HESI EXIT (GRADED A+) COMPREHENSIVE EXAM | Download To Score An A

Comprehensive Exam 133- Cyclobenzaprine(Flexeril)isprescribedtoaclientwithmultiplesclerosisforthetreatmentof musclespasms.Forwhichcommonsideeffectofthismedicationdoesthenursemonitortheclient? A. Diarrhea B. Drowsines Correct C. Abdominalpain D. Increasedsalivation 134- Anurseadministersnitroglycerinsublingualytoaclientwithanginapectoriswhocomplainsof chestpain.Themedicationisineffective,sothenursepreparestoadministeraseconddose.Before administeringthenitroglycerin,whichactiondoesthenursemakeapriority? A. Checkingtheclient'sblo dpresureCorrect B. Obtainingblo dlevelsofcardiacenzymes C. Askingtheclientwhetherhehasaheadache D. Obtaininga12-leadelectrocardiogram (ECG) 135- Ciprofloxacinhydrochloride(Cipro)isprescribedtoaclientwithaurinarytractinfection.The nurse,providinginstructionabouthemedication,telstheclienthatitisbestotakethemedication: A. Withmilk B. Withanantacid C. 2hoursaftermealCorrect D. Withaluminum hydroxide 136.- Anurseprovideshomecareinstructionstoaclientwithcoronaryarterydisease(CAD)whoisbeing dischargedfrom thehospital.Whichstatementbytheclientindicatesane dforfurtherinstruction? A. "Ine dtocarrymynitroglycerinwithmeataltimes." B. "Ine dtocheckmypulsebefore,during,andafterexercise." C. "Ine dtoavoidfo dswithsaturatedfatsandfo dshighincholesterol." D. "Ine dtoparticipateinaerobicandweightliftingexercisethre timesawek.Correct 137-Anurseprovidesinformationtoaclientwhowilbeundergoingendoscopicretrograde cholangiopancreatography(ERCP).Thenursetelstheclienthat: A. Thereisnone dtofast(NPOstatus)beforetheprocedure B. Thegalblad eriseasilyremovedduringthisprocedureifgalstonesarefound C. Theprocedureisperformedspecificalytovisualizetheesophagus,stomach,and duodenum D. Dyemaybeinjectedduringtheproceduretopermitvisualizationofthepancreaticand biliaryductCorrect 138ID: Aclientwhohasundergonekne-replacementsurgerywilbeself-administeringenoxaparinsodium (Lovenox)athome.Thenurseteachestheclientabouthemedicationandtelsthecliento: A. Storethemedicationintherefrigerator B. LiedowntoadministerthesubcutaneousinjectionCorrect C. Injecthemedicationintheup erouteraspectofthearm D. Discardthemedicationifthesolutionap earspaleyelow 139ID: Anintravenousdoseofadenosine(Adenocard)isprescribedforaclientotreatWolff-Parkinson- Whitesyndrome.Whichpieceofequipmentdoesthenursemakeapriorityofobtainingbefore administeringthemedication? A. Pulseoximeter B. Cardiacmonito Correct C. Blo d-presurecuff D. Suctioncatheterandsuctionmachine 140ID: Anurseprovidesinformationtoaclientwithcoronaryarterydisease(CAD)aboutsmoking-cesation measures.Whichstatementbytheclientindicatesane dforfurtherinformation? A. "Acommunitysup ortgroupwilhelpmequit." B. "Ishoulddrinkacupofcoffe ifIfe ltheurgetosmoke.Correct C. "Relaxationexerciseswilhelpcontrolmyurgetosmoke." D. "Icantrychewinggum orsuckingonhardcandyifIfe ltheurgetosmoke." 141ID: Captopril(Capoten)isprescribedforahospitalizedclientwithheartfailure.Whichactionisapriority oncethenursehasadministeredthefirstdose? A. Checkingtheclient'sapicalheartrate B. Maintainingtheclientonbedrestfor3hour Correct C. Monitoringtheclientforincreasedurineoutput D. Checkingtheclient'sbreathsoundsfordecreasedwhe zing 142ID: Aclientwithheartfailuresud enlyexperiencesprofounddyspnea,palor,audiblewhe zing,and cyanosis,andthenursesuspectspulmonaryedema.Thenursewouldfirst: A. Obtainapulseoximetryreading B. Raisetheheadoftheclient'sbedCorrect C. Administeradoseofmorphinesulfate D. Obtainaspecimenforanarterialblo dgasdetermination 143ID: Thenurseadministersintravenousmorphinesulfatetoaclientinpulmonaryedema.Forwhich intendedeffectofthemedicationdoesthenursemonitortheclient? A. Reliefofpain B. ReliefofanxietCorrect C. Decreasedurineoutput D. Increasedblo dpresure 14 ID: Anurseisprovidinghomecareinstructionstoaclientwithcoronaryarterydisease(CAD)whowil bedischargedhomeandwilbetaking1aspirindaily.Thenursetelstheclient: A. Tostoptheaspirinifnauseaocur Incorrect B. Totaketheaspirinonanemptystomach C. Thatheaspirinisashort-term treatmentandwilprobablybediscontinuedin2 we ks 145ID: Aclientreceivingparenteralnutrition(PN)sud enlyexperienceschestpainanddyspnea,andthe nursesuspectsanairembolism.ThenurseimmediatelyplacestheclientinalateralTrendelenburg position,ontheleftside.Whatactiondoesthenursetakenext? A. Auscultatingheartsounds B. Clampingtheintravenouscathete Correct C. Checkingtheclient'sblo dpresure D. Obtaininganarterialblo dgasspecimen 146ID: Anurseisteachingaclientwithleft-sideweaknes howtowalkwiththeuseofaquad-cane.The nurseensuresthat: A. Theclientplacesthecaneontheleftside B. Thetopofthecaneislevelwiththeclient'swaist C. 30-degre flexionoftheclient'selbowismaintainedwhentheclientisholdingthe caneCorrect D. Theclientleansonthecaneandplacesasmuchweightasposibleonthecane whenmovingitforward 147ID: Anurseispreparingthero m ofaclientinskeletaltractionwhowilbeadmitedtothenursingunit. Whichitem forusebytheclientdoesthenurseidentifyasthemostimportant? A. Telephone B. Television C. Trapezeba Correct D. Bedsidecommode 148ID: Anursetakingthevitalsignsofaclientimmediatelyaftershehasdeliveredanewbornnotesthathe client'sheartrateis1 0beats/min.Thenursewouldfirst: A. Documenthefindings B. Offertheclientoralfluids C. Rechecktheheartratein1hour D. ChecktheuterusandamountoflochiadischargeCorrect 149ID: Aclientisreceivinganintravenousinfusionofalteplase(tisueplasminogenactivator,recombinant; tPA).Forwhichadverseeffectofthemedicationdoesthenursemonitortheclientmostclosely? A. Ble dingCorrect B. Hearinglos C. Decreasedurineoutput D. Increasedblo dpresure 150ID: Viewvideo.Thenurseisperformingasterilechangeofanabdominaldresing.Oncethedresing hasbe nremovedanddiscardedinawaterpro fbag,whichactionshouldthenursetakenext? A. AsesingthewoundCorrect B. Don ingsterilegloves C. Cleansingthewound D. Setingupthesterilefield 151ID: Anurseisprovidingmorningcaretoaclientwhohasundergonesurgerytorepairafracturedleft hip.Whichitem ismostimportantforthenursetouseinturningtheclientfrom sidetosidetochange thebedlinens? A. Trapezebar B. Slidingboard C. Ad uctiondevice D. AbductiondeviceCorrec 152ID: Anurseprovidesdietaryinstructionstoaclientwithosteoporosiswhohassustainedafractureabout fo dsthatwilpromotehealing.Thenursetelstheclienthatitisbestoconsumefo dsthatare highin: A. Fats B. VitaminCCorrect C. Carbohydrates D. Concentratedsugar 153ID: Anurseinaphysician'sofficeistalkingtoaclientwhounderwentmastectomyoftherightbreast2 weksago.Theclientsaystothenurse,"Ihatelokingathisincision.Ife lthatI'm notevenmyself anymore."Thenurseinterpretsthisstatementomeanthatheclientisexperiencingwhichproblem? A. Inabilitytocope B. DistortedbodyimageCorrect C. Inabilitytocareforself D. Inabilitytomaintainhealth 154ID: Anursediscoversthataclientreceivingheparinsodium bywayofcontinuousintravenous(IV) infusionhasremovedtheIVtubingfrom theinfusionpumptochangehishospitalgown.After asesingtheclientandplacingthetubingbackintheinfusionpump,whichmedicationdoesthe nursecheckforinthemedicationro m incaseaheparinoverdosehasocurred? A. ProtaminesulfateCorrect B. Enoxaparin(Lovenox) C. Phytonadione(vitaminK) D. Aminocaproicacid(Amicar) 15 ID: Themotherofanewbornfoundtohaveacongenitaldiaphragmaticherniaasksthenursetoexplain thediagnosis.Thenursetelsthemotherthatinthiscondition: A. Theesophagusterminatesbeforeitreachesthestomach B. Gastriccontentsareregurgitatedbackintotheesophagus C. Abdominalcontentsherniatethroughanopeningofthediaphragm Correct D. Aportionofthestomachprotrudesthroughtheesophagealhiatusofthediaphragm 156ID: Anurseisperforminganasesmentofanewbornwithadiagnosisofesophagealatresia(EA)and tracheoesophagealfistula(TEF).Whichfindingsdoesthenurseexpectonoteintheinfant?Select allthatapply. A. Dro lingCorrect B. Whe zing C. Hicuping D. Shortperiodsofapnea E. Excesiveoralsecretion Correct F. Bowelsoundsoverthechest 157ID: Anurseisreviewingthemedicalrecordofaninfantinwhom hypertrophicpyloricstenosis(HPS)is suspected.Whichcharacteristicsasociatedwiththedisorderdoesthenurseexpectsse documentedintheinfant’smedicalrecord?Selectallthatapply. A. Weightlos Correct B. Facialedema C. Metabolicacidosis D. ProjectilevomitingCorrect E. Distendedup erabdomenCorrect 158ID: Aclientwithahistoryofanginapectoristelsthenursethathechestpainusualyocurswith moderatetoprolongedexertionandisgeneralyrelievedbynitroglycerinorest.Whichtypeof anginadoesthenurserecognizeintheclient’sdescription? A. StableCorrect B. Variant C. Unstable D. Crescendo 159ID: Methylergonovine(Methergine)isprescribedforaclientocontrolpostpartum ble ding.Which actiondoesthenursetakebeforeadministeringthemedication? A. Checkingtheepisiotomysite B. Palpatingtheclient'sblad er C. Checkingtheclient'sblo dpresureCorrect D. Ensuringthatheuterusiscontracted 160ID: Anurseisteachingaclientwithanginapectoriswhoisbeingdischargedfrom thehospitalabout managingchestpainathome.Whichstatementbytheclientindicatesane dforfurtherteaching? A. "Ine dtoke pfreshnitroglycerinavailableincaseIne dit." B. "Ine dtochecktheexpirationdateonthenitroglycerinbotle." C. "IfIhaveanychestpain,Ine dtostopwhatIam doingandsitorliedown." D. "IfIgetchestpain,Ishouldput3nitroglycerintabletsundermytongueandthengoto theemergencydepartmentifthatdoesn’twork.Correct 161ID: Anursedevelopsalistofhomecareinstructionsforaclientwhoiswearingahalofixationdevice aftersustainingacervicalfracture.Whichinstructionsshouldthenurseinclude?Selectallthat apply. A. UseastrawtodrinkCorrect B. Avoidsexualactivitywhilethevestisinplace. C. Ap lypowderunderthevestopreventirritation. D. Usecautionwhenleaningforwardorbackward Correct E. Wearsnugclothingtopreventhedevicefrom shifting. F. Donotdrive,becausefulrangeofvisionisimpairedwiththedevice Correct 162ID: Anurseisasesingaclientwhoisexperiencingchestpain.Whichofthefolowingobservations indicatestothenursethathepainismostlikelyaresultofangina? A. Thepainisrelievedbyrestandnitroglycerin Correct B. Thepainisrelievedbytheadministrationofanantacid. C. Thepainisrelievedbytheadministrationofanantinflammatorymedication. D. Thepainisrelievedwithanuprightsitingpositionandtheadministrationofan analgesic. 163ID: Anursehasprovidednutritioninstructionstoamotherofaninfant.Whichstatementbythemother indicatestothenursethathemotherequiresfurtherinstruction? A. "It’sbestousecow'smilk,aslongasit’swholemilkandnotskim.Correct B. "WhenIstartfe dingsolidfo ds,Imightne dtoad watertothefo d." C. "Whenthebabystartstotakejuices,Ishouldn’twarm thejuice,becausethatwil destroythevitaminC." D. "ThebabywilgetherightnutritionifIfe dbreastmilkorstore-boughtformulathat’s be nfortifiedwithiron.” 164ID: Apediatricnurseiscaringforahospitalizedtod ler.Whichofthefolowingactivitiesdoesthenurse de m themostap ropriateforthetod ler? A. Singinggames B. Watchingvideos C. Simpleboardgames D. Largebuildingblock Correct 165ID: Anurseinaphysician'sofficeisreviewingthemedicalrecordofachildwithadiagnosisoflactose intolerance.Whichofthefolowingfindingsdoesthenurseexpectose documentedinthechild's record? A. Fatystols B. Episodesofoul-smelingribonlikesto ls C. Episodesofprofusewaterydiarrheaandvomiting D. Episodesofcrampingabdominalpainandexcesiveflatu Correct 16 ID: Anurseisprovidingdietaryinstructionstothemotherofachildwithceliacdisease.Thenursetels themotherthatitisaceptabletogivethechild: A. BoiledriceCorrect B. Cokedpasta C. Warm oatmeal D. Bakedmacaroniandche se 167ID: Anurseadmitinganewborntothenurserynotesthathephysicianhasdocumentedthathe newbornhasagastroschisis.Thenurseperformsanasesment,expectingtonotethatheviscera are: A. Insidetheabdominalcavityandundertheskin B. Insidetheabdominalcavityandunderthedermis C. Outsidetheabdominalcavity,notcoveredwithasa Correct D. Outsidetheabdominalcavitybutinsideatranslucentsaccoveredwithperitoneum andamnioticmembrane 168ID: Anurseismonitoringachildwithintususceptionforsignsofperitonitis.Forwhichofthefolowing findings,indicativeofthiscomplication,doesthenursenotifythephysician? A. Increasedalertnes B. IncreasedheartrateCorrect C. Asausage-shapedabdominalmas D. Diarrheaandthepasageofblo dymucoussto l 169ID: Thenurse,auscultatingthebreathsoundsofaclient,hearsthesesounds.Whatarethey? A. Rhonchi B. Crackles C. Whe ze Correct D. Vesicular 170ID: Aregisterednurseisplan ingclientasisgnmentsfortheday.Thereisalicensedpracticalnurse andanursingasistantontheteam.Whichclientistheap ropriatechoiceforthenursingasistant? A. Aclientwithhemophiliawhone dsasistancewithshaving B. Aclientwithpneumoniawhorequiresfrequentoropharyngealsuctioning C. Aclientwithrheumatoidarthritiswhone dsasistancewithfe dingand ambulationCorrect D. Aclientwithheartfailurewhonedsdailyweightsandmonitoringofintakeandoutput 171ID: Anurseismonitoringaclientwithbronchogeniccarcinomaforsignsofsuperiorvenacava syndrome.Forwhichearlysignofthisoncologicalemergencydoesthenurseases theclient? A. Dyspnea B. Cyanosis C. Hypotension D. StokessignCorrect 172ID: Anurseiscaringforaclientwhohasundergonetransphenoidalhypophysectomytoremovea microadenomaofthepituitarygland.Whichofthesefindingswouldbeofgreatestconcerntothe nurse? A. UrinaryspecificgravityislowCorrect B. Blo dpresureis138/80mm Hg. C. Theclientcomplainsofadrymouth. D. Theclientfrequentlyperformsde p-breathingexercises. 173ID: Thenursenotesthepresenceofdrainageonthemustachedresingofaclientwhohasundergone transphenoidalhypophysectomy.Theinitialnursingactionisto: A. Contacthesurgeon B. Changethedresing C. Documenthefindings D. CheckthedrainageforglucoseCorrect 174ID: Anurseismonitoringaclientwhohasundergonesubtotalthyroidectomyforsignsofpostoperative complications.Whichofthefolowingfindingswouldbeamaterofconcernforthenurseasan indicationofhypocalcemia? A. Theclient'stemperatureis10 .6˚F. B. Theclient'svoiceishoarseandweak. C. Theclient'sheartrateis92beats/min. D. Theclientcomplainsofatinglingsensationaroundthemouth Correct 175ID: Anurseismonitoringaclientwhowasbroughtotheemergencydepartmentinanunresponsive stateandisnowbeingtreatedforhyperglycemichyperosmolarnonketoticsyndrome(HHNS).Which ofthefolowingfindingsindicatestothenursethatfluidreplacementisinadequate? A. Increasedurineoutput B. Potasium levelof3.6mEq/L C. Blo dpresureof128/80mm Hg D. Levelofconsciousnes remainsunchangedCorrect 176-Anurseisreviewingthelaboratoryresultsofaclientintheemergencydepartmentwithdiabetic ketoacidosis(DKA).Whichlaboratoryresultwouldthenurseexpectonote? A. Creatinine1.0mg/dL B. Serum bicarbonateof12mEq/LCorrect C. Blodureanitrogen(BUN)of15mg/dL D. Negativeresultsonurinaryketonetesting 17 ID: Propylthiouracil(PTU)hasbenprescribedforaclientwithGravesdisease,andthenurseprovides instructionstotheclientabouthemedication.Forwhichofthefolowingocurencesdoesthenurse telstheclientocontacthephysician? A. Fatigue B. Diaphoresis C. Sorethroa Correct D. Heatintolerance 178ID: Anurseisprovidinginformationtoaclientwithdiabetesinsipiduswhowilbetakingdesmopresin acetate(DDAVP)bywayofthenasalroute.Forwhichofthefolowingocurrencesdoesthenurse teltheclientocontacthephysician? A. Abdominalcramps B. Stuffyorunynose C. HeadacheandnauseaCorrect 179ID: Aclientwithdiabetesmelituscalstheclinicnurseandreportsthatshehasbe nvomitingduringthe nightandnowhasdiarrhea.Whichquestiondoesthenursemakeapriorityofaskingtheclient? A. "Doyouhaveafever?" B. "Didyoueatanybreakfast?" C. "Areyouurinatingfrequently?" D. "Haveyoutestedyourblo dglucose? Correct 180ID: Anurseisprovidinginformationtoaclientwhowilbeself-administeringregularinsulinabout storageoftheinsulin.Thenursetelstheclient: A. Thatplacingthevialnearheatorinsunlightwilnotaffectheinsulin B. Tofrezeunopenedvialsandremoveavialfrom thefrezer24hoursbeforeopening it C. Thatinsulinstoredatro m temperaturecausesmorediscomfortoninjectionthan doescoldinsulin D. Thathevialincurentusemaybekeptatro m temperatureforaslongas1month withoutsignificantlos ofactivitCorrect 181ID: Anursereviewsthemedicalrecordofaclientwithhistoplasmosis.Whichclinicalmanifestationof thisinfectiondoesthenurseexpectose documented? A. Neurologicaldeficits B. Cardiacdysrhythmias C. Gastrointestinaldisturbances D. Flulikepulmonarysymptom Correct 182ID: Aclientwithamedicalhistoryofdiabetesmelitusisfoundtohavesarcoidosis,andoralprednisone isprescribed.Thenurseprovidesinstructionstotheclientabouthemedicationandtelstheclient to: A. Eatfo dsthatarehighinsodium B. Decreasethedailydoseofinsulin C. Eatfo dsthatarelowinpotasium D. Closelymonitortheblo dglucoseleveCorrect 183ID: Aclientwithtuberculosiswilbetakingpyrazinamide(Pyrazinamide),andthenurseprovides instructionsaboutheadverseeffectsofthemedication.Forwhichofthefolowingocurencesdoes thenurseteltheclientocontacthephysician? A. Headache B. YelowskinCorrect C. Difficultysle ping D. Nasalcongestion 184ID: Aclientwhowasinvolvedinahigh-spe dmotorvehiclecrashisbroughtotheemergency department.Whichofthefolowingfindingsindicatestothenursethatheclienthassustainedflail chest? A. Asymmetricalchestmovemen Correct B. Complaintsofmildchestdiscomfort C. Increasedbreathsoundsonauscultation D. Deprespirations,18breaths/min 185ID: Aclientisfoundtohavehypoxemicrespiratoryfailure.Whichfindingdoesthenurseexpectonote onreviewoftheresultsoftheclient'sarterialblodgasanalysis? A. Pao2 of73mm Hg,Paco2 of62mm Hg B. Pao2 of58mm Hg,Paco2 of35mm Hg C. Pao2 of60mm Hg,Paco2 of45mm Hg D. Pao2 of49mm Hg,Paco2 of32mm HgCorrect 186ID: Aclientwithacutegoutyarthritisisbeingstartedonmedicationtherapywithindomethacin(Indocin). Thenurse,providingmedicationinstructions,andtelstheclientotakethemedication: A. Atbedtime B. Withfo dCorrect C. 1hourbeforemeals D. Onanemptystomach 187ID: Anemergencydepartmentnurseismonitoringaclientwhosustainedasevereinhalationburninjury duringafireinwhichtheclientwastrap edinanenclosedspace.Thenurseauscultatestheclient's tracheaandnotesthathepreviouslyheardwhe zingsoundshavedisap eared.Thenurse mostapropriately: A. Continuesmonitoringtheclient B. NotifiestheemergencydepartmentphysicianCorrect C. Documentstheclient'simprovementinthemedicalrecord D. Removestheoxygenmaskandfitstheclientwithanasalcan ula 18 ID: Anursereviewsarterialblo dgasvaluesandnotesapHof7.50andaPco2 of30mm Hg.The nurseinterpretsthesevaluesasindicativeof: A. Metabolicacidosis B. Metabolicalkalosis C. Respiratoryacidosis D. RespiratoryalkalosiCorrect 189ID: Anurseprovidesinformationtoaclientwithchronicobstructivepulmonarydisease(COPD)about methodsofaleviatingshortnes ofbreathwhiletheclientiseating.Whichstatementbytheclient indicatesane dforfurtherinstruction? A. "IshouldrestbeforeIeat." B. "Ishouldusemybronchodilator30minutesbeforeIeat." C. "Pursed-lipbreathingwilhelprelievemyshortnes ofbreath." D. "Ishouldeathre mealsaday,andthebig estmealshouldbeat supertime.Correct 190ID: Apostoperativeclientwithde p-veinthrombosisisatriskforpulmonaryembolism.Forwhich characteristicsignorsymptom ofthiscomplicationdoesthenursemonitortheclient? A. PleuriticchestpainCorrect B. Slowedheartrate C. Chilsandahighfever D. Decreasedrespiratoryrate 191ID: Anursecaringforaclient24hoursafteraradicalneckdisectionnotesthepresenceof serosanguineousdrainageintheportablewoundsuctiondeviceatachedtothesurgicalsite.Onthe basisofthisfinding,thenurseshould: A. Contacthephysician B. Documenthefinding Correct C. Askthephysiciantoremovethedrains D. Increasethepresureonthewoundsuctiondevic 192-Althoughpreviouslywelcontroledwithglyburide(Diabeta),aclient’sfastingblo dglucosehas benrun ing180to20 mg/dL.Onreviewingtheclient'srecord,whichmedication,recentlyad ed totheclient'sregimen,doesthenurserecognizeasaposiblecontributortothehyperglycemia? A. Phenelzine(Nardil) B. Atenolol(Tenormin) C. Alopurinol(Zyloprim) D. Lithium carbonate(Lithobid Correct 193ID: Anurseisperforminganasesmentofaclientwithsuspectedpheochromocytoma.Whichclinical manifestationdoesthenurseexpectonote? A. Weightgain B. Flushedface C. Clientcomplaintofdiarrhea D. AblodpresurehigherthanthenormalrangeCorrect 194ID: Thenurseisthefirstresponderathesceneofabuscrash.Afteraquickasesmentofthevictims, whichonedoesthenursecareforfirst? A. Avictim withatwistedankleandlegbruises B. Avictim withanopenfractureofthearm thatisble dingprofuselCorrect C. Avictim whoisanxiouslymovingamongthevictims,searchingforherhusband D. Avictim whoisunresponsive,withsevereswelingandbruisingaroundtheeyes,and isnotbreathing 195ID: AclientwithsuspectedHIVinfectionhaspositiveresultsonenzyme-linkedimmunosorbentasay (ELISA)andWesternblotests.TheplasmaHIVRNAlevelisasesed,andtheresultisreportedas 800copies/mL.ThenurseinterpretstheresultsoftheHIVRNAtestasindicatingthatheclient: A. IsatlowriskforAIDSCorrect B. IsathighriskforAIDS C. IsatriskforHIVinfection D. Requiresfurthertestingtoconfirm thepresenceofHIV 196ID: AnursedevelopingaplanofcareforaclientwithHIVinfectionidentifiesseveralconcerns.Listhem inorderofpriority,from highestolowest. Correct 1. Posibleinfection 2. Decreasednutrition 3. Fatigue 4. Despair 197ID: Aclientisfoundtohaveiron-deficiencyanemia,andferoussulfate(Feosol)isprescribed.Thenurse telstheclienthatitisbestotakethemedicationwith: A. Milk B. Aplejuice C. OrangejuiceCorrect D. Scrambledegs 198ID: Anurseismonitoringaclientwithpheochromocytomawhoisreceivinganintravenous(IV)infusion ofphentolamine.Whichvitalsigndoesthenursemonitormostcloselyduringtheinfusion? A. Apicalpulse B. Respirations C. Temperature D. Blo dpresureCorrect 19 ID: Oralprednisone5mg/dayhasbe nprescribedforaclientwithachronicrespiratorydisorder,and thenurseprovidesinstructionstotheclientabouthemedication.Thenursetelsthecliento: A. Takethemedicationonanemptystomach B. Takehalfofthedailydoseifweightgainocurs C. Stoptakingthemedicationiftheanklesbegintoswel D. Calthephysicianifafever,sorethroat,ormuscleachesdevelopCorrect 20 ID: Asanursepreparestoadministermedicationstoanasignedclient,theclientasks,"Whydon'tyou justleavemealone?"Whatisthebestresponsebythenurse? A. "Don'tyelatme." B. "Thesemedicationswilhelpyoufe lmuchbeter." C. "Whydoyouwantobeleftalone?I’m heretohelpyou." D. "Icanse thatyou’reupset.Wouldyouliketotalkaboutit? Correct 201ID: Anurseisasesingaclientwithhepatitisforsignsofjaundice.Whichareadoesthenursecheck, knowingthatitwilprovidethebestdataregardingthepresenceofjaundice? A. Lips B. Soles C. Palms D. Mucousmembrane Correct 202ID: Amothercalstheemergencydepartmentandtelsthenursethather3-year-oldchilddrank ammoniafrom abotlewhilethemotherwascleaninghouse.Thenursetelsthemotherto immediately: A. Inducevomiting B. Calthechild'sphysician C. Bringthechildtotheemergencydepartment D. Encouragethechildtodrinkwaterormilkinsmalamount Correct 203ID: Calcium disodium edetate(EDTA)andBritishantilewisite(BAL,dimercaprol)isprescribedforachild withleadpoisoning.Whatdoesthenurseaskthechild'smotherbeforeadministeringthe medications? A. "Canyourchildswalowpils?" B. "Hasyourchildbe nruningafever?" C. "Doesyourchildhaveanalergytopeanuts? Correct D. "Howlonghasyourchildbe nexposedtothelead?" 204ID: Achildisbroughtotheemergencydepartmentbyambulanceafterswalowingseveralcapsulesof acetaminophen(Tylenol).Whichmedicationdoesthenurseprepare,anticipatingthatitwilbe prescribedtotreathechild? A. Protaminesulfate B. Sucimer(Chemet) C. Phytonadione(vitaminK) D. Acetylcysteine(MucomystCorrect 205-Afemaleclientwithrheumatoidarthritisistaking3.6gofacetylsalicylicacid(aspirin)dailyina divideddose.Athephysician'soffice,theclientelsthenursethatshehasbenexperiencing ringingintheearsoverthepastfewdays.Thenursetelstheclienthat: A. Thisisexpectedandnothingtobeconcernedabout B. Itisimportantodrinkatleast10glasesofwateradaytopreventringingintheears C. Thisisasignoftoxicity,sotheaspirinwilbediscontinuedandreplacedwitha nonsteroidalantinflammatorymedication D. Thephysicianwilprobablywith oldtheaspirinuntilthesymptomshavesubsided,then resumetheaspirinatalowerdosageCorrect 206ID: Anurseiscaringforaclientwhosustainedburninjuriesontheanteriorlowerlegsandanterior thorax.Whatpercentageoftheclient’sbody,acordingtotheRuleofNines,hasbe naffected? A. 36% Correct B. 42% C. 45% D. 31.5% 207ID: Aclientisbroughtotheemergencydepartmentaftersustainingsmokeinhalationinjuryduringafire intheclient'shome.Thenurseplanstofirst: A. CheckforapatentIVline B. Provideemotionalsuportotheclient C. Providetheclientwith10 % oxygenbymas Correct D. Administerintravenous(IV)fluidsasprescribed 208ID: Aclientwithemphysemaisreceivingtheophyline(Theo-24).Whileprovidingdietaryinstructions,the nursetelstheclienthatitisaceptabletoconsume: A. Cola B. Coffe C. Hotcocoa D. AplejuiceCorrect 209-Testingoftheplasmatheophylinelevelinaclientwhoisreceivingacontinuousintravenous infusionoftheophylinerevealsalevelof20mcg/mL.Thenurseinterpretsthisresultas: A. Belowthetherapeuticrange B. Inexces ofthetherapeuticrange C. AthetopofthetherapeuticrangeCorrect D. Inthemid leofthetherapeuticrange 210ID: Fluticasonepropionate(Advair)andalbuterol(VentolinHFA),administeredbyinhalationtwicedaily, areprescribedforaclientwithasthma.Thenurse,providinginformationtotheclientabout administrationofthemedication,telstheclientousethe: A. Fluticasonepropionateimmediatelyafterinhalingthealbuterol B. Albuterolimmediatelyafterinhalingthefluticasonepropionate C. Fluticasonepropionateseveralminutesbeforeinhalingthealbuterol D. AlbuterolseveralminutesbeforeinhalingthefluticasonepropionateCorrect 21 ID: Anurseasesingthewoundofaclientwithastage3presureulcerandnotesthathewoundbed ispale.Thenurseinterpretsthisfindingasaposibleindicationthat: A. Thewoundishealthy B. Thewoundisimproving C. Necrotictisueispresent D. Theclient'shemoglobinlevelislowCorrect 212ID: Aclientcalstheemergencydepartmentandtelsthenursethathemayhavecomeincontactwith poisonivywhiletrimmingbushesinhisyard.Thenursetelstheclientoimmediately: A. Contacthephysician B. Reportotheemergencydepartmentfortreatment C. Getintotheshowerandrinsetheskinforatleast15minute Correct D. Gotothedrugstore,purchaseanover-the-countertopicalcorticosteroid,andrubit intotheexposedskin 213-Anurseprovidesskincareinstructionstoaclientwithacnevulgaris.Whichstatementbythe clientindicatesanedforfurtherinstruction? A. "Ishoulduseoil-basedcosmetics.Correct B. "Ishouldn'tleavemake-uponovernight." C. "Ishouldavoidrub ingmyfacevigorously." D. "Ishouldwashmyfacetwoorthre timesadaywithamildcleanser." 214ID: Oralcandidiasis(thrush)developsinaclientinfectedwithHIV,andthenurseprovidesinstructionto theclientaboutmeasurestorelievethediscomfort.Whichstatementbytheclientindicatesane d forfurtherinstruction? A. "Ishouldavoidspicyfo ds." B. "Ishouldeatfo dswithasoftexture." C. "Ishoulduseasoft-bristledtothbrush." D. "Ishouldputiceinmydrinkstohelpsothethediscomfort.Correct 215ID: AclientwithHIVinfectionwhohasbe nfoundtohavehistoplasmosisisbeingtreatedwith intravenousamphotericinB(Fungizone).Whichparameterdoesthenursechecktodetecthemost commonadverseeffectofthismedication? A. Temperature B. Blo dpresure C. Peripheralpulses D. Intakeandoutpu Correct 216ID: Ahospitalizedclientscheduledforsurgeryistoldbythephysicianthatsheisextremelyanemicand wilnedablo dtransfusion.Theclient,aJehovah'sWitnes,telsthenursethatsheisrefusingthe transfusion.Whatisthemostap ropriateinitialnursingaction? A. Sup ortingtheclient'sdecisiontorefusethetransfusionCorrect B. Teachingtheclientwaystoincreasedietaryintakeofiron C. Telingtheclientaboutheimportanceoftheblo dtransfusion D. Telingtheclienthatifsherefusestheblo dtransfusion,thesurgerywilhavetobe canceled 217ID: AnurseisperforminganasesmentofaclientwithMénièredisease.Whichquestiondoesthe nurseasktoelicitdataabouthemanifestationsofthisdisease? A. "Doyouhaveheadaches?" B. "Haveyouhadanylos ofap etite?" C. "Doyouhaveepisodesofdizines? Correct D. "Haveyoube nhavinganydiarrhea?" 218ID: Aclientwithchronicbackpainasksanurseaboutheuseofcomplementaryandalternative therapiestotreathepain.Thenursewouldinitialy: A. Identifytheclient'streatmentgoalCorrect B. Sharecurrentresearchoutcomeswiththeclient C. Offeroptionsthatmaybebeneficialtotheclient D. Teltheclienthathephysiciandoesnotbelieveinthesetherapies 219ID: Aclienthasbenscheduledforanelectronystagmography(ENG),andthenurseprovides instructionstotheclientabouthetest.Whichstatementbytheclientelsthenursethatheclient understandstheinstructions? A. "Ine dtonotdrinkcoffe beforethetest.Correct B. "I’lne dtoreceivesedationbeforethetest." C. "Iwon’tbeabletoeatfor24hoursafterthetest." D. "Icaneatalightbreakfastonthemorningofthetest." 2 0ID: Anemergencydepartmentnursehasaphysician'sprescriptiontoirrigateaclient'sears.Listinorder ofprioritythestepsthathenurseshouldtakeinperformingthisprocedure. Correct 1. Useanotoscopetoensurethathetympanicmembraneisintact. 2. Warm tapwatertobodytemperature. 3. Filanirrigatingsyringewithwarm water. 4. Insertheirrigatingsolutionbydirectingthesolutiontowardthewaloftheearcanal. 5. Documenthecompletionoftheprocedureandhowtheclientoleratedit. 2 1ID: Acommunityhealthnurseispreparingaposterforahealthfairthatwilincludeinformationabouthe waystopreventearinfectionoreartrauma.Whichpreventionmeasuresdoesthenurseincludeon theposter?Selectallthatapply. A. Alwayssnezewiththemouthclosed. B. Ocludeonenostrilwhenblowingthenose. C. Ke pthevolumeofheadphonesathelowestseting Correct D. Avoidenvironmentalconditionsinvolvingrapidchangesinairpresure Correct E. CleantheexternalearandcanaldailyintheshowerorwhilewashingthehairCorrect F. Becautiouswhenusingcoton-tip edap licatorstocleantheexternalearcanal. 2 2ID: Anurseasignsanursingasistantocareforaclientwhoishearingimpairedandprovides instructionstothenursingasistantaboutheeffectivemethodsforcommunicatingwiththeclient. Whichstatementbythenursingasistantindicatesthatfurtherinstructionisne ded? A. "Ishouldspeakslowlyandclearlytotheclient." B. "IshouldstanddirectlyinfrontoftheclientwhenI’m talking." C. "Ishouldmakesurethathero m iswelitwhenI’m talkingtotheclient." D. "Ishouldraisethevolumeofmyvoiceandstandontheclient'saffectedsidewhenI’m talkingtohim.Correct 2 3ID: ATensilontestisperformedonaclientwithsuspectedmyastheniagravis.Whichfindingconstitutes apositiveresult? A. Adecreaseinmusclestrength B. Nochangeinmusclestrength C. AnincreaseinmusclestrengthCorrect D. Thepresenceoftremorsinpreviouslyweakenedmuscles 2 4ID: Aclientwithmyastheniagraviswhohasbe ntakingpyridostigminebromide(Mestinon)forthe treatmentofthedisordercomestotheemergencydepartmentcomplainingofseveremuscle weaknes,andcholinergiccrisisisdiagnosed.Whichmedicationdoesthenursepreparefor immediateuseintreatingthecrisis? A. AtropinesulfateCorrect B. Carisoprodol(Soma) C. Cyanocobalamin(vitaminB12) D. Cyclobenzaprinehydrochloride(Flexeril) 2 5ID: AnurseprovidesinformationaboutactivityandexercisetothewifeofaclientwithParkinson's disease.Whichstatementbythespouseindicatesanedforfurtherinstruction? A. "Hene dstohaveabroadbaseofsup ortwhenambulating." B. "Hene dstoavoidstayinginonepositionforaprolongedperiod." C. "Ishouldencouragehim toke phishandshangingathissidewhenhe walks.Correct D. "Ishouldhelphim perform range-of-motionexercisesofhisjointsthre timesaday." 2 6ID: Anurseiscaringforaclientwhohashadastrokeandisexperiencinghemianopsia.Whichofthe folowingmeasuresdoesthenursetakeinthecareoftheclient? A. Ap roachingtheclientfrom thesideofnonintactvision B. Teachingtheclientomovetheheadfrom sidetoside(scan)wheneatingCorrect C. Placingobjectsnededforself-carewithintheclient'snonintactvisualfield D. Positioningtheclientinthero m sothathisnonintactvisualfieldfacesthedor 2 7ID: Anursehasprovidedinformationaboutexercisetoaclientwithadiagnosisofdegenerativejoint disease(osteoarthritis).Whichofthefolowingtypesofexercisedoesthenursetelthecliento avoid? A. High-impactexerciseCorrect B. Swimmingandwaterexercise C. Dailyrange-of-motionexercises D. Regularexercisewithwarm-upandco l-downsesions 2 8ID: Aclientwithschizophreniasaystothenurse,"Idecidednototakemymedicationbecauseitcan't help.Iam theonlyonewhocanhelpme."Whichnursingresponseistherapeuticinthissituation? A. "Onlyyoucanhelp?" B. "Youdecidednototakeyourmedication?" C. "Ifyoucanmakethatobservation,youprobablydon'tne dyourmedicationany longer." D. "Yourdoctorwantsyoutocontinuethismedicationbecauseit’shelpingyou.Doyou recalne dingtobehospitalizedbecauseyoustop edyourmedication? Correct 2 9ID: Anursepreparestoadministerdigoxin(Lanoxin)toaclientwithcongestiveheartfailure.Whichvital signmustbecheckedbeforethemedicationisadministered? A. Temperature B. Respirations C. ApicalpulseCorrect D. Blo dpresure 230ID: Anursepreparingtoadministerdigoxin(Lanoxin)toaclientcalsthelaboratoryfortheresultofthe digoxinasayperformedonaspecimenthatwasdrawnat6a.m.Thelaboratoryreportsthathe resultwas2.4ng/mL.Onthebasisofthisresult,thenursewould: A. ContacthephysicianCorrect B. Administerthedigoxin C. Waitforthephysiciantomakeroundsandreportheresult D. Checktheclient'sapicalheartrateandadministerthedigoxiniftherateisfasterthan 60beats/min 231ID: Anursetranscribingtheprescriptionsofaclientadmitedtothenursingunitnotesthatmetformin (Glucophage)850mg/dayhasbe nprescribed.Thenursemakesanoteintheclient'smedication recordthathemedicationshouldbeadministered: A. Atno n B. Withsup er C. WiththemorningmeaCorrect D. Withthemidafterno nsnack 232ID: Thewifeofaclientwithdiabetesmelituscalsthenurseandreportsthatherhusband'sblo d glucoselevelis60mg/dLandthatherhusbandisawakebutgrog y.Thenursetelstheclient'swife toimmediately: A. Calthephysician B. Administerglucagonhydrochloride(Glucagon) C. Calanambulancetobringherhusbandtotheemergencydepartment D. Placesomehoneyinherhusband'smouth,betwe nhisgumsandche Correct 23 ID: Aclientwithtype1diabetesmelitusisinstructedbythephysiciantoobtainglucagonhydrochloride (Glucagon)foremergencyhomeuse.Thenurseprovidesinformationtotheclient'swifeabouthe medication.Whichstatementbytheclient’swifeindicatesthatsheunderstandstheinformation? A. "Ine dtostorethismedicationinthefre zer." B. "Iknowthathisisusedtotreatepisodesofhighblo dsugar." C. "Icangivethismedicationinsteadofinsulinifhisinsulinrunsout." D. "Ine dtogivethisifhehassignsoflowblo dsugarandgoesintoacoma.Correct 234ID: Aclientwithhypoparathyroidism istakingcalcium gluconatetotreathypocalcemia.Theclientcals theclinicnurseandcomplainsofbecomingconstipatedsincestartingthemedication.Thenurse telsthecliento: A. Stopthemedication B. Contacthephysicianimmediately C. Increaseintakeofhigh-fiberfo d Correct D. Ad ahalf-ounceofmineraloiltothedailydiet 235-Aclienthasaphysician'sap ointmentogetaprescriptionforsildenafil(Viagra).Thenurse obtainsthehealthhistoryfrom theclient.Whichfindingindicatesthathemedicationis contraindicated? A. Theclienthastype2diabetesmelitus. B. Theclienthasahistoryofrenalcalculi. C. Theclientistakingglargine(Lantus)insulin. D. Theclientakesisosorbidedinitrate(Isordil)Correct 236ID: Vasopresin(Pitresin)isprescribedtoaclientwithdiabetesinsipidus.Forwhichsign,indicativeof anadverseeffectofthemedication,doesthenursemonitortheclient? A. ChestpainCorrect B. Constipation C. Los ofap etite D. Decreasedurineoutput 237.ID: Desmopresin(DDAVP)isprescribedtoaclientwithdiabetesinsipidus.Whichparameterdoesthe nurseteltheclienthatitisimportantomonitorwhilesheistakingthemedication? A. Ap etite B. Pulserate C. Bowelpatern D. Intakeandoutpu Correct 238ID: Warfarinsodium (Coumadin)isprescribedforahospitalizedclient.Whiletranscribingthephysician's prescription,thenursenotesthatheclientistakinglevothyroxine(Synthroid)totreathypothyroidism. Thenursecalsthephysiciantoconfirm theprescriptionforwarfarinsodium because: A. Warfarinsodium amplifiestheeffectoflevothyroxine B. Levothyroxineamplifiestheeffectofwarfarinsodium Correct C. Warfarinsodium iscontraindicatedwiththeuseoflevothyroxine D. Aseverealergicreactionmayocurifwarfarinsodium isadministeredconcurrently withlevothyroxine 239ID: Iodinesolution(Lugolsolution)isprescribedtoaclientwhoisscheduledforsubtotalthyroidectomy. Theclientcalsthenurseatheclinicandcomplainsofaburningsensationinthemouthand sorenes ofthegumsandteth.Thenursemostap ropriatelytelstheclient: A. TocontacthephysicianCorrect B. Thatheseareexpectedsideeffectsofthemedication C. Thathesediscomfortswilresolvewithcontinuedtherapy D. Tostopthemedicationforthenext24hoursandthencontinueasprescribed 240ID: Levothyroxine(Synthroid)isprescribedtoaclientwithhypothyroidism.Onewe kafterbegin ingthe medication,theclientcalsthephysician'sofficeandtelsthenursethathemedicationhasnot helped.Thenursemostap ropriatelytelstheclienthat: A. Themedicationwilne dtobechanged B. Thefultherapeuticeffectmaytake4we k Correct C. Anaditionalmedicationwilhavetobead edtotheregimen D. Theblodlevelsoftheclient’sthyroidhormoneswilne dtoberechecked 241ID: Anurseprovidesinstructionstoaclientwhowilbetakinglevothyroxine(Synthroid)for hypothyroidism.Thenursetelstheclienthatitisbestotakethemedication: A. Withmilk B. Atbedtime C. Withanantacid D. Inthemorning,beforebreakfasCorrect 242ID: Aclientisbroughtotheemergencydepartmentbyambulance,anddiabeticketoacidosisis suspected.Blo dsamplesaretaken,andthenurseobtainssup liesthatwilbene dedtotreathe client.Whichtypeofinsulindoesthenursetakefrom themedicationsup lyro m forintravenous (IV)administration? A. NPH(HumulinN) B. Lente(HumulinL) C. Regular(HumulinR Correct D. NPH/regular50%/50% (Humulin50/50) 243ID: AhomecarenurseprefilssyringescontainingNPH(HumulinN)andregular(HumulinR)insulinfor aclientwithdiabetesmelituswhowilbeadministeringhisowninsulinbuthasdifficultyseingand acuratelypreparingdoses.Thenurseplacesthemedicationintheclient'srefrigeratorwiththe syringes: A. Lyingflat B. Inahorizontalposition C. Inaverticalpositionwiththene dlespointingupCorrect D. Inaverticalpositionwiththene dlespointingdown 24 ID: Tolbutamide(Orinase)isprescribedtoaclientwhosetype2diabetesmelitushasnotben controledwithdietandexercisealone.Thenurseprovidesinstructionstotheclientabouthe medication.Whichstatementbytheclientindicatesane dforfurtherinstruction? A. "Ine dtomaintainmyexerciseprogram." B. "Ine dtostayonmycalorie-restricteddiet." C. "Icantakethemedicationwithfo difitupsetsmystomach." D. "Icanhaveabe rorglas ofwineaslongasIstaywithinmydailydietary restrictions.Correct 245ID: Anurseistranscribingaphysician'sprescriptionfororalprednisone5mg/daythatwaswriteninthe chartofaclientwithtype2diabetesmelituswhoisalreadytakinganoralhypoglycemicmedication. Thenursecontactsthephysiciantoaskaboutheprescriptionbecause: A. Prednisonecanlowertheblo dglucoselevel B. Prednisonecanincreasetheblo dglucoseleveCorrect C. Prednisoneiscontraindicatedwiththeuseoforalhypoglycemicmedications D. Forprednisonetobeeffectiveinaclientakinganoralhypoglycemicagent,ahigher dosageofprednisoneisrequired 246ID: Oralprednisone10mg/dayisprescribedforaclientwithanacuteexacerbationofrheumatoid arthritis.Thenurse,providinginformationtotheclientabouthemedication,telstheclienthatitis bestotakeit: A. Atbedtime B. Withlunch C. Intheevening,after9p.m. D. Inthemorning,before9:0 a.m Correct 247ID: Achildwithgrowthhormonedeficiencywilbereceivingsomatropin(Humatrope).Thenurse providesinformationtothemotherabouthemedication.Whichofthefolowinglaboratoryvalues doesthenursetelthemotherwilrequiremonitoring? A. Creatinine B. Hemoglobin C. Blo dureanitrogen(BUN) D. Thyroid-stimulatinghormone(TSH Correct 248ID: Laboratorystudiesareperformedonaclientwithsuspectedsickleceldisease,andelectrophoresis revealsalargepercentageofhemoglobinS(HbS).Whichad itionalaboratoryfindingwilthenurse expectonotethatisacharacteristicofthisdisease? A. Lowreticulocytecount B. Lowtotalbilirubinlevel C. Increasedhematocritcount D. Increasedwhiteblodcel(WBC)coun Correct 249ID: Aclientbeingseninthecliniccomplainsofatigueandweaknes.Laboratorystudiesare performedbecausethephysiciansuspectsiron-deficiencyanemia.Whichfindingindicativeofthis typeofanemiadoesthenurseexpectofindonreviewingthelaboratoryresults? A. AnincreasedRBCcount B. Anincreasedhematocritlevel C. Anincreasedhemoglobinlevel D. Microcyticredblo dcels(RBCs Correct 250ID: Alendronate(Fosamax)isprescribedforaclientwithpostmenopausalosteoporosis.Thenurse providesinformationonthemedicationtotheclient.Whendoesthenurseteltheclientotakethe alendronate? A. Atbedtime B. Withorangejuice,toenhanceabsorptionatnight C. Everymorningbeforebreakfast,withafulglas ofwate Correct D. Everymorningafterbreakfast,afterwhichtheclientshouldliedownfor30minutes 251ID: Calcium carbonate(Os-Cal50)isprescribedforaclientwithmildhypocalcemia.Whatfo ddoes thenurseinstructheclientoavoidconsumingwhiletakingthismedication? A. Fish B. Milk C. SpinachCorrect D. Watermelon 252ID: Anemergencydepartmentnurseiscaringforaclientinhypovolemicshock,aresultofexternal hemorrhagecausedbyagunshotwound.Whichnursinginterventionsshouldthenursetake?Select allthatapply. A. MaintainingtheclientinahighFowler’sposition B. Checkingtheclient'svitalsignseveryhouruntilstable C. Ensuringthatdirectpresureisap liedtotheexternalhemorrhagesiteCorrect D. Ensuringapatentairwayandsup lyingoxygentotheclientasprescribedCorrect E. Insertinganintravenous(IV)catheterandadministeringfluidsasprescribedCorrect F. Ensuringthathecalbelisinplacefortheclient'susewhenthenurseisoutofthe ro m 253ID: AchildwithadiagnosisofWilms’tumorisbeingadmitedtothepediatricunit.Thenurseprepares thero m forthechildandplacesasignathechild'sbedsidethatelsstafftoavoid: A. PalpatingtheabdomenCorrect B. Takingtemperaturesrectaly C. Turningthechildtotherightside D. Measuringblo dpresureintherightarm 254ID: Aclientwithmultiplesclerosishasbe nstartedonbaclofen(Lioresal)formusclespasms.Theclient calsthephysician'soffice1wekafterbegin ingthemedicationandtelsthenursethatshefels extremelydrowsy.Thenursemostap ropriatelytelstheclient: A. Thatshewilne dtobesenbythephysician B. Thathemedicationwilne dtobediscontinued C. Thatdrowsines usualydiminisheswithcontinuedtherap Correct D. Tostopthemedicationfor2daysandthenresumeitatheprescribeddosage 25 ID: Alprazolam (Xanax)isprescribedforaclientotreatananxietydisorder.Whichsideeffectdoesthe nursewarntheclientof? A. Headache B. Urineretention C. Lightheadednes Correct D. Increasedsalivation 256ID: Viewvideo.Thenurseispreparingtoadministeratubefe dingbywayofanasogastrictube.Which actiondoesthenursecarryoutasaprioritybeforestartingtheflowofthesolution? A. Flushingthetubewith30mLoftapwater B. Checkingurineoutputintheprevious24hours C. Scrubingtheportwithpovidone-iodine(Betadine)solution D. Checkingforgastricresidualvolumeandasesingtubeplacemen Correct 257ID: Anurseiscaringforaclientwhohashadacastapliedtotheleftlegandisatriskforacute compartmentsyndrome.Forwhichearlysignofthiscomplicationdoesthenursemonitortheclient? A. ParesthesiaCorrect B. Cold,bluishtoes C. Weakpedalpulse D. Severepainrelievedbymedication 258ID: Aphysicianwritesaprescriptionfor10 0mLof0.9% normalsalinesolutiontobeadministered intravenously(IV)toaclientover10hours.Thedropfactorfortheinfusionsetis15gt/mL.Atwhat dripratedoesthenursesetheinfusion? Typeanswerintheboxprovided. gt/min Correct 259ID: Anurseisperforminganasesmentofaclientbeingadmitedtothehospitalwithadiagnosisof multiplesclerosis.Theclientelsthenursethatsheto kbaclofen(Lioresal)forthepast9months butcompletelystop edthemedication2daysagobecauseitwasmakingherfelweak.Onthe basisofthisinformation,thenursenotesintheplanofcarethatheclientshouldbemonitoredmost closelyfor: A. Spasticity B. Drowsines C. Musclespasms D. SeizureactivitCorrect 260ID: Anurseiscaringforaclientwhoisimmobilizedinskeletaltractionaftersustainingalegfractureina motorvehiclecrash.Thenursenotesthatheclientisrestles,andtheclientcomplainsofbeing bored.Whichproblem doesthenurseidentifyonthebasisofthisinformation? A. Lackofcontrol B. Lackofphysicalmobility C. LackofadequatediversionalactivitCorrect D. Lackofenergytobatheandfe dself 261ID: Aclientisfoundtohavepostraumaticstres disorder(PTSD)afterwitnesingaterroristatackthat causedthedeathsofhundredsofpeople.Thenurse,developingaplanofcarefortheclient, identifiespostraumasyndromeasaconcernandidentifiesaclientoutcomethatstates,"Theclient wilcopeeffectivelywiththoughtsandfe lingsoftheevent."Whichnursinginterventionswilasist theclientinachievingthisoutcome?Selectallthatapply. A. Beinghonest,nonjudgmental,andempathetiCorrect B. AsesingtheimmediatepostraumaticreactionCorrect C. Encouragingtheclientoke pajournalfocusedonthetraumaCorrect D. Askingtheclientaboutheuseofalcoholanddrugsbeforeandsincethe even Correct E. Promotingdiscusionofthereasonstheclientwasresponsibleforthetraumaticevent F. Discouragingtheuseofsuportgroupsuntiltheclientisabletouseeffectivecoping techniques 262ID: Anursereviewstheresultsofatotalserum calcium determinationinaclientwithrenalfailure.The resultsindicatealevelof12.0mg/dL.Inlightofthisresult,whichfindingdoesthenurseexpecto noteduringasesment? A. Decreasedurineoutput B. Hyperactivebowelsounds C. Bounding,fulperipheralpulse Correct D. Hyperactivede ptendonreflexes 263ID: Anurseispreparingtoprovideinformationtoaclientwhohasbe nfoundtohavestableangina. Thenurseplanstoteltheclienthathistypeofangina: A. Requiressurgicaltreatment B. Canbecuredwithmedication C. Wileventualyne dtobetreatedwithacoronaryarterybypas graft D. Isoftenmanagedmedicalywithmedicationssuchascalcium chan elblockersand beta-blockingmedication Correct 264ID: Whilebeingsenbyaphysician,aclientcomplainsofpersistentfever,malaise,andnightsweats. Onphysicalexamination,thephysicianpalpatesenlargedlymphnodes,andtheclientstatesthathe nodesarepainles.Hodgkin'slymphomaissuspected,andseveraldiagnosticstudiesare performed.Whichcharacteristicofthistypeoflymphomadoesthenurseexpectonotewhile reviewingtheresultsofthediagnosticstudies? A. Blastcelsinthebonemarrow B. Epstein-Barrvirusintheblod C. Increasedblo dureanitrogen(BUN) D. Re d-SternbergcelsonbiopsyofalymphnodeCorrect 265ID: Anurseispreparingmedicationinstructionsforaclientwhowilbetakingadailyoraldoseofdigoxin (Lanoxin)0.25mginthetreatmentofcongestiveheartfailure(CHF).Whichinstructionsshouldthe nurseincludeonthelist?Selectallthatapply. A. Takeyourpulsebeforetakingeachdose Correct B. Avoideatingfo dsthatcontainpotasium C. TakethedigoxinathesametimeeachdayCorrect D. Takethedigoxinwithachewableantacidtopreventnausea. E. Ifyouforgetotakeyourdailydose,doublethedoseonthenextday. F. Notifythephysicianifyouexperiencelos ofap etite,muscleweaknes,orvisual disturbancesCorrect Show Less