.A patient's chart indicates a history of ketoacidosis. Which of the following would you not expect to see with this patient if this condition were acute? A: Vomiting B: Extreme Thirst C: Weight gain D: Acetone breath smell 31. A patient's chart indicates a history of meningitis. Which of the following would you not expect to see with this patient if this condition were acute?A: Increased appetite B: Vomiting C: Fever D: Poor tolerance of light 32. A nurse if reviewing a patient's chart and notices that the patient suffers from conjunctivitis. Which of the following microorganisms is related to this condition? A: Yersinia pestis B: Helicobacter pyroli C: Vibrio cholera D: Hemophilus aegyptius 33. A nurse if reviewing a patient's chart and notices that the patient suffers from Lyme disease. Which of the following microorganisms is related to this condition? A: Borrelia burgdorferi B: Streptococcus pyrogens C: Bacilus anthracis D: Enterococcus faecalis 34.A fragile 87 year-old female has recently been admitted to the hospital with increased confusion and falls over last 2 weeks. She is also noted to have a mild left hemiparesis. Which of the following tests is most likely to be performed? A: FBC (full blood count) B: ECG (electrocardiogram) C: Thyroid function tests D: CT scan 35. A 84 year-old male has been loosing mobility and gaining weight over the last 2 months. The patient also has the heater running in his house 24 hours a day, even on warm days. Which of the following tests is most likely to be performed? A: FBC (full blood count) B: ECG (electrocardiogram) C: Thyroid function tests D: CT scan 36. A 20 year-old female attending college is found unconscious in her dorm room. She has a fever and a noticeable rash. She has just been admitted to the hospital. Which of the following tests is most likely to be performed first? A: Blood sugar check B: CT scan C: Blood cultures D: Arterial blood gases 37. A 28 year old male has been found wandering around in a confused pattern. The male is sweaty and pale. Which of the following tests is most likely to be performed first?A: Blood sugar check B: CT scan C: Blood cultures D: Arterial blood gases 38.A mother is inquiring about her child's ability to potty train. Which of the following factors is the most important aspect of toilet training? A: The age of the child B: The child ability to understand instruction. C: The overall mental and physical abilities of the child. D: Frequent attempts with positive reinforcement. 39. A parent calls the pediatric clinic and is frantic about the bottle of cleaning fluid her child drank 20 minutes. Which of the following is the most important instruction the nurse can give the parent? A: This too shall pass. B: Take the child immediately to the ER C: Contact the Poison Control Center quickly D: Give the child syrup of ipecac 40. A nurse is administering a shot of Vitamin K to a 30 day-old infant. Which of the following target areas is the most appropriate? A: Gluteus maximus B: Gluteus minimus C: Vastus lateralis D: Vastus medialis 41.A nurse has just started her rounds delivering medication. A new patient on her rounds is a 4 year-old boy who is non-verbal. This child does not have on any identification. What should the nurse do? A: Contact the provider B: Ask the child to write their name on paper. C: Ask a co-worker about the identification of the child. D: Ask the father who is in the room the child's name. 42. A nurse is observing a child's motor, sensory and speech development. The child is 7 months old. Which of the following tasks would generally not be observed? A: Child recognizes tone of voice. B: Child exhibits fear of strangers. C: Child pulls to stand and occasionally bounces. D: Child plays patty-cake and imitates. 43. A nurse is observing a child's motor, sensory and speech development. The child is 5 months old. Which of the following tasks would generally not be observed?A: Child sits with support. B: Child laughs out loud. C: Child shifts weight side to side in prone. D: Child transfers objects between hands. 44.A nurse is caring for an adult that has recently been diagnosed with renal failure. Which of the following clinical signs would most likely not be present? A: Hypotension B: Heart failure C: Dizziness D: Memory loss 45. A nurse is caring for an adult that has recently been diagnosed with hypokalemia. Which of the following clinical signs would most likely not be present? A: Leg cramps B: Respiratory distress C: Confusion D: Flaccid paralysis 46. A nurse is caring for an adult that has recently been diagnosed with metabolic acidosis. Which of the following clinical signs would most likely not be present? A: Weakness B: Dysrhythmias C: Dry skin D: Malaise 47. A nurse is caring for an adult that has recently been diagnosed with metabolic alkalosis. Which of the following clinical signs would most likely not be present? A: Vomiting B: Diarrhea C: Agitation D: Hyperventilation 48. A nurse is caring for an adult that has recently been diagnosed with respiratory acidosis. Which of the following clinical signs would most likely not be present? A: CO2 Retention B: Dyspnea C: Headaches D: Tachypnea 49. A nurse is caring for an adult that has recently been diagnosed with respiratory alkalosis. Which of the following clinical signs would most likely not be present? A: Anxiety attacks B: DizzinessC: Hyperventilation cyanosis D: Blurred vision (C) Hyperventilation cyanosis is associated with respiratory acidosis. 50. A nurse is reviewing a patient's medication list. The drug Pentoxifylline is present on the list. Which of the following conditions is commonly treated with this medication? A: COPD B: CAD C: PVD D: MS 51. A patient has been on long-term management for CHF. Which of the following drugs is considered a loop dieuretic that could be used to treat CHF symptoms? A: Ciprofloxacin B: Lepirudin C: Naproxen D: Bumex 52. A patient has recently been diagnosed with polio and has questions about the diagnosis. Which of the following systems is most affected by polio? A: PNS B: CNS C: Urinary system D: Cardiac system 53. A nurse is educating a patient about right-sided heart deficits. Which of the following clinical signs is not associated with right-sided heart deficits? A: Orthopnea B: Dependent edema C: Ascites D: Nocturia 54. A nurse is reviewing a patient's medication. Which of the following is considered a potassium sparing dieuretic? A: Esidrix B: Lasix C: Aldactone D: Edecrin 55. A nurse is reviewing a patient's medication. The patient is taking Digoxin. Which of the following is not an effect of Digoxin? A: Depressed HR B: Increased CO C: Increased venous pressure D: Increased contractility of cardiac muscle56. A patient has been instructed by the doctor to reduce their intake of Potassium. Which types of foods should not worry about avoiding? A: Bananas B: Tomatoes C: Orange juice D: Apples 57. A patient's chart indicates the patient is suffering from Digoxin toxicity. Which of the following clinical signs is not associated with digoxin toxicity? A: Ventricular bigeminy B: Anorexia C: Normal ventricular rhythm D: Nausea 58. A fourteen year old male has just been admitted to your floor. He has a history of central abdominal pain that has moved to the right iliac fossa region. He also has tenderness over the region and a fever. Which of the following would you most likely suspect? A: Appendicitis B: Acute pancreatitis C: Ulcerative colitis D: Cholecystitis 59. A thirteen-year old male has a tender lump area in his left groin. His abdomen is distended and he has been vomiting for the past 24 hours. Which of the following would you most like suspect? A: Ulcerative colitis B: Biliary colic C: Acute gastroenteritis D: Strangulated hernia 60. Which of the following is the key risk factor for development of Parkinson's disease dementia? A: History of strokes B: Acute headaches history C: Edward's syndrome D: Use of phenothiazines 61. A father notifies your clinic that his son's homeroom teacher has just been diagnosed with meningitis and his son spent the day with the teacher in detention yesterday. Which of the following would be the most likely innervention? A: Isolation of the son B: Treatment of the son with Aciclovir C: Treatment of the son with Rifampicin D: Reassure the father62.A patient has recently been diagnosed with hyponatremia. Which of the following is not associated with hyponatremia? A: Muscle twitching B: Anxiety C: Cyanosis D: Sticky mucous membranes 63. A patient has recently been diagnosed with hypernatremia. Which of the following is not associated with hypernatremia? A: Hypotension B: Tachycardia C: Pitting edema D: Weight gain 64.Which of the following normal blood therapeutic concentrations is abnormal? A: Phenobarbital 10-40 mcg/ml B: Lithium .6 - 1.2 mEq/L C: Digoxin .5 - 1.6 ng/ml D: Valproic acid 40 - 100 mcg/ml 65. Which of the following normal blood therapeutic concentrations is abnormal? A: Digitoxin 09 - 25 mcg/ml B: Vancomycin 05 - 15 mcg/ml C: Primidone 02 - 14 mcg/ml D: Theophylline 10 - 20 mcg/ml 66.Which of the following normal blood therapeutic concentrations is abnormal? A: Phenytoin 10 - 20 mcg/ml B: Quinidine 02 - 06 mcg/ml C: Haloperidol 05 - 20 ng/ml D: Carbamazepine 5 - 25 mcg/ml 67. An older adult is admitted to the medical surgical unit with dehydration. The nurse performs which of these assessments to determine whether the client is safe for independent ambulation? A. Assesses for dry oral mucous membranes B. Checks for orthostatic blood pressure changes C. Notes pulse rate is 72 beats/min and bounding D. Evaluates that the serum potassium level is 4.0 mEq/L (4.0 mmol/L) 68.The nurse is assessing fluid balance in the client with heart failure. Which of these strategies will the nurse employ? E. Ask the client how much fluid was consumed yesterday.F. Place an indwelling catheter to measure urine output. G. Auscultate the lungs for adventitious sounds. H. Weigh the client daily, at the same time. 69.The nurse is preparing a client a diagnosis of congestive heart failure (CHF) for discharge. Which statement by the client indicates a correct understanding of self-management of CHF? I. “I can gain 2 pounds (1 kg) of water a day without risk.” J. “I should call my provider if I gain more than 1 pound (0.5 kg) a week.” K. “Weighing myself daily can determine if my caloric intake is adequate.” L. “Weighing myself daily can reveal increased fluid retention.” 70. The nurse is caring for an older adult with hypernatremia. Which of these interventions does the nurse perform frst? a. Restrict the client’s intake of sodium b. Administer a diuretic c. Monitor the serum osmolarity d. Encourage fluid intake 71. The nurse is caring for a group of clients with electrolytes and blood chemistry abnormalities. Which client will the nurse see frst? a. The client with a random glucose reading of 123 mg/dL (6.8 mmol/L) b. The client who has a magnesium level of 2.1 mEq/L (1.0 mmol/L) c. The client whose potassium is 6.2 mEq/L (6.2 mmol/L) d. The client with a sodium level of 143 mEq/L (143 mmol/L) 72.The nurse is infusing 3% saline for a client with syndrome of inappropriate secretion (SIADH). Which of these complications does the nurse report to the primary care provider? e. Peripheral edema f. Crackles ½ way up the lung felds g. Serum osmolarity of 294 mOsm/kg (294 mmol/kg) h. Urine output of 1300 mL over 24 hours73. The nurse is discussing safety when administering bumetanide with a nursing student. The nurse recognizes that the student understands side effects of this medication when the student makes which statement? a. “The client’s PT and INR may be prolonged while taking this medication.” b. “The client may develop hypoglycemia during treatment.” c. “Inverted T waves and a U wave may appear on the ECG.” d. “I need to tell the client to avoid salt substitutes.” 74. A client develops fluid overload while in the intensive care unit. Which nursing intervention does the nurse perform frst? a. Draws blood for laboratory tests b. Elevates the head of the bed c. Places the extremities in a dependent position d. Puts the client in a side-lying position 75. The nurse is assessing a client with a sodium level of 118 mEq/L (118 mmol/L). Which activity takes priority? a. Monitoring urine output b. encouraging sodium rich fluids and foods throughout the day c. instructing the client not to ambulate without assistance d. assessing deep tendon reflexes 76. The nurse at a long-term care facility is teaching a group of unlicensed assistive personnel (UAP) about fluid intake principles for older adults. Which of these should be included in the education session? a. “Be careful not to overload them with too many oral fluids.” b. “Offer fluids that they prefer frequently and on a regular schedule.” c. “Restrict their fluids if they are incontinent.” d. “Wake them every 2 hours during the night with a drink.” 77. The nurse is caring for a client who is receiving intravenous (IV) magnesium sulfate. Which assessment parameter is critical? a. Monitoring 24-hour urine outputb. Asking the client about feeling depressed c. Assessing the blood pressure hourly d. Monitoring the serum calcium levels 78. The charge nurse on a medical-surgical unit is completing assignments for the day shift. Which client is most appropriate to assign to the LPN/LVN? a. A 44-year-old with congestive heart failure (CHF) who has gained 3 pounds (1.4 kg) since the previous day b. A 58-year-old with chronic renal failure (CRF) who has a serum potassium level of 6 mEq/L (6.0 mmol/L) c. A 76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/kg (300 mmol/kg) d. An 80-year-old with 3+ peripheral edema and crackles throughout the posterior chest 79. The step down unit receives a new admission who has uncontrolled diabetes, polyuria, and a blood pressure of 86/46 mm Hg. Which staff member is assigned to care for her? a. LPN/LVN who has floated from the hospital’s long-term care unit b. LPN/LVN who frequently administers medications to multiple clients c. RN who has floated from the intensive care unit d. RN who usually works as a diabetes educator 80. The nurse is planning care for a 72-year-old resident of a long-term care facility who has a history of dehydration. Which action does the nurse delegate to unlicensed assistive personnel (UAP)? a. Assessing oral mucosa for dryness b. Choosing appropriate oral fluids c. Monitoring skin turgor for tenting d. Offering fluids to drink every hour 81. The nurse is caring for a group of clients on a medical surgical unit. Which newly written prescription will the nurse administer frst?a. Intravenous normal saline to a client with a serum sodium of 132 mEq/L (132 mmol/L) b. Oral calcium supplements to a client with severe osteoporosis c. Oral phosphorus supplements to a client with acute hypophosphatemia d. Oral potassium chloride to a client whose serum potassium is 3 mEq/L (3 mmol/L) 82. The primary care provider writes prescriptions for a client who is admitted with a serum potassium level of 6.9 mEq/L (6.9 mmol/L). What does the nurse implement frst? a. Administer sodium polystyrene sulfonate (Kayexalate) orally. b. Ensure that a potassium-restricted diet is ordered. c. Place the client on a cardiac monitor. d. Teach the client about foods that are high in potassium. 83. Which client is most appropriate for the nurse manager of the medical-surgical unit to assign to the LPN/LVN? a. A client admitted with dehydration who has a heart rate of 126 beats/min b. A client just admitted with hyperkalemia who takes a potassium-sparing diuretic at home c. A client admitted yesterday with heart failure with dependent pedal edema d. A client who has just been admitted with severe nausea, vomiting, and diarrhea 84. The RN is caring for a client who is severely dehydrated. Which nursing action can be delegated to the unlicensed assistive personnel (UAP)? a. Consulting with a health care provider about a client’s laboratory results b. Infusing 500 mL of normal saline over 60 minutes c. Monitoring IV fluid to maintain the drip rate at 75 mL/hr d. Providing oral care every 1 to 2 hours 85. After receiving change-of-shift report, which client does the RN assess frst? a. A client with nausea and vomiting who complains of abdominal cramps b. A client with a nasogastric (NG) tube who has dry oral mucosa and is complaining of thirst c. A client receiving intravenous (IV) diuretics whose blood pressure is 88/52 mm Hg d. A client with normal saline infusing at 150 mL/hr whose hourly urine output has been averaging 75 mL86. The RN is assessing a 70-year-old client admitted to the unit with severe dehydration. Which fnding requires immediate intervention by the nurse? a. Client behavior that changes from anxious to lethargic b. Deep furrows on the surface of the tongue c. Poor skin turgor with tenting remaining for 2 minutes after the skin is pinched d. Urine output of 950 mL for the past 24 hours 87. The nurse manager of a medical-surgical unit is completing assignments for the day shift staff. The client with which electrolyte laboratory value is assigned to the LPN/LVN? a. Calcium level of 9.5 mg/dL (2.4 mmol/L) b. Magnesium level of 4.1 mEq/L (2.1 mmol/L) c. Potassium level of 6.0 mEq/L (6.0 mmol/L) d. Sodium level of 120 mEq/L (120 mmol/L) 88. A client with hypermagnesemia is seen in the emergency department (ED). Which of these interventions is most appropriate? a. Monitor for hyperactive reflexes b. prepare for endotracheal intubation c. Institute teaching on avoiding magnesium rich foods d. Place the client on a cardiac monitor 89. A client with mild hypokalemia caused by diuretic use is discharged home. The home health nurse delegates which of these interventions to the home health aide? a. Assessment of muscle tone and strength b. Education about potassium-rich foods c. Instruction on the proper use of drugs d. Measurement of the client’s weight 90. The rapid response team (RRT) is called to the bedside of a client with heart rate of 38 beats per minute and a potassium level of 7.0 mEq/L (7.0 mmol/L). For which medication will the nurse anticipate a prescription? a. Insulin b. atropinec. Sodium polystyrene sulfonate (Kayexalate) d. potassium phosphate 91. Furosemide (Lasix) has been ordered for a client with heart failure, shortness of breath, and 3+ pitting edema of the lower extremities. Which assessment fnding indicates to the nurse that the medication has been effective? a. The client’s potassium level is 5.1 mEq/L (5.1 mmol/L). b. The client’s heart rate is 101 beats per minute. c. The client is free from adventitious breath sounds. d. The client has experienced a weight gain of 1 pound (0.5 kg). 92. The nurse is caring for a client who takes furosemide (Lasix) and digoxin (Lanoxin). The client’s potassium (K+) level is 2.5 mEq/L (2.5 mmol/L). Which additional assessment will the nurse make? a. Heart rate b. Blood pressure (BP) c. Increases in edema d. Sodium level 93. A client with hypokalemia has a prescription for parenteral potassium chloride (KCl). Which of these interventions does the nurse use to safely administer KCl? (Select all that apply.) a. Use a potassium infusion prepared by a registered pharmacist. b. Assess for burning or redness during infusion. c. Infuse at a rate of no more than 10 mEq per hour. d. Administer only through a central venous catheter. e. Administer by IV push only during cardiac arrest. 94. The nurse is caring for a client who is receiving a loop diuretic for treatment of heart failure. Which of these actions will be included in the plan of care? (Select all that apply.) a. Assess daily weights. b. Encourage consumption of citrus fruits. c. Weigh the client weekly. d. Monitor serum potassium. e. Discourage intake of spinach.f. Monitor for bradycardia. 95. A client is brought to the emergency department for increasing weakness and muscle twitching. The laboratory results include a potassium level of 7.0 mEq/L (7.0 mmol/L). Which assessments does the nurse make? (Select all that apply.) a. History of liver disease b. Use of salt substitute c. Use of an ACE inhibitor d. Potassium-sparing diuretics e. Prescription for insulin 96. A client is admitted to the hospital with dehydration secondary to influenza and vomiting. The provider orders an intravenous (IV) potassium replacement for potassium level of 2.7 mEq/L (2.7 mmol/L). Which of these best practice techniques does the nurse include when administering this medication? (Select all that apply.) a. Ensuring that the concentration is no greater than 1?9?mEq/10?9?mL of solution b. Use a vein in the hand for better flow c. Use an IV pump to deliver the medication d. Check IV access for blood return after the infusion e. Push the medication over 5 minutes 97. The nurse is caring for a client receiving lactated Ringer’s solution IV for rehydration. Which assessments will the nurse monitor during intravenous therapy? (Select all that apply.) a. Blood serum glucose b. Blood pressure c. Pulse rate and quality d. Urinary output e. Urine specifc gravity 98. A client with diarrhea for 3 days and inability to eat or drink well is brought to the emergency department (ED) by her family. She states she has been taking her diuretics for congestive heart failure (CHF). What nursing actions are indicated at this time? (Select all that apply.) a. Place the client on bed rest. b. Evaluate the electrolyte levels.c. Administer the ordered diuretic. d. assess for orthostatic hypotension. e. initiate cardiac monitoring 99. The nurse is teaching a client who is taking a potassium-sparing diuretic about precautions while taking this medication. Which of these does the nurse teach the client to avoid or use cautiously? (Select all that apply.) a. Apples b. Bananas c. ACE inhibitors d. Grapes e. Salt substitute 100. The nurse and nursing student are caring for a client with a new diagnosis of diabetes whose blood glucose is 974 mg/dL (54.1 mmol/L). Which of these statements indicates the student understands the relationship between blood glucose and acid base balance? a. “The excess glucose in the blood causes the client to hypoventilate and retain carbon dioxide resulting in respiratory acidosis” b. “The hyperglycemia is caused by inability of glucose to enter the cell causing a starvation state and break down of fats” Correct c. “The client has a hyperosmolar condition causing polyuria and polyphagia, but the acid base balance is normal” d. “The client is retaining carbon dioxide which led to respiratory acidosis and somnolence” 101. When caring for a client with a burn injury and eschar banding the chest, the nurse plans to observe the client for which of these acid base disturbances? a. Respiratory acidosis Correct b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis102. When caring for a client who has the following blood gas results, which of these interventions does the nurse plan to use to correct the acid base disturbance? pH 7.47—pCO2 37 mm hg- HCO3 30 mEq/L (30 mmol/L)—pO2 88mm hg a. Endotracheal suctioning b. Applying oxygen c. Administering an antiemetic Correct d. Administering sodium bicarbonate 130.Which of these fndings causes the critical care nurse to notify the primary care provider (PCP) for evaluation for intubation? e. Increasing somnolence Correct f. Pallor g. Deep respirations h. Bounding pulse 103. The nursing assistant reports that the client with metabolic acidosis due to kidney failure is breathing rapidly and deeply. The nurse explains this to the nursing assistant in which of these manners? a. “The client is acting out and we should pay him no mind” b. “Rapid breathing is a way to compensate for acidosis caused by his condition” Correct c. “Normally a client with this disorder will breathe slowly, I will go assess him” d. “Deep breathing is a symptom of diabetes, I will check his blood glucose” 104. The nurse is caring for a client with sepsis and impending septic shock. Which of these interventions will help prevent lactic acidosis? a. Ensure adequate oxygenation Correct b. Restrict carbohydrates c. Supplement potassium d. Monitor hemoglobin 105. The nurse is caring for a client with long standing emphysema and respiratory acidosis. For which of these compensatory mechanisms will the nurse assess? a. Decreased rate of breathing b. Increased loss of bicarbonate through the kidney c. Decreased depth of breathing d. Decreased loss of bicarbonate through the kidney Correct106. The nurse is caring for a client who has developed postoperative respiratory acidosis. Which of these interventions will the nurse use to help correct this problem? e. Medicate for pain. f. Encourage use of incentive spirometer. Correct g. Perform fngerstick blood glucose. h. Encourage protein intake. . 106. The nurse is caring for a group of clients. Which client will the nurse carefully observe for signs and symptoms of hyperkalemia? a. The client who has metabolic acidosis Correct b. The client receiving total parenteral nutrition c. The client who has profuse vomiting d. The client taking a thiazide diuretic 107. The nurse is caring for a client with acute respiratory failure and PaCO2 level of 88 mm Hg For which of these signs and symptoms will the nurse assess? (Select all that apply.) a. Hyperactivity b. Headache Correct c. Shallow breathing Correct d. pH 7.49 e. Fatigue Correct 108. The nurse checking an IV fluid order questions its accuracy. What does the nurse do frst? a. Asks the charge nurse about the order b. Contacts the health care provider who ordered it Correct c. Contacts the pharmacy for clarifcation d. Starts the fluid as ordered, with plans to check it later 109. A client is to receive an IV solution of 5% dextrose and 0.45% normal saline at 125 mL/hr. Which system provides the safest method for the nurse to accurately administer this solution?a. Controller b. Glass container c. Infusion pump Correct d. Syringe pump 110. A client who used to work as a nurse asks, “Why is the hospital using a ‘fancy new IV’ without a needle? That seems expensive.” How does the nurse respond? a. “OSHA, a government agency, requires us to use this new type of IV.” b. “These systems are designed to save time, not money.” c. “They minimize health care workers’ exposure to contaminated needles.” Correct d. “They minimize clients’ exposure to contaminated needles.” 111. The nurse is teaching a hospitalized client who is being discharged about how to care for a peripherally inserted central catheter (PICC) line. Which client statement indicates a need for further education? a. “I can continue my 20-mile (32-km) running schedule as I have for the past 10 years.” Correct b. “I can still go about my normal activities of daily living.” c. “I have less chance of getting an infection because the line is not in my hand.” d. “The PICC line can stay in for months.” 112. The nurse is admitting clients to the same-day surgery unit. Which insertion site for routine peripheral venous catheters does the nurse choose most often? a. Back of the hand for an older adult b. Cephalic vein of the forearm Correct c. Lower arm on the side of a radical mastectomy d. Subclavian vein 113. A client admitted to the intensive care unit is expected to remain for 3 weeks. The nurse has orders to start an IV. Which vascular access device is best for this client? a. Midline catheter Correct b. Peripherally inserted central catheter (PICC) c. Short peripheral catheter d. Tunneled central catheter114. A 22-year-old client is seen in the emergency department (ED) with acute right lower quadrant abdominal pain, nausea, and rebound tenderness. It appears that surgery is imminent. What gauge catheter does the ED nurse choose when starting this client’s intravenous solution? a. 24 b. 22 c. 18 Correct d. 14 115. A client who is receiving intravenous antibiotic treatments every 6 hours has an intermittent IV set that was opened and begun 20 hours ago. What action does the nurse take? a. Change the set immediately. b. Change the set in about 4 hours. Correct c. Change the set in the next 12 to 24 hours. d. Nothing; the set is for long-term use. 116. A client is seen in the emergency department (ED) with pain, redness, and warmth of the right lower arm. The client was in the ED last week after an accident at work. On the day of the injury, the client was in the ED for 12 hours receiving IV fluids. On close examination, the nurse notes the presence of a palpable cord 1 inch (2.5 cm) in length and streak formation. How does the nurse classify this client’s phlebitis? a. Grade 1 b. Grade 2 c. Grade 3 Correct d. Grade 4 117. The nurse who is starting the shift fnds a client with an IV that is leaking all over the bed linens. What does the nurse do initially? a. Assess the insertion site. Correct b. Check connections. c. Check the infusion rate. d. Discontinue the IV and start another. 118. A client is admitted to the cardiothoracic surgical intensive care unit after cardiac bypass surgery. The client is still sedated on a ventilator and has an arterial catheter in the right wrist. What assessment does the nurse make to determine patency of the client’s arterial line?a. Blood pressure b. Capillary refll and pulse Correct c. Neurologic function d. Questioning the client about the pain level at the site 119. Which statement is true about the special needs of older adults receiving IV therapy? a. Placement of the catheter on the back of the client’s dominant hand is preferred. b. Skin integrity can be compromised easily by the application of tape or dressings. Correct c. To avoid rolling the veins, a greater angle of 25 degrees between the skin and the catheter will improve success with venipuncture. d. When the catheter is inserted into the forearm, excess hair should be shaved before insertion. 120. A client is being admitted to the burn unit from another hospital. The client has an intraosseous IV that was started 2 days ago, according to the client’s medical record. What does the admitting nurse do frst? a. Anticipate an order to discontinue the intraosseous IV and start an epidural IV. Correct b. Call the previous hospital to verify the date. c. Immediately discontinue the intraosseous IV. d. Nothing; this is a long-term treatment. 121. The nurse is to administer a unit of whole blood to a postoperative client. What does the nurse do to ensure the safety of the blood transfusion? a. Asks the client to both say and spell his or her full name before starting the blood transfusion b. Ensures that another qualifed health care professional checks the unit before administering Correct c. Checks the blood identifcation numbers with the laboratory technician at the blood bank at the time it is dispensed d. Makes certain that an IV solution of 0.9% normal saline is infusing into the client before starting the unit 122.The nurse is administering a drug to a client through an implanted port. Before giving the medication, what does the nurse do to ensure safety? a. Administer 5 mL of a heparinized solution. b. Check for blood return. Correct c. Flush the port with 10 mL of normal saline. d. Palpate the port for stability. 123. Which client does the charge nurse on a medical-surgical unit assign to the LPN/LVN? a. Cardiac client who has a diltiazem (Cardizem) IV infusion being titrated to maintain a heart rate between 60 and 80 beats/min b. Diabetic client admitted for hyperglycemia who is on an IV insulin drip and needs frequent glucose checks c. Older client admitted for confusion who has a heparin lock that needs to be flushed every 8 hours Correct d. Postoperative client receiving blood products after excessive blood loss during surgery 124. A client who takes corticosteroids daily for rheumatoid arthritis requires insertion of an IV catheter to receive IV antibiotics for 5 days. Which type of IV catheter does the nurse teach the new graduate nurse to use for this client? a. Midline catheter Correct b. Tunneled percutaneous central catheter c. Peripherally inserted central catheter d. Short peripheral catheter 125. The nurse assessing a client’s peripheral IV site obtains and documents information about it. Which assessment data indicate the need for immediate nursing intervention? a. Client states, “It really hurt when the nurse put the IV in.” b. The vein feels hard and cordlike above the insertion site. Correct c. Transparent dressing was changed 5 days ago. d. Tubing for the IV was last changed 72 hours ago. 126. When flushing a client’s central line with normal saline, the nurse feels resistance. Which action does the nurse take frst? a. Decrease the pressure being used to flush the line.b. Obtain a 10-mL syringe and reattempt flushing the line. c. Stop flushing and try to aspirate blood from the line. Correct d. Use “push-pull” pressure applied to the syringe while flushing the line. 127.A severely dehydrated client requires a rapid infusion of normal saline and needs a midline IV placed. Which staff member does the emergency department (ED) charge nurse assign to complete this task? e. RN who is certifed in the administration of oral and infused chemotherapy medications f. RN with 2 years of experience in the ED who is skilled at insertion of short peripheral catheters g. RN with 10 years of experience on a medical-surgical unit who has cared for many clients requiring IV infusions h. RN with certifed registered nurse infusion (CRNI) certifcation who is assigned to the ED for the day Correct 127. The nurse is inserting a peripheral intravenous (IV) catheter. Which client statement is of greatest concern during this procedure? a. “I hate having IVs started.” b. “It hurts when you are inserting the line.” c. “My hand tingles when you poke me.” Correct d. “My IV lines never last very long.” 128. A 70-year-old client with severe dehydration is ordered an infusion of an isotonic solution at 250 mL/hr through a midline IV catheter. After 2 hours, the nurse notes that the client has crackles throughout all lung felds. Which action does the nurse take frst? a. Assess the midline IV insertion site. b. Have the client cough and deep-breathe. c. Notify the health care provider about the crackles. d. Slow the rate of the IV infusion. Correct 129. The nurse is documenting peripheral venous catheter insertion for a client. What does the nurse include in the note? (Select all that apply.) a. Client’s name and hospital number b. Client’s response to the insertion Correct c. Date and time inserted Correctd. Type and size of device Correct e. Type of dressing applied Correct f. Vein used for insertion Correct 130. The nurse is starting a peripheral IV catheter on a recently admitted client. What actions does the nurse perform before insertion of the line? (Select all that apply.) a. Apply povidone–iodine to clean skin, dry for 2 minutes. Correct b. Clean the skin around the site. Correct c. Prepare the skin with 70% alcohol or chlorhexidine. Correct d. Shave the hair around the area of insertion. e. Wear clean gloves and touch the site only with fngertips after applying antiseptics. 131. The nurse is revising an agency’s recommended central line catheter-related bloodstream infection prevention (CR-BSI) bundle. Which actions decrease the client’s risk for this complication? (Select all that apply.) a. During insertion, draping the area around the site with a sterile barrier b. Immediately removing the client’s venous access device (VAD) when it is no longer needed Correct c. Making certain that observers of the insertion are instructed to look away during the procedure d. Thorough hand hygiene (i.e., no quick scrub) before insertion Correct e. Using chlorhexidine for skin disinfection Correct 132. Colostomy surgery is categorized as what type of surgery? a. Cosmetic b. Curative c. Diagnostic d. Palliative Correct 133. The nurse is providing preoperative care for a client who will have an arthroscopy of the left knee. As part of the Joint Commission National Patient Safety Goals (NPSG), what will the nurse be required to do?a. Ensure that the correct procedure is noted in the client’s history. b. Remind the surgeon that the client will have a left knee arthroscopy. c. Verify with the client that a left knee arthroscopy will be performed. d. Mark the left knee site with the client awake and the surgeon present. Correct 134. As the nurse obtains informed consent, the client asks, “Now what exactly are they going to do to me?” What is the nurse’s response? a. Contact the anesthesiologist. b. Contact the surgeon. Correct c. Explain the procedure. d. Have the client sign the form. . 135. The nurse is educating a client who is about to undergo cardiac surgery with general anesthesia. Which statement by the client indicates the need for further instruction? a. “I will wake up with a tube in my throat.” b. “I will have a bandage on my chest.” c. “My family will not be able to see me right away.” d. “Pain medication will take away my pain.” Correct 136. An older client’s adult child tells the nurse that the client does not want life support. What does the nurse do frst? a. Call the legal department to draft the paperwork. b. Document this in the chart. c. Thank the person and do nothing else. d. Talk to the client. Correct 137. A preoperative client smokes a pack of cigarettes a day. What is the nurse’s teaching priority for the best physical outcomes? a. Instruct the client to quit smoking. b. Teach about the dangers of tobacco. c. Teach the importance of incentive spirometry. Correctd. Tell the client that smoking increases postoperative complications. 138. During a preoperative assessment, which statement by a client requires further investigation by the nurse to assess surgical risks? a. “I am taking vitamins.” b. “I drink a glass of wine a night.” c. “I had a heart attack 4 months ago.” Correct d. “I quit smoking 10 years ago.” 139. The nurse completes the preoperative checklist on a client scheduled for general surgery. Which factor contributes the greatest risk for the planned procedure? a. Age 59 years b. General anesthesia complications experienced by the client’s brother c. Diet-controlled diabetes mellitus Correct d. Ten pounds (4.5 kg) over the client’s ideal body weight 140. Which electrolyte laboratory result does the nurse report immediately to the anesthesiologist? a. Creatinine, 1.9 mg/dL (168 mcmol/L) Correct b. Fasting glucose, 80 mg/dL (4.4 mmol/L) c. Potassium, 3.9 mEq/L (3.9 mmol/L) d. Sodium, 140 mEq/L (140 mmol/L) 141. A client is being prepared for gastrointestinal surgery and undergoes a bowel preparation. This preoperative procedure is done to a. decrease expected blood loss during surgery. b. eliminate any risk of infection. c. ensure that the bowel is sterile. d. reduce the number of intestinal bacteria. Correct 142. The nurse is instructing a client about the use of antiembolism stockings. Which statement by the client indicates the need for further teaching? a. “I will take off my stockings one to three times a day for 30 minutes.” b. “My stockings are too loose.” c. “It’s better if they are too tight rather than too loose.” Correctd. “These stockings help promote blood flow.” 143. Which task would be best for the charge nurse to assign to the LPN/LVN working in the surgery admitting area? a. Provide preoperative teaching to a client who needs insertion of a tunneled central venous catheter. b. Insert a retention catheter in a client who requires a flap graft of a sacral pressure ulcer. Correct c. Obtain the medical history from a client who is scheduled for a total hip replacement. d. Assess the client who is being admitted for an elective laparoscopic cholecystectomy. 144. At 8:00 a.m., the registered nurse is admitting a client scheduled for sinus surgery to the outpatient surgery department. Which information given by the client is of most immediate concern to the nurse? a. An allergy to iodine and shellfsh b. Being nauseated after a previous surgery c. Having a small glass of juice at 7:00 a.m. Correct d. Expressing anxiety about the surgery 145. A diabetic client who is scheduled for vascular surgery is admitted on the day of surgery with several orders. Which order does the nurse accomplish frst? a. Use electric clippers to cut hair at the surgical site. b. Start an infusion of lactated Ringer’s solution at 75 mL/hr. c. Administer one-half of the client’s usual lispro insulin dose. d. Draw blood for glucose, electrolyte, and complete blood count values. Correct 146. An unidentifed client from the emergency department requires immediate surgery, but he is not conscious and no one is with him. What must the nurse, who is verifying the informed consent, do? a. Ensure written consultation of two noninvolved physicians. Correct b. Read the surgeon’s consult to determine whether the client’s condition is lifethreatening. c. Sign the operative permit. d. Withhold surgery until the next of kin is notifed.147. A client is having an arthroscopy of the left knee and has just been moved to the surgical holding area. Which statement by the nurse properly identifes the client while the nurse checks the identifcation label? a. “Are you Mr. Smith?” b. “Good morning, Mr. Smith.” c. “What is your name, and when were you born?” Correct d. “What surgery are you having today?” 148. As the unit nurse is about to give a preoperative medication to a client going into surgery, it is discovered that the surgical consent form is not signed. What does the nurse do after verifying the procedure with the client? a. Calls the surgeon b. Calls the anesthesiologist c. Gives the medication as ordered d. Asks the client to sign the consent form Correct 149. Who is the most likely person to administer blood products in an operating suite? a. Circulating nurse Correct b. Holding area nurse c. Scrub nurse d. Specialty nurse 150. If sterile gauze falls to the ground and hits the front of the surgeon’s gown on the way down, what does the nurse do to ensure proper infection control? a. Helps the surgeon change the gown b. Picks the gauze up with a pair of sterile gloves c. Picks the gauze up without touching the surgeon Correct d. Sprays an antimicrobial on the surgeon’s gown 151. Which statement by a nursing student indicates a need for further teaching about operating room (OR) surgical attire? a. “I must cover my facial hair.” b. “I don’t need a sterile gown to be in the OR.” c. “If I go into the OR, I must wear a protective mask.” d. “My scrubs will be sterile.” Correct 152.During surgery, who is most responsible for monitoring for possible breaks in sterile technique? a. Circulating nurse Correct b. Holding nurse c. Anesthesiologist d. Surgeon 153. A preoperative client wears a hearing aid and is extremely hard of hearing without it. What does the nurse do to help reduce this client’s anxiety? a. Actively listen to this client’s concerns. b. Allow the client to wear the hearing aid to surgery. c. Ask if the client may wear the hearing aid until anesthesia is given. Correct d. Explain that it is hospital policy to remove a hearing aid before surgery. 154. A surgical client has signed do-not-resuscitate (DNR) orders before going to the operating room (OR). A complication requiring resuscitation occurs during surgery. What is the nurse’s proper action? a. Call the legal department. b. Call the client’s primary health care provider. c. Honor the DNR order. Correct d. Resuscitate per OR procedure. 155. A client who is preparing to undergo a vaginal hysterectomy is concerned about being exposed. How does the nurse ensure that this client’s privacy will be maintained? a. Remind the client that she will be asleep. b. Ensure that drapes will minimize perianal exposure. Correct c. Explain postoperative expectations. d. Restrict the number of technicians in the procedure. 156. Which intervention does the nurse implement for an older adult client to minimize skin breakdown related to surgical positioning? a. Apply elastic stockings to lower extremities. b. Monitor for excessive blood loss. c. Pad bony prominences. Correct d. Secure joints on a board in anatomic positions.157. A client has undergone an 8-hour surgical procedure under general anesthesia. In assessing the client for complications related to positioning, the nurse is most concerned with which fnding? a. Decreased sensation in the lower extremities b. Diminished peripheral pulses in the lower extremities Correct c. Pale, cool extremities d. Reddened areas over bony prominences 158. The nurse anesthetist notices that a surgical client has an unexpected rise in the end-tidal carbon dioxide level, with a decrease in oxygen saturation and sinus tachycardia. What is the nurse anesthetist’s initial action? a. Administer cardiopulmonary resuscitation. b. Continue as normal. c. Immediately stop all inhalation anesthetic agents and succinylcholine. Correct d. Inform the surgeon. 159. The charge nurse for a hospital operating room is making client assignments for the day. Which client is most appropriate to assign to the least-experienced circulating nurse? a. The 20-year-old client who has a ruptured appendix and is having an emergency appendectomy b. The 28-year-old client with a fractured femur who is having an open reduction and internal fxation c. The 45-year-old client with coronary artery disease who is having coronary artery bypass grafting d. The 52-year-old client with stage I breast cancer who is having a tunneled central venous catheter placed Correct 160. Which staff member will be best for the nurse manager to assign to update standard nursing care plans and policies for care of the client in the operating room (OR)? a. Surgical technologist with 10 years of experience in the OR at this hospital b. Certifed registered nurse frst assistant (CRNFA) who has worked for 5 years in the ORs of multiple hospitals c. Holding room RN who has worked in the hospital holding room for longer than 15 years d. Circulating RN who has been employed in the hospital OR for 7 years Correct161. The nurse is performing a dressing change on a client who underwent abdominal surgery 6 days prior. The nurse notes a moderate amount of serosanguineous drainage on the old dressing. What will the nurse do? a. Apply extra gauze to the new dressing. b. Contact the surgeon to discuss the need for antibiotics. c. Notify the surgeon about possible wound dehiscence. Correct d. Perform the dressing change according to unit protocol. 162. A client has just undergone a surgical procedure with general anesthesia. Which fnding indicates that the client needs further assessment in the post-anesthesia care unit? a. Pain at the surgical site b. Requirement for verbal stimuli to awaken c. Snoring sounds when inhaling Correct d. Sore throat on swallowing 163. Which client is at greatest risk for slow wound healing? a. A 12-year-old healthy girl b. A 47-year-old obese man with diabetes Correct c. A 48-year-old woman who smokes d. A 98-year-old healthy man 164. The nurse reviews a routine discharge teaching plan concerning postoperative care with a client. Which statement by the client indicates that teaching about wound care was effective? a. “I may need to restrict my activities for several months.” Correct b. “I should remove the dressing if the wound is draining.” c. “Some bleeding from the incision is normal for several weeks.” d. “The wound will completely heal in about 2 months.” 165. Which assessment fnding in a postoperative client after general anesthesia requires immediate intervention? a. Heart rate of 58 beats/min b. Pale, cool extremities c. Respiratory rate of 6 breaths/min Correct d. Suppressed gag reflex 166. In conducting a postoperative assessment of a client, what is important for the nurse to examine frst?a. Breathing pattern Correct b. Level of consciousness c. Oxygen saturation d. Surgical site 167. How does the nurse position a client with postoperative nausea and vomiting? a. Flat in bed, with the head in alignment with the body b. Prone, with the head of the bed flat c. Side-lying, with the head in a neutral position Correct d. Supine in bed, with the neck flexed 168. A client has an acute case of opioid depression and receives a dose of naloxone (Narcan). Which statement is true about this client? a. Supplemental pain reduction is needed. Correct b. One dose is needed. c. This is an acute emergency. d. The client will be hostile. 169. What pain management does a client who has been admitted to the post-anesthesia care unit typically receive? a. Intramuscular nonopioid analgesics b. Intramuscular opioid analgesics c. Intravenous nonopioid analgesics d. Intravenous opioid analgesics Correct 170. The nurse assesses a client’s wound 24 hours postoperatively. Which fnding causes the nurse the greatest concern and should be reported to the surgeon? a. Crusting along the incision line b. Redness and swelling around the incision Correct c. Sanguineous drainage at the suture site d. Serosanguineous drainage on the dressing 171. Which action does the nurse implement for a client with wound evisceration? a. Apply direct pressure to the wound. b. Cover the wound with a sterile, warm, moist dressing. Correctc. Irrigate the wound with warm, sterile saline. d. Replace tissue protruding into the opening. 172. Five RNs from other units have been assigned to the post-anesthesia care unit for the day. A 16-year-old client with diabetes has also just arrived from the operating room (OR) after having laparoscopic abdominal surgery. The charge nurse assigns the RN with which kind of experience to care for this new client? a. RN who usually works on the inpatient pediatric unit b. RN who provides education to diabetic clients in a clinic c. RN who has 5 years of experience in the delivery room Correct d. RN who ordinarily works as a scrub nurse in the OR 173. After gastric surgery, a client arrives in the post-anesthesia care unit. Which nursing action is most appropriate for the RN to delegate to an experienced nursing assistant? a. Monitor respiratory rate and airway patency. b. Irrigate the nasogastric tube with saline. c. Position the client on the left side. Correct d. Assess the client’s pain level. 174. An RN and an LPN/LVN are working together in caring for a client who needs all of these interventions after orthopedic surgery. Which action(s) would be best for the RN to accomplish? a. Reinforce the need to cough and deep-breathe every 2 to 4 hours. b. Develop the discharge teaching plan in conjunction with the client. Correct c. Administer narcotic pain medications before assisting the client with ambulation. d. Listen for bowel sounds and monitor the abdomen for distention and pain. 175. The RN has just received reports about all of these clients on the inpatient surgical unit. Which client does the nurse care for frst? a. A 43-year-old who had a bowel resection 7 days ago and has new serosanguineous drainage on the dressing Correct b. A 46-year-old who had a thoracotomy 5 days ago and needs discharge teaching before going homec. A 48-year-old who had bladder surgery earlier in the day and is reporting pain when coughing d. A 49-year-old who underwent repair of a dislocated shoulder this morning and has a temperature of 100.4°F (38°C) 176. The nurse is developing a teaching plan for a client diagnosed with osteoarthritis (OA). The nurse includes which instruction in the teaching plan? a. Begin a running program. b. Take up knitting to slow down joint degeneration. c. Eat at least 2 cups (17 ounces) of yogurt per day. d. Wear supportive shoes. 177. Assessment fndings reveal that an older adult client with severe osteoarthritis of the left hip can no longer perform activities of daily living (ADLs) and has had several falls in the home over the past month. To which community resource does the nurse refer the client? a. Local senior citizen center b. Citizens for Better Care c. Home health care agency d. Meals on Wheels 178. Which element is a risk factor for osteoarthritis (OA)?a. Thin build b. Obesity c. Nonsmoker d. Male 179. A client diagnosed with rheumatoid arthritis (RA) is started on methotrexate (Rheumatrex). Which statement made by the client indicates to the nurse that further teaching is needed regarding drug therapy? a. “Drinking alcoholic beverages should be avoided.” b. “The health care provider should be notifed 3 months before a planned pregnancy.” c. “Any side effects of this drug will be mild.” d. “I will avoid any live vaccines.” 180. The home health nurse conducts a community presentation on Lyme disease for the residents of an assisted-living facility. Which statement from the audience indicates to the home health nurse that further instruction is needed? a. “I will gently remove the tick with tissue and then burn it to prevent the spread of the disease.” b. “It is best to walk in the center of an outside trail.” c. “I should wait 4 to 6 weeks after being bitten by a tick to be tested for Lyme disease.” d.“I’ll wear light-colored clothes with long sleeves, long pants, closed shoes, and a hat when I am walking in the woods.” 181. An alert client who recently underwent total hip arthroplasty and is on anticoagulants is preparing for discharge from the hospital. Which information is most important for the nurse to provide to the client and caregiver? a. Use an abduction pillow between the legs. b. Keep heels off the bed. c. Avoid using a straight razor. d. Re-orient frequently. 182. The nurse is caring for an older, alert adult client diagnosed with osteoarthritis. Which client statement indicates to the nurse that the client is using effective coping strategies? a. “I do not know how long my wife will be able to take care of me at home.” b. “The bus is coming to pick me up from the senior center three times a week so I can play cards.” c. “I am helping with the dishes and laundry, but I hurt so badly when I am doing it.” d. “I do not know how much longer my neighbor can continue to help clean my house.” 183. The nurse is caring for a middle-aged client diagnosed with rheumatoid arthritis. Which client statement requires further assessment for unproductive coping strategies? a. “I’m letting my husband do most of the cooking, but I help plan the menus.” b.“Since I started taking etanercept (Enbrel), I can walk up and down the stairs of my home easier.” c. “My husband is getting used to having sex only once a month.” d. “I worry about what’s going to happen to me if my husband cannot take care of me, but he says he’ll hire someone if he must.” 184. The nurse is teaching a client about the difference between rheumatoid arthritis (RA) and osteoarthritis (OA). Which statement by the client indicates a need for further teaching? a. “RA is inflammatory. OA is degenerative.” b. “The risk factors or causes of RA are probably autoimmune, whereas OA may be caused by age, obesity, trauma, or occupation.” c. “The typical onset of RA is seen between 35 and 45 years of age, whereas the typical onset of OA is seen in clients older than 60 years.” d. “The disease pattern of RA is usually unilateral and is seen in a single joint, whereas OA is usually bilateral and symmetric, and is noted in multiple joints.” 185. A client has symptoms of rheumatoid arthritis (RA). Which laboratory fnding indicates to the nurse that the client may have RA? a. Total serum complement, 75 units/mL