Comprehensive - Predictor review

Comprehensive - Predictor review 1. A nurse is assessing a client who has left-sided heart failure. Which of the following symptoms should the nurse identify as the highest priority? Jugular distention Frothy pink sputum Hepatomegaly Weight gain 2. A nurse in the emergency department is assisting with the suturing of a laceration to the client’s face. Which of the following actions should the nurse take? Pour the sterile cleansing solution holding the bottle 10 cm (4 in.) above the sterile field Pull the top flap of the suture tray towards the body when opening. Place the bottle of local anesthetic 5 cm (2 in) inside the sterile field border. Drop the suture package on to the sterile field from a distance of 30 cm (12 in). 3. A nurse is assessing a client 1 hr following delivery and notes that her uterus is boggy and….to the umbilicus. Which of the following actions should the nurse take first? Massage the fundus. Assess lochia Take vital signs Give oxytocin (Pitocin) IV bolus. 4. (missing) 5.. A nurse is caring for a client who is 1 day postoperative following a hypophysectomy for removal of a pituitary tumor. Which of the following findings requires further assessment by the nurse? Urinary output greater than fluid intake Report of dry mouth Glasgow Coma Scale score of 15 Bloody drainage on the nasal dressing measuring 3 cm 6. A nurse in an emergency department is caring for a client who has multiple wounds due to a crash. Which of the following interventions are appropriate? (Select all that apply). Apply direct pressure to bleeding wounds. Clean lacerations and abrasions with hydrogen peroxide. Administer 650 mg aspirin PO as needed for pain. Cover wounds with a sterile dressing Determine date of last tetanus toxoid vaccination. 7. A nurse is planning care for four clients. Which of the following clients is the highest priority? A client who has frequent incontinence A client who has dry, black eschar on the heel A client who has a reddened skin area with blanching around the coccyx A client who is wearing an arm cast and reports numb fingers 8. A nurse is assisting with mass casualty triage following an explosion at a local factory. Which of the clients should the nurse identify as the priority? A client who has massive head trauma A client who has an open fracture of the lower extremity A client who has full-thickness burns to the face and trunk A client who has indication of hypovolemic shock 9. A nurse is planning care for a newly admitted adolescent client who has bacterial meningitis. Which of the following instructions is appropriate for the nurse to include in the plan of care? Assist the client to a supine position. Recommend prophylactic acyclovir (Zovirax) for the client's family. Initiate droplet precautions for the client. Perform a Glasgow Coma Scale every 24 hr. 10. A nurse is caring for a client who is unconscious and has an advanced directive indicating no extraordinary measures. The client's son wants everything possible done for his father. Which of the following is an appropriate statement by the nurse? "I will notify the health care provider of your wishes." "Have you talked about this with your family?" _X_ "We have to honor your father's wishes." "Have you discussed this with your minister?" 11. A nurse is assessing a client brought to the hospital's psychiatric emergency services by a law enforcement officer. The client has disorganized, incoherent speech with loose associations and religious content. The nurse recognizes these signs and symptoms as being consistent with which of the following? Alzheimer's disease Depression Substance intoxication X Schizophrenia 12. A nurse is caring for a client who has a stool culture that is positive for Clostridium difficile (C. difficile) of the following infection control precautions is appropriate? Place the client in a negative pressure room. _X Place the client in a private room Wear a face shield prior to entering the room. Use an alcohol-based hand rub following client care. 13. A nurse is caring for a client who sprained his left ankle 12 hr. ago. Which of the following orders given by the provider should the nurse clarify? Elevate the affected extremity using two pillows. Apply heat to the affected extremity for 45 min. on and then 45 min off. Assess the affected extremity for sensation, movements and pulse every 4 hr. Wrap the affected extremity with a compression dressing. 14. A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions should the nurse plan to take? Remove the disposable gown after leaving the toddler's room. Place the toddler in a room with negative air pressure. Use a designated stethoscope when caring for the toddler. Wear an N95 respiratory mask while caring for the toddler. 15. A nurse is developing a discharge care plan for a client who has osteoporosis. To prevent injury, the nurse should instruct the client to avoid sitting in one position for prolonged periods. avoid crossing the legs beyond the midline. splint the affected area. X_ perform weightbearing exercises. 16. A nurse receives a change-of-shift report on four clients. Based on the shift report information, which of the following clients should the nurse plan to assess first? A client who had a barium enema 2 days ago and reports constipation A client who has anorexia and peripheral edema. A client who has Addison's disease with a blood glucose level of 75 mg/dL A client who had a hip arthroplasty reports and erythema in his calf. 17. A nurse working in a long-term care facility is caring for an older adult client who has dementia. The client is often agitated and frequently wanders the halls. which of the following interventions should the nurse include in the plan of care? Maintain nutritional requirements by offering finger foods Confront the client regarding unacceptable behavior. Stimulate the client by leaving the television on throughout the day. Give the client several choices when scheduling activities. 18. A nurse is planning care for a client who has a new diagnosis of dysphagia. Which of the foods should be included when initiating feeding? ---- Toast -----Oatmeal ------Beef Broth ------Apple juice 19. A Nurse is performing a skin assessment on a client with risk factors for Development of skin cancer. The nurse should understand that a suspicious lesion is ? -X--asymmetric, with variegated coloring ---brown, with a wart-like texture ---firm and rubbery ---scaly and red 20. A nurse is providing dietary teaching for a client who has hepatic encephalopathy. Which of the following food selections indicates the client understands the teaching ? ---Rice with black beans ---three-eggs omelet with low-sodium ham ---turkey sandwich and milkshake ---Cottage cheese and tuna on lettuce 21. A nurse is caring for a client who has just received the first dose of Lisinopril (Zestril) which is the appropriate nursing intervention ? ---Monitor the client's oxygen saturation. ---Place the client on continuous cardiac monitoring. ---Encourage foods high in potassium. -x--Provide standby assist when the client gets up from bed 22. A Charge nurse is providing teaching to a newly licensed nurse on how to clean up surface contaminated with blood .Which of the following agents should the nurse include in the teaching ? ---Isopropyl alcohol ---Chlorine bleach ---Hydrogen peroxide ---Chlorhexidine 23 (missing) 24. A nurse is receiving report on four clients. Which of the following clients should the nurse assess first? --- A client who has an ileal conduit and mucus in the pouch ---A client who had a transurethral resection of the prostate (TURP) with red-tinged urine in the Bag ---A client who has an arteriovenous fistula that vibrates when palpated ---A client who has chronic kidney disease with cloudy dialyze outflow 25. A nurse in an emergency department is performing a neurologic assessment on a client who has a close head injury. Which of the following cranial nerves should the nurse assess to determine if the client has impaired peripheral vision? ---Seventh cranial nerve ---Eighth cranial nerve ---Tenth cranial nerve ---Second cranial nerve 26. A nurse is obtaining informed consent from a client who is to begin chemotherapy. The client asks if she will be able to have children after completion of the treatment .Which of the following is an appropriate response by the nurse? ---I will have the oncologist return to answer your questions. ---You should focus on your treatment at this time. ---I will give you written information about the risks of chemotherapy ---Chemotherapy has risk of causing infertility 28. A nurse is caring in a mental health facility. The client's daughter is crying and tells the nurse that she feels guilty for leaving her father in the hospital. Which of the following is an appropriate response? ---I'm sure your father doesn't blame you ---Why are you feeling this way -x--I'd like to know more about what's bothering you ---You did the right thing by bringing him here 29. A nurse is planning to provide teaching to a young adult client who has insomnia, Which of the following should the nurse include in the teaching ? ---Keep bedroom cool at night ---Consume a high-carbohydrate snack at bedtime ---Take s short nap during the day ---Exercise an hour before bedtime 30 (missing) 31. A nurse is discussing the social character of play with the parents of a 5 year old. Which of the following should be included when discussing associative play ? ---Playing a board game with other children ---Playing dolls with another child ---Watches others children perform a puppet show ---plays alone while stacking blocks 32. A nurse is caring for a school age child following a cardiac catheterization . which of the following is the priority nursing action? ---Reinforce the dressing at the insertion site ---Check the child's pulse distal to the insertion site ---Assist the child to void ---Offer clear liquid to the child 33. A nurse on a medical-surgical unit is receiving report on four client which of the following client should the nurse assess first ? --- a client who is receiving warfarin (Coumadin) and has am INR of 3.3 --- A client who has acute kidney injury ,a creatinine of 4 mg/dL and BUN of 52 mg / dL --- A client who had a NG tube inserted 6 hr ago and has abdominal distention X-- A client who is 4 hr postoperative following a thyroidectomy and reports fullness in the back of the throat. 34 (missing) 35. A client who is 8 hr postpartum asks the nurse if she will need to receive Rh immune globulin (RhoGAM) the client is gravida 2, para 2, and her blood type is AB negative .The newborn's blood type is B positive. Which of the following statement is a appropriate? ---You should receive Rhogam within 72 hours of delivery ---Rhogam is not necessary since this is your second pregnancy ---You only need to receive Rhogam if you have a positive blood type ---Both you and your baby should receive Rhogam at your 6-weeks appt 36. A nurse is caring form an older adult client who has a prescription for sertraline (Zoloft) to treat depression, Which of the following statements by the client indicates an understanding of the medication treatment plan? ---I will be able to stop taking this medication when I feel better ---I understand I may experience difficulty sleeping while on this medication ---I should decrease my sodium intake while on this medication ---I can expect to urinate frequently while on this medication 37. A nurse is teaching a client who has type2 diabetes mellitus is to start therapy with glipizide (Glucotrol) before meals? Which of the following findings should the nurse instruct the client to monitor and report to the provider? ---Bleeding gums ---Dry couch ---Palpitations ---Insomnia 38. A nurse in an emergency department is serving on a committee that is reviewing the facility protocol for disaster readiness .The nurse should recommend that the protocol include which of the following as a clinical manifestation of smallpox? ---descending paralysis ---ptosis of the eyelids ---bloody diarrhea ---Rash in the mouth 39 (missing) 40. A nurse is providing teaching to a client who has esophageal cancer and is scheduled to start radiation therapy. Which of the following should the nurse include in the teaching ? ---Apply a warm compress to the irradiated site ---Use a washcloth to bathe the treatment area --- Wear clothing over the area of radiation treatment ---Remove dye marking after each radiation treatment 41. A nurse is obtaining the medical history of a client who has a new prescription for isosorbide mononitrate (Imdur) Which of the following should the nurse identify as a contraindication to the medication? ---Glaucoma ---Hypertension ---Migraine headaches ---Polycythemia 42. A nurse administers a dose of metoclopramide (Reglan) to a client prior to a chemotherapy treatment the client develops uncontrolled contractions of the head and neck muscle .Which of following medication should the nurse administer? ---Diphenhydramine (Benadryl) ---Hydromorphone (Dilaudid ) ---Amitriptyline (Elavil ) ---Albuterol sulfate (Proair HFA) 43 A nurse is performing change -of-shift assessments on four clients . Which of the following findings should the nurse report to the provider first ? ---A client who has gastroenteritis and lethargic and confused ---A client who has cystic fibrosis and has a thick productive cough and reports thirst -x--A client who has sickle cell anemia and reports pain 15 min after receiving oral analgesic ---A client who has diabetes mellitus and has a morning fasting capillary glucose of 185 mg/dL 44. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following intervention should the nurse perform ? ---Position the head of the bed at 30o during the feeding ---Mix the client's medications with the tube feedings ---Give 100mL of water with every feeding ----Obtain gastric residuals every 24hr 45. A nurse is completing a dietary assessment for a client who is Jewish and observes kosher dietary practices. Which of the following behaviors should the nurse expect to find? Fasting from meat occurs during Hanukkah. Shellfish is commonly consumed in the diet. Meat and dairy products are eaten separately. Leavened bread may be eaten during Passover. 46. A nurse is conducting an in-service for a group of nurses who work in the emergency department. For which of the following childhood diseases should the nurse initiate airborne precautions? Mumps Whooping cough Scabies Measles 47. A nurse is caring for a full-term newborn immediately following delivery. Which of the following actions should the nurse take first? Weigh the newborn. Instill erythromycin ophthalmic ointment in the newborn's eyes. Place identification bracelets on the newborn. Dry the newborn. 48. A nurse is caring for four clients. Which of the following clients should the nurse care for first? A client who had an appendectomy 2 days ago and has diminished bowel sounds A client who has hypothyroidism and is stuporous A client who received a chemotherapy treatment and reports nausea A client who has a burn requiring a sterile dressing change 49. A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an assistive personnel? A client who had a cerebrovascular accident 2 days ago and needs help toileting. A client who had a myocardial infarction 3 days ago and reports chest discomfort A client who has awoken following a bronchoscopy and requests a drink A client who has chronic obstructive pulmonary disease and needs guidance on incentive spirometry 50. A nurse is providing discharge instructions about engorgement for a client who has decided not to breastfeed. Which of the following statement by the clients indicates a need for further instruction by the nurse? "I will apply cold compresses to my breasts." "I will manually express breast milk." "I can wear a support bra." "I can take a mild analgesic." 51. A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood pressure. The nurse should recognize that these findings are potential manifestations of which of the following? Alcohol withdrawal Heroin intoxication Amphetamine intoxication Nicotine withdrawal 52. A nurse is preparing to administer 2.5 mL of medication intramuscularly to an adult client. Which of the following is the safest site for the nurse to use? Rectus femoris Dorsogluteal Ventrogluteal Vastus lateralis 53. A nurse is preparing to discharge a client who is to be transferred to a long-term care facility. The nurse recognizes that which of the following actions is a breach of client confidentiality? Providing a verbal report of the client's status to a paramedic performing the transfer Leaving a phone message for the provider regarding the status of the client's transfer Faxing the client's medical records to the long-term care facility Discussing the client's reaction to the transfer with another staff nurse 54 (missing) 55. A nurse from the State Health Department is instructing a group of nurses regarding reportable infections. Which of the following infections should the nurse report to the CDC? Staphylococcus aureus Lyme disease Herpes simplex virus 2 Candida albicans 56. A nurse is assessing an older adult client who has a prescription for celecoxib (Celebrex) daily. Which of the following clinical findings demonstrates the medication is effective? Decrease in pain Reduction in fever Absence of bruising Relief of GI distress 57. A nurse is working in the emergency department. Which of the following triaged clients should the nurse assess first? An older adult client who has a blood glucose of 250 mg/dL and numbness in both feet A client who reports urinary frequency, burning and hematuria A client who has a headache and a blood pressure of 180/104 mm Hg An older adult client who has had vomiting and diarrhea for 2 days 58. A nurse is planning care for an adolescent who has chronic renal failure. Which of the following actions should the nurse include in the plan of care? Ensure increased fluid intake Restrict protein intake to the RDA Provide a diet high in potassium Encourage a diet high in calcium 59. A nurse is observing bonding between a client and her newborn. Which of the following actions by the client will require the nurse to intervene? Asking the father to change the newborn's diaper. Requesting the nurse take the newborn to the nursery so she can rest Viewing the newborn's actions to be uncooperative Holding the newborn in an en face position 60. A nurse is caring for a male adolescent client who has heart failure. Based on the client's chart findings, which of the following actions should the nurse plan to take? (Click on the "Exhibit" button below to review the chart. There are three tabs that contain separate categories of data.) Withhold digoxin (Lanoxin). Withhold spironolactone (Aldactone). Administer ferrous sulfate (Feosol). Administer furosemide (Lasix). 61. A nurse is caring for a client undergoing chemotherapy treatments. The client tells the nurse he no longer wishes to undergo chemotherapy. Which of the following statements by the nurse is appropriate? "You have the right to make that choice." "You should talk with other clients undergoing chemotherapy before making this decisions." "Have you talked with the chaplain about your decision to stop chemotherapy?" "You will need to discuss your decision with your family." 62. A charge nurse is discussing the use of applying ice to a client's injured knee with a newly licensed nurse. Which of the following should the nurse identify as a benefit? Increased cellular metabolism Vasodilation Systemic anesthetic effect Decreased capillary permeability 63. A nurse is admitting an older adult client to a medical-surgical unit. Which of the following findings should the nurse report as an indicator of possible abuse? Senile lentigo are present on the hands and forearms. Chafing is present on the client's lower legs The client requests medication for abdominal pain. The client reports frequent disagreements with her daughter. 64. A nurse is reviewing the results of an ABG performed on a client with chronic emphysema. Which of the following results suggests the need for further treatment? HCO3 level of 25 mEq/L pH level of 7.37 PaO2 level of 89 mm Hg X_ PaCO2 level of 55 mm HG 65. A nurse is teaching a client about a new prescription for lisinopril (Zestril). Which of the following should the nurse include in the teaching? Monitor for increased urination Anticipate a dry cough Monitor pulse rate daily Increase intake of green leafy, vegetables. 66. A nurse assesses an older adult client with decreased caloric intake and weight loss. Which of the following findings should the nurse report to the provider immediately? The client reports a burning sensation in the epigastric area. The client experiences a drop in oxygen saturation to 91% while eating The client reports abdominal pain at a 5 on a scale of 0 to 10 The client experiences coughing and wheezing after eating. 67. A nurse is assessing a client who has the following vital signs: oral temperature 37.2 o (99o), apical pulse rate 80/min, radial pulse rate 62/min, respiratory rate 16/min, and blood pressure 132/40 mm Hg. What is the client's pulse pressure? 92 is the pulse pressure_ mm Hg 68. A client who is having suicidal thoughts tells the nurse, "It just does not seem worth it anymore. why not end my misery ?" Which of the following responses by the nurse is appropriate? Why do you think your life is not worth it anymore? X_ Do you have a plan to end your life? You can trust me and tell me what you are thinking I need to know what you mean by misery. 69. A nurse is planning care for a client who has Alzheimer's disease and demonstrates confusion and wandering behavior. Which of the following should the nurse include in the plan of care? Place the client in seclusion when she is confused. Leave one side rail up on the client's bed Dim the lighting in the clients room Request a prescription for PRN restraints when the client is wandering 70. A nurse manager is preparing an educational program on infection control measures. Which of the following should the nurse include when discussing contact precautions? Scarlet fever Herpes simplex Varicella Streptococcal pharyngitis 71. A nurse is taking a medication history from client who has type 2 diabetes mellitus and is scheduled for an arteriogram. Which of the following medications should the nurse instruct the client to discontinue 48 hr. prior to the procedure? Digoxin (Lanoxin) Metformin (Glucophage) Nifedipine (Adalat) Atorvastatin (Lipitor) 72. A nurse is caring for an infant who is postoperative cleft lip and palate repair. Which of the following is an appropriate action for the nurse to take? Place upright in an infant seat. Clean the wound with 1/2 strength hydrogen peroxide Suction frequently Position the infant supine. 73. A nurse is caring for a client who is taking allopurinol (Zyloprim.) The nurse should monitor which of the following laboratory findings to determine the effectiveness of the medication? Serum albumin Magnesium level Uric acid level Serum chloride 74. A nurse is assessing a client in the PACU. Which of the following findings indicates decreased cardiac output? Oliguria Bradypnea Constricted pupils Shivering 75. A nurse is caring for a 7 month old infant who is being treated for severe dehydration. Which of the following assessment findings indicates treatment has been effective? Cool, mottled skin Flat anterior fontanel Skin turgor displays tenting Hyperpnea 76. A client at 38 weeks of gestation enters the emergency department. The nurse should recognize that which of the following indicates that the client is in the latent phase of labor? contractions are 2 to 3 min apart. The cervix is dilated 2 cm The client reports nausea and vomiting. The client reports the urge to push 77. A nurse is providing nutritional teaching to a school-age child who has cystic fibrosis. the nurse should instruct the client to increase enzyme intake prior to consuming which of the following foods? Peanut butter Peach Oatmeal Plain yogurt 78. A nurse is planning to perform a heel stick on a neonate. which of the following actions is appropriate to reduce discomfort during the procedure? apply topical diphenhydramine (Benadryl) prior to the procedure. Gently massage the neonate's heel following the procedure Allow the mother to hold the neonate using skin to skin contact during the procedure. Place an ice pack on the heel 5 min before the procedure. 79. A nurse is caring for a client who is in labor and receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. which of the following should the nurse expect? Head compression Abruptio placentae Fetal hypoxia Post maturity 80. A nurse is caring for a client who has diabetes insipidus and is receiving desmopressin (DDAVP). Which of the following should the nurse monitor? Weight Carbohydrate intake Hematocrit Fasting blood glucose 81. (missing) 82. A nurse is caring for a client who has a prescription for vancomycin (Vancocin) 1 g IV every 12 hr. The client is scheduled to have the morning dose at 0700. the nurse should schedule the trough level to be drawn at which of the following times? 1300 1800 2100 0900 83. A nurse is providing teaching to a client who has mild persistent asthma and has just been prescribed montelukast (Singulair). Which of the following statements should the nurse include in the teaching? This medication helps decrease swelling and mucous production This medication can be used to help when you are having an acute asthma attack This medication should be taken before exercise or physical activity. This medication should be taken for 10 days and then gradually discontinued. 84. A nurse is caring for a client who has lactose intolerance and has eliminated dairy products from his diet. the nurse should instruct the client to increase consumption of which of the following foods? Carrots Ground beef Spinach Peanut butter 85. A nurse is caring for a child who has infectious mononucleosis. Which of the following findings are associated with this diagnosis? (Select all that apply). Splenomegaly Vertigo Sore throat Koplik spots Malaise 86. A nurse is planning non-pharmacological pain management for a preschool child. Which of the following actions should the nurse take when using relaxation techniques? Use a rocking motion while holding the child. Have the child blow bubbles. Give the child a sticker following the procedure. Ask the child to describe a favorite activity. 87. A nurse is caring for a client who has been taking haloperidol (Haldol) for several years. Which of the following assessment finding should the nurse recognize as a long-term side effect of this medication? lip smacking Clang association Agranulocytosis Alopecia 88. A nurse has been caring for a female client who has bruises on her arms that she explains are a result of physical abuse by her husband. The client states, "I don't know how much longer I can take this, but I'm afraid he'll really hurt me if I leave." Which of the following is an appropriate nursing intervention? Help the client to recognize the signs of escalation of abusive behavior. Insist that the client report the abusive behavior to the proper authority. Offer to speak to the client's husband regarding his abusive behavior. Assist the client to identify personal behaviors that trigger abusive behavior 89. A nurse is preparing to administer a measles, mumps, rubella (MMR) immunization to a child. Which of the following is a contraindication for administration? Minor acute illness Recent blood transfusion Low grade fever Allergy to penicillin 90. A nurse is caring for a client recovering from bowel surgery who has a nasogastric (NG) tube connected to low intermittent suction. Which of the following assessment finding s should indicate to the nurse that the NG tube may not be functioning properly? Drainage fluid is greenish-yellow Abdominal rigidity Air bubbles noted in the NG tube Aspirate pH of 3 91. A nurse is planning care for a child who has increased intracranial pressure with a decrease in level of consciousness. Which of the following interventions should the nurse include in the plan of care? Maintain the head at a midline position. Perform active range-of-motion exercises. Perform neurological checks every 4 hr. Suction the airway frequently. 92. A nurse is caring for a group of clients. Which of the following clients should the nurse assess first? A client who had an open cholecystectomy and has green drainage from the T-tube A client who has benign prostatic hyperplasia and is unable to urinate A client who has heart failure and reports shortness of breath while ambulating A client who has abdominal pain and is vomiting coffee-ground emesis. 93. A nurse is planning an education session for a client who has type 1 diabetes mellitus. Which of the following should the nurse plan to include when teaching the client to monitor for hypoglycemia? Abdominal pain Polyuria Diaphoresis Thirst 94. A nurse is planning to delegate client assignments to an assistive personnel. Which of the following tasks is appropriate for the nurse to delegate? Measuring the client's pain level Monitoring blood glucose levels Collecting a urine specimen Adjusting the flow rate of a client's oxygen tank 95. A nurse is planning care for a client who has a sealed radiation implant and is to remain in the hospital for 1 week. Which of the following should the nurse include in the plan of care? Ensure family members remain at least 3 feet from the client. Limit each of the client's visitors to 1 hr per day Remove dirty linens from the room after double bagging Wear a dosimeter film badge in the client's room 96. A nurse is interviewing an older adult client about the physiological changes he has been experiencing. Which of the following changes should the nurse recognize is normally associated with the aging process? Decreased sense of taste Decreased blood pressure Increased accommodation to near vision Increased gastric secretions 97. A nurse is caring for a group of clients in a long-term care facility. which of the following situations should the nurse recognize as a safety hazard? A meal tray left at the bedside from breakfast A call light extension cord pinned to the bedspread A client's wrist restraints tied to the bed rails A client's bedside table placed across the foot of the bed 98. A nurse in the telemetry unit is ` 1 1 reviewing the laboratory findings for an adult male client who is being treated for myocardial infarction. which of the following is an expected finding for this client? Brain Natriuretic Peptide (BNP) 10 ng/L Alanine aminotransferase (ALT) 45 unit/L High Density Lipoprotein (HDL) 75 mg/dl Troponin I (TNI) 8 ng/ml 99, 100, 101, 102, 103, 104 105. A nurse is evaluating a client's understanding of a liver biopsy before obtaining a signed informed consent. which of the following statements by the client indicates understanding of the procedure? I will be able to go home after I recover from general anesthesia I will need to lie flat for 8 hours after the procedure I will leave the pressure dressing in place after discharge for 24 hours. I will know what is wrong with me before I leave the hospital. 106. A nurse observes as assistive personnel providing care to a child who is in skeletal traction. Which of the following actions requires intervention? Massaging of pressure points Providing a high-protein snack Placing weights on the child's bed Assisting the child to reposition 107. A nurse is caring for a client who has human immunodeficiency virus (HIV) with neutropenia. which of the following precautions should then nurse take while caring for this client? Wear an N95 respirator while caring for the client Insert an indwelling urinary catheter to monitor urinary output Use a dedicated stethoscope for the client Monitor the client's vital signs every 8 hr. 108. A nurse is assessing for allergies before administering propofol (Diprivan) to a client placed on a mechanical ventilator. Which of the following allergies is a contraindication to the medication? Eggs Shrimp Milk Peanuts 109. A nurse is caring for a client who has been taking propranolol (Inderal). Which of the following findings indicates a need to withhold the medication? Potassium 5.2 mEq/L Pulse 54/min Sodium 130 mEq/L Blood pressure 156/90 mm Hg 110. A nurse is caring for a client who has a new prescription for enoxaparin (Lovenox) for the prevention of deep vein thrombosis. Which of the following is an appropriate action by the nurse? Inject the medication in the lateral abdominal wall. Administer an NSAID for injection site discomfort Expel the air bubble at the top of the prefilled syringe Massage the injection site to evenly distribute the medication 111. A nurse is teaching a client who has a new diagnosis of peripheral artery disease. Which of the following information should the nurse include when discussing home care? Inspect feet weekly for changes in color Apply warm, moist heat twice a day to affected area Place legs in a dependent position while sleeping Gently massage affected area 112. A nurse is developing a plan of care for a client who is experiencing periodic manic episodes. Which of the following interventions should the nurse include? Arrange for the client to attend group activities Encourage the client to stay in his room Schedule frequent rest periods during the day Have the client sit in the dining room for meals 113. A nurse is teaching post-operative care with the parents of a toddler following a cleft palate repair. Which of the following should be included in the teaching? Provide an orthodontic pacifier for comfort. Offer fluids by using a straw Cleanse suture line with a cotton-tip swab Remove elbow splints periodically to perform range of motion 114. A nurse is assessing a client with post-traumatic stress disorder. Which of the following findings should the nurse expect to find? X_ Loss of interest in usual activities Dependence on family and friends Passive-aggressive behavior Ritualistic behavior 115. A nurse is reviewing the laboratory data of a client who has diabetes mellitus. Which of the following laboratory tests is an indicator of long-term disease management? Postprandial blood glucose Glucose tolerance test X _ Glycosylated hemoglobin Fasting blood glucose 116. A provider has written a do-not-resuscitate order for a client who is comatose and does not have advance directives. A member of the client's family says to the nurse, "I wonder when the doctor will tell us what's going on." Which of the following actions should the nurse take first? Refer the family to a support group for grief counseling Request that the provider provide more information to the family Ask the family what the provider has discussed with them Offer to answer questions that the family members have. 117. A nurse is preparing to perform closed intermittent bladder irrigation for a client following a transurethral resection of the prostate (TURP). Which of the following actions is appropriate by the nurse? Insert the tip of the irrigation syringe into the catheter opening Aspirate the irrigation solution from the bladder Apply sterile gloves Open the flow clamp to the irrigating fluid infusion tubing. 118. A nurse is assessing a client who has a chest tube following a thoracotomy. which of the following findings requires intervention by the nurse? Tidaling with spontaneous respirations Drainage collection chamber is 1/3 full 1 cm of water present in the water seal chamber Suction chamber pressure of -20 cm H2O 119. A nurse is reviewing a new prescription for doxazosin (Cardura) with a client. Which of the following should be included in the teaching? Rise slowly when sitting up from bed. Increase dietary fiber to prevent constipation Take this medication each morning Decrease caloric intake to reduce weight gain 120. A nurse is assessing a client who has a blood glucose level of 250 mg/dL. Which of the following clinical manifestations are associated with this finding? Shakiness Thirst Confusion Diaphoresis 121 (missing) 122. A nurse is providing discharge teaching to a client who has myelosuppression following chemotherapy treatment. Which of the following should the nurse include in the teaching? Check your temperature weekly. Eat a diet rich in fresh fruits and vegetables Children may visit as long as they've recently received a live influenza vaccination Wear disposable gloves under gardening gloves while working with house plants. 123. A nurse is caring for a client who is receiving total parenteral nutrition. Which of the following assessment findings requires immediate intervention by the nurse? blood glucose level of 120 mg/dL Temperature of 37.60 C (99.70 F) Weight increase of 2 kg/day _ Prealbumin level of 20 mg/dL 124. A nurse manager is planning an audit to measure the quality of care on the unit. which of the following is the most appropriate source for the nurse to consult? Nursing manager colleagues Hospital administrators X Evidence-based practice data Protocols in other hospitals 125. Which of the following clients is appropriate for the nurse to refer to speech therapy for a swallow evaluation? A premature infant with a poor suck reflex and failure to thrive An adolescent with anorexia who is cachectic A middle-age adult with gastroesophageal reflux disease An older adult who has difficulty taking in fluids 126. A nurse is providing discharge teaching to a client who has schizophrenia and is starting therapy with clozapine (Clozaril). Which of the following is the highest priority for the client to report to the provider? Dry mouth Blurred vision Constipation Fever 127. A nurse is caring for a client who has a cast due to a compound fracture of the right ankle. Which of the following findings requires immediate intervention? Localized stabbing pain upon movement Pruritus under the cast Paresthesia of the distal extremity Edema present when leg is in a dependent position 128. A nurse on an acute medical-surgical unit is performing assessments on a group of clients. Which of the following findings is the highest priority? A client who has Clostridium difficile with acute diarrhea A client who has surgical hypoparathyroidism and a positive Trousseau's sign A client who has oral cancer and reports a sore on his gum A client who has an acute kidney injury and urin with a low specific gravity 129. A nurse is assessing a client's cardiovascular system. Identify where the nurse should place the diaphragm of the stethoscope to best hear the closing of the aortic heart valve. (Selectable areas or "Hot spots" can be found by moving your cursor over the artwork until the cursor changes appearance, usually into a hand. Click on the Hot Spot that corresponds to your answer.) 2ND intercostal space in the right sternal boarder 130. A nurse is planning to teach a group of parents regarding development of 15 month-old toddlers. Which of the following information should the nurse include in the teaching? Refers to self by name Understands simple commands Builds tower 6 to 7 cubes Picks up object without falling 131. A nurse is performing a dressing change for a client who has a sacral wound using negative pressure wound therapy. Which of the following actions should the nurse take first? Irrigate wound with normal saline Don sterile gloves Apply skin preparation to wound edges Determine pain level 132. A nurse is providing care for a preschooler who has acute gastroenteritis. Based on the information below, which of the following is an appropriate nursing action? (Click on the "Exhibit" button below for additional client information. There are three tabs that contain separate categories of data.) Institute a banana, rice, applesauce, and toast diet. Offer the child a cup of chicken broth Encourage the child's intake of gelatin Administer oral rehydration solutions 133. A nurse is caring for a client who is preparing his advance directives. Which of the following statements by the client indicates an understanding of advance directives? (Select all that apply) My doctor will need to approve my advance directives I can't change my advance directives once submitted My health care proxy can make medical decisions for me. I need an attorney to witness my signature on the advance directives I have the right to refuse treatment 134. A nurse is caring for a client who has bulimia nervosa. For which of the following should the nurse monitor? Amenorrhea Leukopenia Tachycardia Hypokalemia 135. A nurse in an urgent-care clinic is collecting admission history from a client who is 16 weeks of gestation and has bacterial vaginosis. the nurse should recognize that which of the following clinical findings are associated with this infection? Profuse milky white discharge Frequency and dysuria Hematuria Low grade fever 136. A nurse is monitoring a client during an IV urography procedure. which of the following client reports is the priority finding? Feeling flushed and warm Metallic taste in mouth Abdominal fullness Swollen lips 137. A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an assistive personnel? Assess effectiveness of antiemetic medication Provide discharge instructions Perform chest compressions during cardiac resuscitation Perform a dressing change for a new amputee 138, 139 (missing) 140. A nurse in a hospital cafeteria overhears two assistive personnel (AP) discussing a client. They are using the client's name and discussing details of his diagnosis. which of the following actions should the nurse take first? Complete an incident report regarding the AP's conversation Tell the AP to discontinue their conversation Provide the AP with written documentation regarding client confidentiality Report the AP's behavior to their supervisor. 141. A nurse working in a mental health facility observes a client who has bipolar disorder walk over to a table occupied by other clients and knock their game off the table. Which of the following is an appropriate response by the nurse? Apologize to the others for your behavior Come outside with me for a walk If you don't calm down, you will have to go into seclusion I am disappointed that you continue to act out when you are angry 142. A nurse is caring for a client who is taking levothyroxine (Synthroid). which of the following findings indicates to the nurse that the medication is effective? Absence of seizures Weight loss Decreased blood pressure Decreased inflammation 143. A nurse receives report on a group of clients. Which of the following clients should the nurse attend to first? A client who was admitted with asthma and has an SaO2 of 92% while receiving oxygen at 1 L/min A client who has type 2 diabetes mellitus and whose blood glucose level is 80 mg/dL A client who was admitted with angina and reports left arm pain of 4 on a scale from 0 to 10 A client who had a gastric endoscopy and whose nasogastric tube is draining 30 mL/hr of green fluid 144. A nurse is giving discharge instructions to a client who has a new ileostomy. The nurse should recognize that the teaching has been effective when the client states, My stoma size will stay the same, even after it has healed. I will ensure that my medications are enteric coated My stoma will drain liquid fluid continuously I will change my pouch system every 2 weeks. 145. A nurse is caring for a client in preterm labor who is receiving magnesium sulfate by continuous IV infusion. Which of the following client findings indicates medication toxicity? _X_ Urine output 20 mL/hr Blood glucose 150 mg/dL BUN 20 mg/dL Systolic blood pressure 140 mm Hg 146. A nurse is caring for a client who has schizophrenia. Which of the following assessment findings should the nurse expect? Preoccupation with somatic disturbances X_ Poor problem-solving ability Unable to identify common objects Decreased level of consciousness 147. A client with a left leg cast is using crutches for ambulation. The nurse should recognize that the client needs further instruction if the client maintains three to four finger widths between the crutch pad and axilla pushes up from a chair with the crutches on the unaffected side. places the crutches 6 inches in front of and to the side of each foot when standing flexes elbows at 30o when using the hand grips. 148. A nurse is providing preoperative teaching to a client who will use PCA morphine sulfate following surgery. Which of the following information should the nurse include? The client should be cautious to avoid overmedication Family members can administer a dose for the client The client should notify the nurse when administering a dose of the medication The client can administer a dose of medication every 6 to 8 min. 149. A nurse is taking a medication history from a client before administering the first dose of doxycycline (Vibramycin). Which of the following findings should the nurse identify as a contraindication to the medication? Penicillin allergy Active chlamydial infection Prescription for levothyroxine (Synthroid) Currently breastfeeding 150. A nurse working in a clinic is teaching a group of clients who are pregnant on the use of non-pharmacological pain management. Which of the following statements by the nurse is an appropriate description of the use of hypnosis during labor? Hypnosis focuses on the use of biofeedback as a relaxation technique Hypnosis promotes increased control over pain perception during contractions Hypnosis provides distraction to minimize pain Hypnosis uses therapeutic touch to reduce anxiety during labor. 151. A community health nurse is teaching a group of adults about the importance of health screenings. The nurse should include that African American males are almost twice as likely as Caucasian males to experience which of the following? Testicular cancer Stroke Obesity Melanoma 152. A nurse is planning care for a client following gastric bypass surgery. The nurse should include which of the following dietary instructions when preparing the client for discharge. Limit your meals to three times per day Consume at least 25 g of fiber daily Check your blood glucose level before each meal. Start each meal with a protein source. 153. A nurse is teaching a female client how to reduce the risk of urinary tract infections (UTIs). Which of the following should the nurse include as a risk factor for developing a UTI? Wearing underwear with a cotton crotch Urinating immediately after intercourse Wiping from front to back Using perfumed toilet paper 154. A nurse in a clinic suspects a child is experiencing a mild hypoglycemic reaction. which of the following food choices should the nurse offer? 8 oz of regular soft drink One slice of bread with 2 tbsp of peanut butter X_ 4 oz. of fruit juice 3 oz of cheddar cheese and two crackers 155. A nurse manager is explaining a new protocol for the care of central venous access devices to the nurses on her unit. which of the following methods should the nurse manager use to evaluate adherence to the new protocol? Monitor rates of catheter related bloodstream infections Survey client satisfaction with nursing care Offer group discussions to promote questions about the new procedure Provide practice sessions for nurses to perform dressing changes 156. A nurse is caring for a client on the cardiac care unit who is hemodynamically unstable. Which of the following dysrhythmias should the nurse plan for cardioversion? Third-degree AV block Ventricular asystole Ventricular fibrillation Atrial fibrillation 157. A nurse is planning to teach a client who has a new diagnosis of hypertension and is to start therapy with hydrochlorothiazide (Urozide). Which of the following should the nurse plan to include in the teaching? Report a loss of hearing Take the medication in the morning Expect a drop in blood pressure within 24 hr of the first dose Eat vitamin C rich foods 158. A nurse is assessing a client who has pericarditis. Which of the following findings in the priority? Pericardial friction rub Paradoxical pulse Substernal chest pain Dependent edema 159. A charge nurse is evaluating the time management skills of a newly licensed nurse. The charge nurse should intervene when the newly licensed nurse does which of the following? Delegates changing a sterile dressing to a licensed practical nurse Works on several tasks simultaneously X_ Re-evaluates priorities halfway through the shift Groups activities for the same client 160. A nurse in a provider's office is providing education to a client who is 16 weeks of gestation and has a new prescription for ferrous sulfate (Feosol). Which of the following instructions should the nurse provide? If you miss a dose one day, take two doses the next day Avoid strawberries, citrus fruit, and melon to ensure that your iron medication is effective. X_ It is important to take your iron medication on a full stomach Take your iron medication with fluids other than coffee or tea. 161. A nurse on a mental health unit receives report on four clients. Which of the following clients should the nurse attend to first? A client who is making sexual comments to clients of the opposite sex A client who has compulsive behavior and is frequently drinking from the water fountain A client who is having auditory hallucinations and is becoming agitated A client who has begun to demonstrate catatonic behavior 162. A nurse receives a change-of-shift report. Which of the following clients should the nurse attend to first? A client who is in a long leg cast and reports cool feet bilaterally A client who has dark, foul-smelling urine with a urine output of 320 mL in the last 8 hr A client who has a productive cough and an oral temperature of 36o C (96.80F) A client who reports tingling in the fingers following a thyroidectomy 163. A nurse is instructing the parents of a school-age child who has bacterial conjunctivitis. Which of the following should the nurse include in the teaching? Use eye ointment at bedtime Have the child wear an eye patch while sleeping Irrigate the eye to remove secretions Apply cool compresses 4 times a day while awake 164. (missing) 165. A nurse is assessing a toddler's fine motor development. Which of the following is an appropriate developmental ability of the toddler? Copies a triangular shape with a pencil Turns pages of a book two or three at a time Places small objects in a narrow necked bottle Uses scissors to cut out a picture 166. A nurse is caring for the mother of an adolescent who was killed in a motor-vehicle crash after a school event. The mother states, "I never should have let him take the car. It's all my fault!" Which of the following responses by the nurse is appropriate? You appear to be feeling overwhelmed You had no way of knowing this would happen Tell me why you feel this is your fault Most parents blame themselves when losing a child 167. A nurse is caring for a client who is receiving IV conscious sedation with midazolam (Versed). The client has a respiratory rate of 9/min and is not responding to commands. Which of the following is an appropriate action by the nurse? Place the client in a prone position Administer flumazenil (Romazicon) Implement positive pressure ventilation Perform nasopharyngeal suctioning. 168. A nurse in a provider’s office is interviewing a client who is requesting an oral contraceptive. Which of the following findings in the client’s history is a contraindication to the use of combination oral contraceptives? _X_ Impaired liver function Thyroid disease Allergy to penicillin Abnormal blood glucose 169. A nurse is reviewing the laboratory report for a client who reports vomiting for 2 days. The client’s serum potassium level is 2.9 mEq/L. Which of the following is an expected finding of this client? Muscle weakness Numbness and tingling of fingers Hyperactive reflexes Positive Chvostek’s sign 170. A nurse is assessing an adolescent client who has sickle cell anemia. Which of the following is the priority finding by the nurse? New onset of enuresis A pain score of 7 on a scale from 0 to 10 Priapism Shortness of breath 171. A charge nurse for a medical-surgical unit discovers client care assignments that should be reassigned. Which of the following delegated tasks should be reassigned? A licensed practical nurse is to check nasogastric tube placement for a client who has had a bowel resection. A licensed practical nurse is to provide the initial feeding for a client who had a cerebrovascular accident. An assistive personnel is to calculate the intake and output every 2 hr for a client in acute renal failure. An assistive personnel is to collect vital signs every 30 m in. for a client who had a cholecystectomy. 172. A nurse is checking laboratory results for a client. Which of the following laboratory findings indicates hypervolemia? Serum calcium 10 mg/dL Urine pH 6 Urine specific gravity 1.001 Serum sodium 138 mEq/L 173. A nurse is reviewing a client’s admission laboratory results. Which of the following findings requires further evaluation? Creatinine 1.8 mg/dL Potassium 4.2 mEq/dL Sodium 138 mEq/L Hemoglobin 15 g/dL 174. A nurse in an intensive care unit is planning care for a client who has alcohol withdrawal syndrome. Which of the following should the nurse include in the plan of care? Provide frequent orientation to time and place Perform gastric lavage. Engage the client in group therapy. Administer disulfiram (Antabuse). 175. A nurse is admitting a client who is in labor and at 38 weeks of gestation to the maternal newborn unit. The client has a history of herpes simplex virus 2. Which of the following questions is most important for the nurse to ask the client? “Do you have an active lesion?” “Have your membranes ruptured?” “Are you positive for beta strep?” “How far apart are your contractions?” 176. A nurse is caring for a client who has a prescription for atorvastatin (Lipitor). Which of the following client conditions is a contraindication to this medication? Crohn’s disease Peptic ulcer disease Hepatitis C Bronchitis 177. A nurse is caring for a client who has end-stage osteosarcoma and is reporting severe pain. The client’s respiratory rate is 14/min. Which of the following medications should the nurse expect to be the highest priority to administer to the client? Promethazine (Phenergan) Ketorolac (Toradol) Amitriptyline (Elavil) Hydromorphone (Dilaudid) 178. A nurse is providing discharge instructions for a client who has a new prescription for furosemide (Lasix). Which of the following client statements indicates a need for further teaching? “I will limit my intake of fish.” “I will weigh myself every day.” “I will notify the nurse if I have muscle cramps.” “I will take my morning pills with food or milk.” 179. A nurse is caring for a client who has breast cancer and has been receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider? WBC 3,000/mm3 aPTT 30 seconds Platelet count 250,000/mm3 Hemoglobin 14 g/dL 180. A nurse is caring for a newborn who is under phototherapy lights. Which of the following is an appropriate nursing action? Apply lotion to exposed skin. Offer glucose water between feedings Ensure eye shield is covering the eyes. Discontinue breastfeeding during treatment.