NSG 210CAT VERSION 3

NSG 210CAT VERSION 3 I remember the CAT 1.At a routine prenatal visit, client 24 week gestation____ Answer: Estrogen 2. UAP take vitals a client HIV------- None 3. Multipara post partum breast feeding- ------ Take analgesic 1 hour prior breastfeeding 4.Child with mielomeningocele ----- The purpose of the dressing to protect the incision 5. A client with multaq ------ Palpate radial pulse 6.A middle aged with chest pain ---- Administer aspirin 325mg 7.Fall prevention program ----- clients wear rubber soled shoes 8. 86 year old female , not like eat ------ A loss appetite occur in orders 9.Mono spot test -----clarify symptoms no respond antibiotic therapy 10. A client with permetrin ----- Shower 8-14 hours 11.Pregnant 32 sg DTR 4 ------Determine blood pressure 12. Client reddened area on coccyx of a wheelchair----- Encourage the client to shift weight 13.Client anxiety disorder in hallway -----Obtain vital signs 14.Client with GERD ------ Ask the client usual administration time . 15.Use dopamine ----Experiencing ventricular fibrillation 16.Client 2 defibrillation shocks -----Resume CPR 17.Place a sensor for a pulse oximeter ----- Left lower 3+dorsal pedis pulse 18.Client myocardial infarction ---- vasodilator 19. Client using contraceptives for 1 year ----Take medication with food CAT 1 2,14,17,24,30,38,40,43,46,50,79,116,118,126,127,140,147,148,154,155,156,158. CAT 2 1,3,14,15,19,23,38,41,45,58,62,118,123,124,127,139,142. CAT 3 1,18,34,36,62,65,79,84,93,94,105,110,114,116,120,157. CAT 4 7,28,30,31,42,67,93,103,117,125,136,143 Otras que recuerdo 1. What group teaching is directed to overweight???? 2. The nurse gave morphine to a patient that the doctor prescribed, is negligence ????? 3. Child with respiratory syncytial virus --- put in a private room 4. Bioterrorism-----Tularemia 5. Attend first child ---- a bee sting 1. At a routine prenatal visit, a client at 24-weeks gestation complains of nasal stuffiness and occasional nosebleeds. Which hormone is responsible for these changes? A. Human chorionic gonadotropin. B. Progesterone. C. Relaxin. D. Estrogen. Correct: D 2. A multipara postpartum client complain intense cramping while breastfeeding. Whatinstruction should the nurse provide to the client? A. Change the infant's position during the next feeding. B. Void and completely empty bladder before each feeding. C. Take a prescribed analgesic an hour prior to breastfeeding. D. Drink two glasses of water 30 minutes prior to breastfeeding. Correct: C 3. While the nurse is preparing to administer a high volume saline enema to a male client, the client appears anxious and states that he is not able to turn on his right side without help because of a recent stroke. What action should the nurse take first? A. Reassure the client that he can remain in any position of comfort during the enema. B. Assess the client's ability to independently turn to his left side. C. Instruct the client that the procedure will only last about ten minutes. D. Ask a UAP to assist the client to maintain a right lateral position. Correct: D 4. A client is receiving an IV infusion of regular insulin, 50 units in 100 ml of normal saline at 4 units/ hour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only.) Correct: 8 5 A client takes dronedarone (Multaq) 400 mg PO twice daily is admitted with chest pain and shortness of breath. The nurse should withhold the Multaq if the client manifests which finding? A. Three premature ventricular beats/minute. B. QTc interval less than 500 milliseconds. C. Respiratory rate greater than 30 beats/minute. D. Palpable radial pulse less than 50 beats/minute. Correct: D 6. A middle-aged client with complaints of chest pain radiating into his jaw is en route to the hospital via ambulance. Oxygen was started, threee nitroglycerin sprays of 5 minute intervals were administered, with no pain relief, and an IV was initiated. The cardiac monitor indicates normal sinus rhythm. On arrival at the Emergency Department, which intervention should the nurse implement first? A. Prepare for defibrillation or cardioversion. B. Inject 5,000 units heparin subcutaneously C. Obtain a 12 lead EKG. D. Administer a chewable aspirin 325 mg. Correct: D 7. The nurse is planning a fall prevention program for the residents at a long-term care facility. Which intervention is most important in providing a safe environment? A. Encourage clients to wear rubber-soled shoes. B. Accompany residents older than 80 years during ambulation. C. Apply a vest restraint prophylactically to confused residents. D. Leave the hall lights on during the night. Correct: A 8. For a client who has been receiving linezolid (Zyvox) for two weeks to treat an MRSA- infected wounds, what finding requires the most immediate action by the nurse? A. Ecchymosis B. Insomnia C. Tongue discoloration D. Vaginal discharge Correct: A 9. The unlicensed assistive personnel (UAP) caring for a postoperative client reports to the charge nurse that the client is not using the incentive spirometer effectively. What action should the charge nurse implement? A.Schedule time later in the morning to review the use of incentive spirometer with the client. B. Ask the practical nurse assigned to care for the client to review the use of spirometer with the client. C. Encourage the UAP to demonstrate the effective use of the incentive spirometer to the client. D. Advise the UAP that the respiratory therapist is responsible to supervise the client's use of the spirometer. Correct: B 10. The RN is in charge of a 20-bed surgical unit and is preparing assignments for the shift. Which nursing task should be assigned to the LPN? A. Administer a unit of blood to a client who has decreased hemoglobin and hematocrit. B. Take the routine vital signs on a client who just returned from surgery. C. Teach a client who has a new sigmoid colostomy how to irrigate the colostomy. D. Administer a pain medication to a client who had a bowel resection yesterday. Correct: D 11. The culture and sensitivity report for a client who has been receiving a broad spectrum antibiotic indicated that the bacteria is resistant to the currently prescribed medication. What action should the nurse implement in response to this finding. A. Notify the lab of the need for drug peak and trough levels B. Determine if the white blood cell count has increased. C. Administer the next scheduled dose of the antibiotic. D. Assess the oral mucosa for signs of superinfection. Correct: B 12. When the healthcare provider calls to check on the status of a client with congestive heart failure who was given IV furosemide (Lasix) four hours ago, the nurse reports that the client has bibasilar crackles. What additional information is most important for the nurse to report to the healthcare provider? The client: A. is taking ice chips B. is receiving intravenous fluids at 125 ml/hour C. is receiving 50% oxygen per venturi mask D. has had a urine output of 600 ml the past four hours. Correct: B 13. A client at 8 weeks gestation is told her hemoglobin is 9.5 mg/dl. Which nursing intervention has the highest priority? A. Explain that this is a normal finding in early pregnancy. B. Instruct the client to eat a well-balanced diet. C. Provide the client with a list of foods high in iron D. Obtain a prescription for an iron supplement. Correct: D 14. The healthcare provider prescribes fluoxetine (Prozac) for a client with major depressive disorder. Which instruction should the nurse include in this client's medication teaching plan? A. Avoid eating avocados and drinking red wine B. Expect to feel more tired and lethargic C. Dry, cold skin is a common side effect D. Take the medication in the early morning Correct: A 15. The nurse assess a client who is immunosuppressed and is diagnosed with a respiratory infection. The client has respirations at 20 breaths/minute, pulse oximetry of 95%, clear bilateral breath sounds, and is afebrile with no productive cough. Which nursing diagnosis should the nurse include in client's plan of care? A. Risk for activity intolerance B. Impaired gas exchanged C. Risk for ineffective airway clearance D. Impaired tissue perfusion Correct: C 16. A male client who takes carvedilol (Coreg) 25 mg twice daily is admitted with atrial flutter. His ejection fraction (EF) is 30%, his blood pressure is 190/86, and he has a history of type 1 diabetes mellitus. The healthcare provider prescribes dronedarone (Multaq) 400 mg PO twice daily. Which assessment finding warrants immediate intervention by the nurse? A. Chronic dermatitis B. Abdominal pain C. Severe headache D. Sinus bradycardia Correct: D 17. Two nurses were in a conflict related to weekend scheduling, but after a discussion, report that they resolved the issue between themselves. Which question should the nurse- manager ask to evaluate the quality of the decision-making process in this conflict resolution? A. "How much cooperation had been generated?" B. "Has understanding been increased between the two of you?" C. " How practical and realistic are the decisions that have been made?" D. "Are you both willing to work together?" Correct: C 18. An adult client receives a prescription for permethrin (Acticin Cream 5%) to treat an infestation of scabies. The nurse instructs the client to massage the cream into the skin from the head to the soles of the feet, avoiding the eyes. Which additional instruction should the nurse provide? A. Remove the cream from the skin immediately is pruritis occurs, B. Shower or bathe 8 to 14 hours after treatment to remove cream. C. Avoid areas between fingers and toes during application D. Reapply cream in seven days to prevent reinfestation. Correct: B 19. When assessing a client at 32-weeks gestation, the nurse determines that her deep tendon reflexes (DTRs) are 4+. What action should the nurse take first? A. Notify the healthcare provider B. Assess the client for pitting edema C. No action is required since this is a normal finding D. Determine the client's blood pressure Correct: D 20. The nurse is teaching a client newly diagnosed with diabetes mellitus the signs of hypoglycemia. What symptom should be included in the description of early signs of hypoglycemia? A. Difficulty swallowing B. Polyuria C. Tremors D. Bradycardia Correct: C 21. The nurse should question the use of dopamine, and adrenergic agonist, for a client with which assessment finding? A. Currently receiving a loop diuretic B. Experiencing ventricular fibrillation C. Blood pressure if 90/60 D. Is taking a tricyclic antidepressant Correct: B 22. A client with a prescription for "do not resuscitate " (DNR) begins to manifests signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement? A. Assess the client's need for pain medication B. Notify the chaplain of the client's status C. Report the client's status to the healthcare provider D. Document the client's signs of impending death. Correct: A 23. The nurse is caring for a client who is admitted to the telemetry unit for complications related to a myocardial (MI) that occurred 4 days ago. A 12 lead electrocardiogram (ECG) shows right axis deviation and poor R wave progression. Which assessment findings suggest that the client is at risk for right ventricular hypertrophy? A. Generalized fatigue, dizziness, swollen ankles B. Severe chest pain and shortness of breath C. Nausea, vomiting, and generalized edema D. Sharp, non-radiating chest pain and nausea Correct: A 24. A client with an anterior wall myocardial infarction is admitted to the intensive care unit with persistently low blood pressure. The nurse determines the client's pulmonary capillary wedge pressure (PCWP) is 28 mm Hg and systemic vascular resistance (SVR) is 2000 dynes/sec/cm5. Which classification of medication is likely to optimize the client's SVR? A. Adrenergic B. Vasodilator C. Diuretic D. Positive inotropic agent Correct: B 25. The nurse is evaluating discharge teaching of an adolescent who had a long log cast applied in the emergency department. Which statement by the adolescent indicates an understanding of cast care? A. " I should wrap a cloth around a stick before using it to scratch under my cast." B. " I will not be able to take a shower until the cast is removed from my leg." C. " I will put adhesive tape around the edges of the cast if they become sharp." D. " If my toes are tingling I will elevate my leg above my heart, on several pillows." Correct: C 26. A client is taking cromolin sodium (Intal) Inhaler for chronic asthma. Which statement indicates the client understands the medication teaching? A. " I will have my liver enzymes checked monthly." B. " It is more important to take this medication with food." C. "I should keep my inhaler with me at all time." D. "I will not discontinue taking this medication abruptly." Correct: D 27. A client with a diagnosis of bipolar disorder is taking lithium and divalproex sodium (Depakote). In assessing this client, which symptom should the nurse report to the healthcare provider immediately? A. Recent significant hair loss B. Noticeable find hand tremors C. Describes having a dry mouth. D. Complains of blurred vision Correct: B 28. The nurse is discussing the use of isotertinoin (Accutane) with a 19-year old female client, who has been taking oral contraceptives for one year. The client agrees to use a second form of contraception while on the medication, and has had two negative pregnancy tests. What other instruction should the nurse provide regarding the use of Accutane? A. If depression occurs, the use of St. John's Wort is recommended. B. The medication must be taken with food to enhance absorption. C. Fluids should be limited to sips when swallowing this medication. D. Serum lipids should be evaluated at the beginning and end of treatment. Correct: B 29 Which intervention is best for the nurse to implement for a client who is experiencing severe toe pain as the result of acute gout? A. Minimize calcium rich foods in diet B. Provide passive ROM to the foot and toes C. Place a foot cradle under the linen D. Apply anti-embolism stocking bilaterally. Correct: C 30. Nursing assessment of a client with Type 2 diabetes reveals that the client is 5' 6" tall, weighs 238 lbs, works behind a desk all day, does not exercise, and smokes 2 packs of cigarettes daily. In planning care for this client, which intervention is most important for the nurse to implement? A. Discuss changing eating habits with a goal of losing 2 lbs/week. B. Instruct the client to decrease the number of cigarrettes smoke daily. C. Determine the client's feelings about being diagnosed with a chronic disease D. Encourage other family members to be tested for diabetes. Correct: A 31. A woman who recently delivered a normal newborn calls the clinic crying and describes feeling overwhelmed and discouraged. Which information is most important for the nurse to obtain? A. Is there anyone with her at this time? B. Has she seen a mental health provider? C. Does she describe herself as depressed? D. How long has she been feeling this way? Correct: A 32. The nurse is performing an admission physical assessment of a newborn who is small for gestational age (SGA). Which finding should the nurse report immediately to the pediatric healthcare provider? A. High pitched shrill cry B. Widened, tense, bulging fontanel C. Head circumference of 35 cm (14 inches) D. Heel stick glucose of 65 mg/dl Correct: A 33. The nurse notes that an elderly client who is receiving a continuous tube feeding is increasingly fatigued and confused. Which assessment is most important for the nurse to complete before notifying the healthcare provider? A. Bowel sounds B. Breath sounds C. Skin turgor D. Capillary refill Correct: B 34. A client diagnosed with myxedema coma has assessed vital signs of: T 99.8F; P= 92 beats/minute; R= 22 breaths/minute, B/P 108/70 mmHg. Based on this information, what intervention should the nurse implement first? A. Monitor the vital signs q1h for the next 8 hours B. Notify the healthcare provider immediately C. Assess the client for presence of infection D. Encourage the client to use an incentive spirometer Correct: C 35. In evaluating the effectiveness of a client's nocturnal sleep patterns, what question is best for the nurse to ask the client? A. " How often do you awaken during the night?" B. " Do you remember dreaming at night?" C. " How many hours do you sleep each night?" D. " Do you feel rested in the morning?" Correct: D 36. A nurse is taking a health history of a 46 year old male client who has smoked cigarettes for 30 years. He has had chronic bronchitis for the past 6 months. What statement best describes the rationale for obtaining information from the family as well as from the client? A. Poor oxygenation inhibits the client’s memory and renders information unreliable. B. Client's tend to grow accustomed to their cough and underestimates their nicotene use. C. Including the family helps to ensure that the client will comply with the treatment regimen. D. Family members are usually more anxious than the client to get the physical problem resolved. Correct: C Acetylcysteine=14 Amoxicillin=12.5 An infant Penicillin =0.3 Caring for a laboring ct. = 42 Ct. receiving IV infusion= 12 Ct. receives IV 500=1080 Cyanocabalmin=0.1 Half strength=200 Heparin=14 IV infusion of insulin- 8 Meperidene=1.3 Methylergonovine = 2 Nitroglycerin = 3 Penicillin G Procaine = 0.23 Polycarhophil = 12 Polycillin = 9 The HP heparin protocol = 8 Vanconin = 800 3 liters of D5W= 125 ¾ Cleanse = 750 I remember the CAT 1.At a routine prenatal visit, client 24 week gestation____ Answer: Estrogen 2. UAP take vitals a client HIV------- None 3. Multipara post partum breast feeding- ------ Take analgesic 1 hour prior breastfeeding 4.Child with mielomeningocele ----- The purpose of the dressing to protect the incision 5. A client with multaq ------ Palpate radial pulse 6.A middle aged with chest pain ---- Administer aspirin 325mg 7.Fall prevention program ----- clients wear rubber soled shoes 8. 86 year old female , not like eat ------ A loss appetite occur in orders 9.Mono spot test -----clarify symptoms no respond antibiotic therapy 10. A client with permetrin ----- Shower 8-14 hours 11.Pregnant 32 sg DTR 4 ------Determine blood pressure 12. Client reddened area on coccyx of a wheelchair----- Encourage the client to shift weight 13.Client anxiety disorder in hallway -----Obtain vital signs 14.Client with GERD ------ Ask the client usual administration time . 15.Use dopamine ----Experiencing ventricular fibrillation 16.Client 2 defibrillation shocks -----Resume CPR 17.Place a sensor for a pulse oximeter ----- Left lower 3+dorsal pedis pulse 18.Client myocardial infarction ---- vasodilator 19. Client using contraceptives for 1 year ----Take medication with food 2. A client is receiving a continuous half strength tube feeding at 50 ml/hr. To prepare enough of the solution for eight hours, how many ml of full strength feeding will the nurse need Answer: 400 14. When assessing a 7-year-old girl, the nurse notes that she has multiple bruises on her back and upper arms. The child’s aunt tells the nurse that the child’s parents abuse drugs and alcohol. What intervention is most essential for the nurse to implement?(moretones) D. Report assessment findings to the proper legal authorities 17. A 2-year-old with sickle cell anemia has an axillary temperature of 102 F. In planning care for this child, which nursing diagnosis has the highest priority? B. High risk for fluid volume deficit related to temperature elevation 24. The nurse is preparing to administer an intramuscular injection in the ventrogluteal site of a client who weighs 80 kg. What size needle should the nurse select? C. 21-gauge, 1.5-inch needle 30. What is the most important symptom the nurse should monitor the client for while assisting with the insertion of a subclavian central venous catheter? D. Shortness of breath 38. The healthcare provider performs a paracentesis on a client with ascites and 3 liters of fluid are removed. Which assessment parameter is most critical for the nurse to monitor following the procedure? Vital signs (PARA DETECTAR POSIBLES COMPLICACIONES) 40. A client is receiving a continuous infusion of normal saline at 125 ml per hour. The nurse prepares to change the primary IV tubing and hang a new bag of normal saline to maintain the prescription. In which sequence should the nurse implement the procedure? (Arrange with first on top and last on bottom) 1. Spike a new bag of normal saline 1000ml using new tubing 2. Open the clamp on the tubing to bleed all air from the line 3. Close the clamp below the pump and at the client’s venous access 4. Place the pump on hold and replace the tubing in the chamber 5. Attach the distal end of the new tubing to the client’s venous 6. Open all tubing clamps to the client and start the pump 43. A client with a general anxiety disorder is pacing the hallway. The client tells the nurse, “My heart is just racing and sometimes it feels like it’s fluttering. I’m feeling short of breath and dizzy.” What action should the nurse implement first? D. Obtain the client’s signs (ASEGURAR QUE NO TIENE UN CARDIOVASCULAR RISGO) 46. The nurse should carefully assess the client with which urinary problem for fluid volume deficit? B. Polyuria (AL ORINAR MUCHO SE DESIDRATAN) 46. The nurse should carefully assess the client with which urinary problem for fluid volume deficit? B. Polyuria (AL ORINAR MUCHO SE DESIDRATAN) 50. An alert and oriented client requiring droplet precautions is placed in a private room at the end of the hallway. Several days later, the nurse finds that the client is restless and anxious. What action should the nurse implement? A. Encourage family members to maintain a regular visitation schedule 79. The nursing diagnosis, “Altered nutrition: less than body requirements,” is included in the plan of care for a client with hyperthyroidism. What primary etiology should the nurse identify when planning care for this client? A. Increased metabolic needs 116. The industrial health nurse who works in a mobile clinic is developing an exposure control plan for blood-borne pathogens. Which topics should be included in this plan? (Select all that apply) C. Self-sheathing or needleless medication systems D. Hepatitis B vaccine series 118. A client diagnosed with acute epididymitis secondary to a sexually transmitted disease receives a prescription for ceftriaxone (Rocephin). Prior to administering the prescription, which question should the nurse ask the client? B. “Have you ever had an allergic reaction to any other antibiotic?” 127. Following a fracture, a client develops early symptoms of anterior tibial compartment syndrome. In planning care, the nurse identifies the prevention of what problem as the priority goal? C. Ischemia 140. A client with a compound fracture of the left ankle is being discharged with a below-the-knee cast. Before being discharged, the nurse should provide the client with what instruction? A. Do not attempt to scratch the skin under the cast No intente arañar la piel bajo el yeso 147. During shift report, the nurse learns that a postoperative client has atelectasis. What nursing diagnosis should the nurse expect to include in the client’s plan of care? D. Impaired gas exchange 148. The nurse knows that the blood urea nitrogen (BUN) can be expected to change as one ages. Which statement best explains this expected changes? B. BUN increases because of a decrease in renal functioning and a decrease in cardiac output de BUN aumenta debido a una disminución en el funcionamiento renal y una disminución en el gasto cardíaco 154. An infant is admitted to the newborn nursery, and is believed to have Down syndrome. Which physical finding might the nurse expect to see? A. Postural hypotonia 155. The healthcare provider prescribes oxytocin synthetic (Pitocin), 10 units/L via IV drip to augment a client’s labor because she is experiencing a prolonged active phase. Because the client is receiving Pitocin, the nurse should closely monitor for which complication? B. Uterine tetany(contraciones uterinas involuntarias o exeso ) 156. A female client who has been taking the corticosteroid methylprednisolone (Solu-Medrol) for three weeks reports to the nurse that she has gained ten pounds since starting the medication, and she wants to stop taking it. What is the best response by the nurse? C. The medication must be discontinued gradually, tapering the dose each day 158. An infant has a medical diagnosis of tracheoesophageal fistula (TFE). What nursing intervention is indicated for this infant prior to surgical repair? C. Keep suction equipment available at all times Mantener un equipo de succión disponible en todo momento 1. A client with a hemothorax has a chest tube in the fourth intercostal space connected to suction at 20 cm H2O pressure. Four hours after insertion, which client outcome should the nurse consider to be within normal limits for this client? C. Fluctuation with respiration in the water-seal chamber of the Pleuravac 3. In caring for a client who is receiving peritoneal dialysis, the nurse should be alert for that what complications? C. Abdominal pain, tenderness, and rigidity (peritonitis) 14. The nurse is preparing a teaching plan for a client receiving magnesium-based antacids for treatment of gastro-esophageal reflux disease (GERD). Which instruction should the nurse plan to include? B. “Avoid taking any other drugs 1 to 2 hours before and after taking the antacid” 15. The nurse is caring for a young adult male client with facial injuries resulting from a motor vehicle collision. Which client statement indicative of the highest priority for nursing intervention? D. “I can’t sleep through the night because I awaken with pain when I move” 19. Following the administration of total parenteral nutrition (TNP) via a central line to a client diagnosed with inflammatory bowel disease (IBD), the nurse should expect what outcome? C. Afebrile with no purulent drainage from catheter site 23. A woman is brought to the labor and delivery unit after delivering a term infant and the placenta in the hospital parking lot 10 minutes ago. What action should the nurse perform first? D. Perform a fundal massage 38. A client with peptic ulcer disease (PUD) is admitted to the emergency room complaining of sudden severe upper abdominal pain. Assessment indicates an extremely tender and rigid abdomen, B/P of 90/60 mm Hg, and pulse of 110 beats/minute. The emergency department nurse should anticipate implementation of which intervention? C. Preparing the client for emergency abdominal surgery 41. A male college student returns to the student health clinic one week after receiving a positive mono spot test for mononucleosis and requests a prescription for amoxicillin (Amoxil, Polymox). He is afebrile and complains of fatigue, a sore throat, dysphagia, and extremely swollen glands. What response should the nurse provide? C. Clarify that these symptoms will not respond to antibiotic therapy 45. A female client is admitted to the psychiatric department on an emergency commitment. The client’s husband asks the nurse, “What is going to happen to my wife? Can I take her home now?” Which information should the nurse provide? D. Hospitalization is mandated until a mental health court hearing is held 58. The nurse is preparing to teach the parents of a child who had a surgical repair of a myelomeningocele how to change an occlusive dressing on the child’s back. Which statement by the parents indicates that they understand this procedure? A. “The purpose of the dressing is to protect the incision from fecal contamination” 62. Which foods are best for the nurse to offer a bipolar client who is in an acute manic phase and is pacing in the hallway? B. Bologna sandwich, ear corn, candy bar 118. An 89-year-old male client complains to the nurse that people are whispering behind his back and mumbling when they talk to him. What age-related condition is likely to be occurring with this client A. Presbycusis(NO ESCUCHA BIEN ) 123. Elastic stockings have been prescribed for a client who is recovering from a myocardial infarction. What is the best time to apply the stockings? C. Noon time 124. The nurse notices a reddened area on the coccyx of a wheelchair-bound client. Which intervention should the nurse implement? D. Encourage the client to shift weight while sitting 127. In developing a plan of care for a child with acute lymphocytic leukemia, the nurse identifies the nursing diagnosis of, “Potential for injury related to brushing and bleeding.” What laboratory finding provides supporting data for this diagnosis? A. Thrombocytopenia 139. The nurse includes the diagnosis, “Impaired mobility related to weakness and fear of falling” in the plan of care of a postoperative client. Which goal should be added to the care plan o address this diagnosis? The client will D. Demonstrate increased mobility 142. A client is diagnosed with an anxiety disorder. According to behavioral therapy, which cognitive restructuring intervention should the nurse recommend when the client is addressing anxiety-producing situations? D. Recite a favorite poem when feeling anxious 1. An adult client being admitted to the psychiatric unit with a diagnosis of bipolar disorder arrives in an elated state. What is the best room assignment the nurse can make for this client? a. A quiet room away from the nurse’s station. 18. Which statement by a 16-year-old male client with acute osteomyelitis in his leg indicates the best understanding of the appropriate activity level for his disorder? a. “During this illness, I need to keep my leg as immobile as possible.” 34. The nurse is evaluating discharge teaching of an adolescent who had a long leg cast applied in the emergency department. Which statement by the adolescent indicates an understanding of cast care? d. “I will put adhesive tape around the edges of the cast if they become sharp.” 36. Which type of therapeutic bath should the nurse recommend to a client who is complaining of pruritis? c. A colloidal bath. 62. A client two days postoperative after receiving a coronary artery bypass graft is suspected of having a pulmonary embolus (PE). Which assessment finding should the nurse recognize as characteristic of PE? b. Respiratory rate of 34 breaths/minute 65. The nurse assigns an unlicensed assistive personnel (UAP) to take the vital signs of the client whi is positive for Human Immunodeficiency Virus (HIV). What protective apparel should the nurse counsel the UAP to wear when carrying out this assignment? a. None. 79. An infant admitted to the neonatal intensive care unit is tachypneic, tachycardiac, and has bounding brachial pulses. The healthcare provider suspects that the infant has coarctation of the aorta. Which intervention is most important for the nurse to include in the infant’s plan of care? b. Monitor for congestive heart failure. 84. A client is having trouble breathing while lying in a dorsal recumbent position. What action should the nurse implement first? a. Elevate the head of the bed. 93. In assigning care on a telemetry unit, it is most important for the charge nurse to assign which client to an RN rather than an LPN? b. An older adult with dyspnea and edema due to heart failure who is receiving nesiritide (Natrecor). 94. Following two defibrillation shocks, the client’s ECG continues to indicate ventricular fibrillation (VF). Which intervention should the nurse implement next? d. Resume CPR immediately. 105. What is the priority nursing diagnosis when caring for a client with a Jackson-Pratt drain and a surgical wound that is healing by secondary intention? c. Risk for infection related to open wound. 110. The nurse-manager observes that the staff nurse has used wrist restraints to help secure an elderly female in her wheelchair. The client is pleading for the nurse to release her arms. The nurse explains to the nurse manager that the client needs to be restrained in the wheelchair so that the nurse can …………. a. Advise the staff nurse to remove the restraints from the client’s wrists. 114. While the nurse is inserting a nasogastric tube, the client becomes cyanotic. What intervention should the nurse implement? d. Withdraw the nasogastric tube. 116. While the nurse is bathing a bedfast client with generalized weakness, the client develops labored respirations and an audible pharyngeal rattles. The nurse auscultates coarse rattles in the upper lung fields. What action should the nurse implement first? a. Performing oropharyngeal suctioning. 120. The first day postoperative, a client’s vital signs are: temperature 99 F oraly, respiration 29 breaths/minute, blood pressure 120/74 mm Hg, heart rate 88 beats/minute. Based on these findings, what nursing action should the nurse implement first? a. Auscultate the lung sound. 157. A client returns to the acute care unit following surgery with 0.9% normal saline infusing at 45 drops/minute through tubing with a drop factor of 60 drops per ml. The postoperative prescription include 0.9% normal saline at 75 ml/hour to alternate with Lactated Ringer’s solution at 75 ml/hour. An intravenous infusion pump is not available. What action should the nurse implement? b. Increase the rate of the present normal saline infusion to 75 drops per minute. 7- The nurse-manager of a perinatal unit is notified that one client from the medical-surgical unit needs to be transferred to male room for new admissions. Which client should the nurse recommend for transfer to the antepartal unit? b. A 35-year-old with lupus erythematous 28- The nurse is caring for a 10-year-old who is diagnosed with acute glomerulonephritis. Which outcome is the priority or this child? d. Fluid balance maintained as evidenced by a urine output of 1 to 2 ml/kg/hr 30- The nurse in the newborn nursery admits a baby from labor and delivery who is suspected of having a congenital heart disease. Which finds helps to confirm this diagnosis? c. Centralized cyanosis and tachycardia when crying 31- A postoperative client returns to the nursing unit following a ureter lithotomy via a flank incision. Which potential nursing problem has the highest priority when planning nursing care for this client? a. Ineffective airway clearance 42- A female client on the mental health unit tells the nurse that her roommate is sitting on the bathroom floor with superficial cuts on her wrists. The nurse cleans and assesses the client’s wrists and asks what happened. She doesn’t respond. What should the nurse do next? b. Take the client to a room for supervision by staff 67- The nurse observes a client in a wheelchair with a vest restraint in place. What nursing intervention is most important for the nurse to implement? a. Assess the need for continued restraint 93- The nurse is preparing to teach the parents of a child who had surgical repair of a myelomeningcole how to change an occlusive dressing on the child’s back. Which statement by the parents indicates that they understand this procedure? c. The incision should be protected from fecal contamination by an intact dressing 103- What assessment data should lead the nurse to suspect that a client has progressed from HIV infection to AIDS? c) Recent history of recurrent pneumonia 117. Which nursing entry to the client record best reflects significant data on a male client who is admitted with complaints of chest pain? c. Client states he will notify the nurse if chest returns 125. When the nurse is designing a plan of care for a client diagnosed with pheochromocytoma, a goal statement should be prepared that relates to which topic? c. Preoperative and postoperative teaching for adrenalectomy 136. A newborn whose mother is HIV positive is admitted to the nursery from labor and delivery. Which action should the nurse implement first? b. Bathe the infant with dilute chlorhexidine (Hibiclens) or soap 143. Which situation is a violation of the client confidentiality, as described in the Health Insurance Portability Accountability Act (HIPAA)? b. A nurse's handwritten notes from a telephone report discarded in the office wastebasket Otras que recuerdo 1. What group teaching is directed to overweight???? 2. The nurse gave morphine to a patient that the doctor prescribed, is negligence ????? 3. Child with respiratory syncytial virus --- put in a private room 4. Bioterrorism-----Tularemia 5. Attend first child ---- a bee sting 1. At a routine prenatal visit, a client at 24-weeks gestation complains of nasal stuffiness and occasional nosebleeds. Which hormone is responsible for these changes? A. Human chorionic gonadotropin. B. Progesterone. C. Relaxin. D. Estrogen. 2. A client who has localized eczematous eruptions on b oth hands is diagnosed as having contact dermatitis. What instruction should the nurse include in this client's discharge teaching plan? A. Wear latex gloves whenever outdoors. B. Apply an oil-based ointment to the affected areas. C. Take prescribed antihistamine near bedtime. D. Soak hands in warm soapy water three times a day. 3. While transcribing a new prescription, the nurse notes that the prescribed dosage is much lower than the recommended dosage listed in the drug reference guide. Which client data supports the dosage reduction? A. Decreased serum creatinine B. Increased serum protein. C. Increased liver enzymes. D. Prolonged prothrombin time. 4. The nurse assigns an unlicensed assistive personnel (UAP) to take the vital signs of a client who is positive for Human Immunodeficiency Virus (HIV). What protective apparel should the nurse counsel the UAP to wear when carrying out this assignment? A. None. B. Gown, gloves, mask. C. Gloves and mask. D. Gloves only. 5. A client with Guillain-Barre syndrome requires a tracheostomy and mechanical ventilation due to the progression of the disease. What nursing intervention is most helpful in aiding this clinet to communicate with the staff and family? A. Speak slowly and disntinctly while in direct view of the client. B. Teach the client to point to a letter board word chart to communicate needs. C. Provide the client with a pencil and tablet of paper. D. With the client, develop a system of eye blinks to communicate "yes" or "no." 6. A client with peptic ulcer disease (PUD) is admitted to the emergency room complaining of sudden severe upper abdominal pain. Assessment indicates an extremely tender and rigid abdomen, B/P of 90/60 mmHg, and pulse of 110 beat/minute. The emergency department nurse should anticipate implementation of which intervention? A. Preparing the client for emergency abdominal surgery. B. Infusing the proton pump inhibitor Protonix intravenously. C. Administering an iced saline lavage. D. Inserting a nasogastric tube to decompress the bowel. 7. Which finding should the nurse expect a client to exhibit who is newly diagnosed with fibromyalgia? A. Recent joint trauma. B. Disruption in sleep patterns. C. Unexplained weight gain. D. Itching and rash. 8.A male client with diabetes mellitus reports that he has had trouble following his diet, and the result of his fasting blood glucose test is 90 mg/dl. What action should the nurse implement first? A. Obtain a urine specimen from the client to test for ketonuria. B. Assure the client that his diabetes control is within normal limits. C. Schedule the client to attend classes about diet management. D. Review the findings of his glycosylated hemoglobin test. 9. A multipara postpartum client complain intense cramping while breastfeeding. Whar instruction should the nurse provide to the client? A. Change the infant's position during the next feeding. B. Void and completely empty bladder before each feeding. C. Take a prescribed analgesic an hour prior to breastfeeding. D. Drink two glasses of water 30 minutes prior to breastfeeding. 10. A nurse is preparing to teach the parents of a child who had a surgical repair of myelomeningocele how to change an occlusive dressing on the child's back. Which statement by the parents indicates that they understand this procedure? A. "We should rapidly remove the tape from the edges of the dressing when changing it." B. "The dressing should be wetted periodically to keep the skin incision moist." C. "The dressing will help dry the sutures for ease of removal." D. " The purpose of the dressing is to protect the incision from fecal contamination." 11. While the nurse is preparing to administer a high volume saline enema to a male client, the client appears anxious and states that he is not able to turn on his right side without help because of a recent stroke. What action should the nurse take first? A. Reassure the client that he can remain in any position of comfort during the enema. B. Assess the client's ability to independently turn to his left side. C. Instruct the client that the procedure will only last about ten minutes. D. Ask a UAP to assist the client to maintain a right lateral position. 12. The nurse notes that a client is experiencing supraventricular tachyacardia (SVT). Which action should the nurse implement? A. Assess the client's heart sounds and vital signs. B. Call a code and start CPR immediately. C. Prepare to administer adenosine, an antidysrhythmic. D. Place a crash cart at the client's bedside. 13. A client is receiving an IV infusion of regular insulin, 50 units in 100 ml of normal saline at 4 units/ hour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only.) 14 A client takes dronedarone (Multaq) 400 mg PO twice daily is admitted with chest pain and shortness of breath. The nurse should withhold the Multaq if the client manifests which finding? A. Three premature ventricular beats/minute. B. QTc interval less than 500 milliseconds. C. Respiratory rate greater than 30 beats/minute. D. Palpable radial pulse less than 50 beats/minute. 15. A middle-aged client with complaints of chest pain radiating into his jaw is en route to the hospital via ambulance. Oxygen was started, threee nitroglycerin sprays of 5 minute intervals were administered, with no pain relief, and an IV was initiated. The cardiac monitor indicates normal sinus rhythm. On arrival at the Emergency Department, which intervention should the nurse implement first? A. Prepare for defibrillation or cardioversion. B. Inject 5,000 units heparin subcutaneously C. Obtain a 12 lead EKG. D. Administer a chewable aspirin 325 mg. 16. The nurse is planning a fall prevention program for the residents at a long-term care facility. Which intervention is most important in providing a safe environment? A. Encourage clients to wear rubber-soled shoes. B. Accompany residents older than 80 years during ambulation. C. Apply a vest restraint prophylactically to confused residents. D. Leave the hall lights on during the night. 17. For a client who has been receiving linezolid (Zyvox) for two weeks to treat an MRSAinfected wounds, what finding requires the most immediate action by the nurse? A. Ecchymosis B. Insomnia C. Tongue discoloration D. Vaginal discharge 18. The unlicensed assistive personnel (UAP) caring for a postoperative client reports to the charge nurse that the client is not using the incentive spirometer effectively. What action should the charge nurse implement? A.Schedule time later in the morning to review the use of incentive spirometer with the client. B. Ask the practical nurse assigned to care for the client to review the use of spirometer with the client. C. Encourage the UAP to demonstrate the effective use of the incentive spirometer to the client. D. Advise the UAP that the respiratory therapist is responsible to supervise the client's use of the spirometer. 19. During discharge teaching the mother asks why her premature infant should get monthly Synagis (Palivizumab) injections. The nurse's response should be bsed on what information? A. Monthly injections promote normal neurological and physical development. B. This drug protects the premature infant from respiratory syncytial virus (RSV) C. These injections prevent retinopathy of prematurity caused by high levels of oxygen. D. This medication provides surfactant, which helps the lungs mature more quickly, 20. In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse? A. A client with panreatic cancer who is experiencing intractable pain. B. An older client who fell yesterday and is now complaining of diplopia. C. An adult newly diagnosed with Type 1 diabetes and high cholesterol. D. An elderly client with Alzeimer's disease complicated by dysphagia. 21. The RN is in charge of a 20-bed surgical unit and is preparing assignments for the shift. Which nursing task should be assigned to the LPN? A. Administer a unit of blood to a client who has decreased hemoglobin and hematocrit. B. Take the routine vital signs on a client who just returned from surgery. C. Teach a client who has a new sigmoid colostomy how to irrigate the colostomy. D. Administer a pain medication to a client who had a bowel resection yesterday. 22. Following the administration of total parenteral nutrition (TPN) via a central line to a client diagnosed with inflammatory bowel disease (IBD), the nurse should expect what outcome? A. Afebrile with no purulent drainage from catheter site. B. Hydration as evidenced by tented skin turgor. C. A weight loss of 6 pounds within two weeks. D. A negative nitrogen balance during TPN administration 23. What is the most important primary preventative measure the nurse can emphasize as a means of reducing the risk of developing acute glomerulonephritis in the general population? A. Encourage all persons to have a yearly physical with urinalysis B. Teach all females to seek medical attention for urinary tract infections. C. Use good handwashing techniques to prevent throat and skin infections. D. Eat a low salt diet and monitor the blood pressure frequently. 24. The culture and sensitivity report for a client who has been receiving a broad spectrum antibiotic indicated that the bacteria is resistant to the currently prescribed medication. What action should the nurse implement in response to this finding. A. Notify the lab of the need for drug peak and trough levels B. Determine if the white blood cell count has increased. C. Administer the next scheduled dose of the antibiotic. D. Assess the oral mucosa for signs of superinfection. 25. When the healthcare provider calls to check on the status of a client with congestive heart failure who was given IV furosemide (Lasix) four hours ago, the nurse reports that the client has bibasilar crackles. What additional information is most important for the nurse to report to the healthcare provider? The client: A. is taking ice chips B. is receiving intravenous fluids at 125 ml/hour C. is receiving 50% oxygen per venturi mask D. has had a urine output of 600 ml the past four hours. 26. In caring for a client who is receiving peritoneal dialysis, the nurse should be alert for what complications? A. Clear dialysate drainage and burning on urination. B. Abdominal pain, tenderness, and rigidity. C. An occluded vascular access device and flank pain. D. Increased serum albumin level, decreased BUN, and increased hematocrit. 27. The home care nurse observes an older client place the walker in front of the chair for support upon standing. What action should the nurse take? A. Observe the client's strength and balnce as she arises. B. Instruct the client to use the arms of the chair for support. C. Encourage the client to stand upright independently. D. Apply a gait belt to assess the client out of the chair. 28. An adult client being admitted to the psychiatric unit with a diagnosis of bipolar disorder arrives in an elated state. What is the best room assignmenrt the nurse can make for this client? A. A room that contain very little furniture B. A quiet room awat from the nurse's station C. A room that has at least two other clients assigned to it D. A bright-colored room located near the recreation room. 29. The nurse plans to place a sensor for a pulse oximeter. Which placement ensures the best measurement of oxygen saturation? A. Right upper extremity with 2+ pitting edema B. Left upper extremity with capillary refill 3 seconds C. Left lower extremity with a 3+ dorsalis pedis pulse D. Right lower extremity with a 1+ pedal pulse. 30. A client at 8 weeks gestation is told her hemoglobin is 9.5 mg/dl. Which nursing intervention has the highest priority? A. Explain tha this is a normal finding in early pregnancy. B. Instruct the client to eat a well-balanced diet. C. Probvide the client with a list of foods high in iron D. Obtain a prescription for an iron supplement. 31. The nurse is performing a routine well-child exam on a 5 year-old. While palpating the lymph nodes, the nurse feels several 0.5 cm nodes in the cervical area that are round, mobile, non-tender, and non warm to the touch. What do these findings most likely represent? A. An indicator of early stage mumps B. An expected finding for a well child of this age. C. A sign of acute lymphadenitis D. An abnormal finding in need of further investigation 32. An 86-year old female client complains to the nurse that she does not like to eat as much she used to because things taste differently to her now that she is olde. The nurse's response should be based on which fact? A. Taste sensation decreased in older adults because of diminished gastric secretions B. Older people often use poor taste sensation as an excuse to avoid eating foods they do not like. C. Poorly prepared meals and eating alone are the usual causes of a decreased appetite in older adults. D. A loss of appetite often occurs in older adults as a result of a decreased sense of smell. 33. The nurse is conducting health assessments. Which assessment finding increases a 56 year olf woman's risk for developing osteoporosis? A. Cigarrette smoking B. Family history of coronary heart disease C. Use of birth control pills until age 45 D. Obesity 34.The nurse is developing a teaching plan for a client with varicose veins. What instruction should be included in this plan? A. Soak feet in warm water when fatigues. B. Use elevators, instead of stairs C. Walk several minutes every hours D. Cross legs at the thighs only 35. The charge nurse in a critical care unit is reviewing client's conditions to determine who is stable enough to be transferred. Which client status report indicates readiness for transfer from the critical care unit to a medical unit? A. Myocradial infraction with sinus bradycardia and multiple ectopic beats B. End- stage renal failure with creatinine of 2.5 mg/dl and urinary output of 10 ml/hr C. Pulmonary embollus with an intravenous heparin infusion and new onset hematuria D. Adult respiratory distress with pulse oximetry of 88% 36. A male client sitting in his room tells the nurse," The CIA put this transistor right here under my left ear. They are transmitting messages. Can't you hear them? They're so loud they scare me." Which response is best for the nurse to provide? A. " What is the message telling you." B. " How long have you been hearing the messages." C. " The messages scare you?" D. "Do you think others hear the messages?" 37. In caring for a client with laryngitis, the nurse observes that the client has a frequent, dry cough while conversing with family members. The client also reports experiencing dysphagia due to pain. What action should the nurse implement? A. Instuct the client to restrict conversations B. Encourage the client to use the incentive spirometer C. Apply a cold compress to the client's throat. D./ Advise the client to restrict intake of oral liquids. 38. A male college student returns to the student health clinic one week after receiving a positive mono spot test for mononucleosis and requests a prescription for amoxicillin (Amoxil, Polymox). He is afevrile and complains of fatigue, a sore throat, dysphagia, and extremely swollen glands. What response should the nurse provide? A. Inform the healthcare provider of the client's request for the prescription. B. Explain that no effective treatment is available for these symptoms. C. Emphasize the need to avoid contact sports for at least two weeks. D. Clarify that these symptoms will not respond to antibiotic therapy 39. In establishing goals for the client's plan of care, which information is most important for the nurse to consider? A. Nursing diagnosis B. Evaluation strategies C. Clusteres assessment data D. Planned interventions 40. The nurse includes the diagnosis, "Impaired mobility related to weaknedd and fear of falling" in the plan of care of a postoperative cilent. Which goal should be added to the care plan to address this diagnosis? The client will: A. report any weakness to the nurse B. be instructed in safety measures C. not fall during the hospital stay D. demonstrate increased mobility 41. A client is receiving a continuous half strength tube feedinf at 50 ml/hour. To prepare enough of the solution for eight hours, how many ml of full strength feeding will the nurse need? (Enter numeric value only.) 42. A client is receiving an IV of Heparin Sodium 20,000 Units in 5% Dextrose Injection 500 ml at 27 ml/hr. The nurse wants to verify that the client is receiving the prescribed amount of heparin. How many untis is the client receiving every hour? (Enter numeric value only.) 43. The healthcare provider prescribes fluoxetine (Prozac) for a client with major depressive disorder. Which instruction should the nurse include in this client's medication teaching plan? A. Avoid eating avocados and drinking red wine B. Expect to feel more tired and lethargic C. Dry, cold skin is a common side effect D. Take the medication in the early morning 44. A client with hemothorax has a chest tube in the fourth intercostal space connected to suction at 20 cm H2O pressure. Four after insertion, which client outcome should the nurse consider to be within normal limits for this client? A. No bubbling in the suction chamber of the Pleuravac B. The dry gauze dressing over the insertion site is clean and intact C. Serous fluid in the drainage chamber of Pleuravac. D. Fluctuation with respiration in the water-seal chamber of the Pleuravac 45. The nurse assess a client who is immunosuppressed and is diagnosed with a respiratory infection. The client has respirations at 20 breaths/minute, pulse oximetry of 95%, clear bilateral breath sounds, and is afebrile with no productive cough. Which nursinf diagnosis should the nurse include in client's plan of care? A. Risk for activity intolerance B. Impaired gas exchanged C. Risk for ineffective airway clearance D. Impaired tissue perfusion 46. After diagnosis and initial treatment of a 3-year old child with cystic fibrosis, the nurse provides home care instructions to the mother. Which statement by the child's mother indicates that she understands home care treatment to provide pulmonary function? A. "Cough suppressants can be used four times a day." B."Chest physiotherapy should be performed at least twice a day." C. "Activities should be planned to avoid physical exertion." D. "The oxygen should be kept at 4 to 6 L/minute." 47. A male client who takes carvedilol (Coreg) 25 mg twice daily is admitted with atrial flutter. His ejection fraction (EF) is 30%, his blood pressure is 190/86, and he has a history of type 1 diabetes mellitus. The healthcare provider prescribes dronedarone (Multaq) 400 mg PO twice daily. Which assessment finding warrants immediate intervention by the nurse? A. Chronic dermatitis B. Abdominal pain C. Sever headache D. Sinus bradycardia 48. Two nurses were in a conflict related to weekend scheduling, but after a discussion, report that they resolved the issue between themselves. Which question should the nurse- manager ask to evaluate the quality of the decision-making process in this conflict resolution? A. "How much cooperation had been generated?" B. "Has understanding been increased between the two of you?" C. " How practical and realistic are the decisions that have been made?" D. "Are you both willing to work together?" 49. Which explanation of autonomic cardiac regulation mediated by sympathetic innervation is correct? A. Sympathetic activatin decreased dromotrophy by lowering conduction. B. Sympathetic activation boosts K+ efflux and increases the inotropic effect. C. Increased Na+ influx with sympathetic stimulation reduces pacemaker. D. Increased Ca+ influx with sympathetic stimulation raises the heart rate. 50. It is most important for the nurse to use an IV pump and/ or Buretrol, an in-line volume control device, when initiating IV therapy for a client following which surgical procedure? A. Femoral popliteal bypass B. Colostomy C. Craniotomy D. Total hip replacement 51. An adult client receives a prescription for permethrin (Acticin Cream 5%) to treat an infestation of scabies. The nurse instructs the client to massage the cream into the skin from the head to the soles of the feet, avoiding the eyes. Which additional instruction should the nurse provide? A. Remove the cream from the skin immediately is pruritis occurs, B. Shower or bathe 8 to 14 hours after treatment to remove cream. C. Avoid areas between fingers and toes during application D. Reapply cream in seven days to prevent reinfestation. 52. When assessing a client at 32-weeks gestation, the nurse determines that her deep tendon reflexes (DTRs) are 4+. What action should the nurse take first? A. Notify the healthcare provider B. Assess the client for pitting edema C. No action is required since this is a normal finding D. Determine the client's blood pressure 53. The nurse notices a reddened area on the coccyx of a wheelchair-bound client. Which intervention should the nurse implement? A. Encourage the client to shift weight while sitting. B. Ask the team leader to document the assessment findings C. Carefully rewash the site and apply Duoderm patch D. Provide a donut-shaped cushion for the client to use. 54. A client with a general anxiety disorder is pacing the hallway. The client tells the nurse," My heart us just racing and sometimes it feels like it's fluttering. I'm feeling short of breath and dizzy." What action should the nurse implement first? A. Administer an anti-anxiolytic B. Obtain the client's vital signs C. Escort the client to a quiet room. D. Initiate a diversionary activity 55. A client with general anxiety disorder is pacing the hallway. The client tells the nurse, "My heart is just racing and sometimes it feels like it's fluttering. I'm feeling short of breath and dizzy." What action should the nurse implement first? A. Adminster an anti-anxiolytic B. Obtain the client's vital signs C. Escort the client to a quiet room D. Initiate a diversionary activity. 56. A male client with gastroesophageal reflux (GERD) tells the clinic nurse that he continues to have epigastric distress, even after starting lansoprazole (Prevacid) Delayed Release capsules last week. Which action should the nurse take first? A. Ask the client about the usual administration time. B. Determine if the client is chewing or crushing the capsule contents C. Recommend that the client remain upright after meals for 30 minutes. D. Encourage mixing the granules with appplesauce, 57. The nurse is teaching a client newly diagnosed with diabetes mellitus the signs of hypoglycemia. What symptom should be included in the description of early signs of hypoglycemia? A. Difficulty swallowing B. Poluria C. Tremors D. Bradycardia 58. The nurse should question the use of dopamine, and adrenergic agonist, for a client with which assessment finding? A. Currently receiving a loop diuretic B. Experiencing ventricular fibrillation C. Blood pressure if 90/60 D. Is taking a tricyclic antidepressant 59. Following two defibrillation shocks, the client's ECG continues to indicate ventricular fibrillation (VF). Which intervention should the nurse implement next? A. Resume CPR immediately B. Perform the third defribrillation shock. C. Obtain an arterial blood gas sample. D. Administer an IV bolus of epinephrine 60. A client with a prescription for "do not resuscitate " (DNR) begins to manifests signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement? A. Assess the client's need for pain medication B. Notify the chaplain of the client's status C. Report the client's status to the healthcare provider D. Document the client's signs of impending death. 61. Which technique should be used to obtain a sterile urine specimen using a straight catheter? A. Discard the first specimen, clamp the catheter, then collect the next specimen. B. Drain the urine from the catheter into a sterile container C. Use a sterile syringe to obtain the specimen from the port. D. Drain the urine from the collection bad into a sterile container. 62. The nurse is caring for a client who is admitted to the telemetr unit for complications related to a myocardial (MI) that occurred 4 days ago. A 12 lead electrcardiogram (ECG) shows right axis deviation and poor R wave progression. Which assessment findings suggest that the client is at risk for right ventricular hypertrophy? A. Generalized fatigue, dizziness, swollen ankles B. Severe chest pain and shortness of breath C. Nausea, vomiting, and generalized edema D. Sharp, non-radiating chest pain and nausea 63. The nurse plans to place a sensor for a pulse oximeter. Which placement ensures the best measurement of oxygen saturation? A. Right upper extremity with 2+ pitting edema B. Right lower extremit with a 1+ pedal pulse C. Left upper extremity with capillary refill 3 seconds D. Left lower extremity with a 3+ dorsalis pedis pulse 64. The nurse should question a prescription for docusate sodium (Colace) for a client with which problem? A. First day post myocardial infarction B. Abdominal pain of unknown etiology C. Two days following a knee replacement D. History of liver disease 65. A client with an anterior wall myocardial infarction is admitted to the intensive care unit with persistently low blood pressure. The nurse determines the client's pulmonary capillary wedge pressure (PCWP) is 28 mm Hg and systemic vascular resistance (SVR) is 2000 dynes/sec/cm5. Which classification of medication is likely to optimize the client's SVR? A. Adrenergic B. Vasodilator C. Diuretic D. Positive inotropic agent 66. The nurse is evaluating discharge teaching of an adolescent who had a long log cast applied in the emergency department. Which statement by the adolescent indicates an understanding of cast care? A. " I should wrap a cloth around a stick before using it to scratch under my cast." B. " I will not be able to take a shower until the cast is removed from my leg." C. " I will put adhesive tape around the edges of the cast if they become sharp." D. " If my toes are tingling I will elevate my leg above my heart, on several pillows." 67. Which technique should the nurse use to assess for manifestations of erythema infectiosum (fifth disease) in a 4 year-old? A. Auscultate breath sounds B. Observe physical appearance C. Visualize oropharynx D. Palpate lymph nodes 68. A client is taking cromolin sodium (Intal) Inhaler for chronic asthma. Which statement