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In a disaster, triage situation, the nurse should be least concerned with which of the following regarding a client in crisis?
The teaching plan for a postpartum client who is about to be discharged should include which of the following instructions?
When a client wishes to improve her appearance by removing excess skin from her face and neck, the nurse should provide teaching regarding which of the following procedures?
A client with urinary tract calculi needs to avoid which of the following foods?
Which of the following viruses is most likely to be acquired through casual contact with an infected individual?
An 80-year-old aphasic CVA client had abdominal surgery 2 days ago. Which of the following puts this client at the highest risk for inadequate pain management?
When a woman is receiving postpartum epidural morphine, the nurse should plan to observe for which of the following side effects to occur within the first 3 hours?
Which of the following home-care strategies is most likely to negatively impact the body image of a client with Cushing’s syndrome?
Safety measures for using crutches must be taught to clients. Safety measures for the use of crutches include:
Which of the following statements indicates adequate dietary understanding in a client with constipation?
Which of the following statements by a client indicates adequate preparation for magnetic resonance imaging?
The nurse should utilize data about which of the following to provide information about the nutritional status of a client being evaluated for malnutrition?
When a middle-age woman says to the nurse, “I’m really worried about menopause. When my mom went through it, she got really depressed.” The nurse’s best response is:
Mrs. Owens is the 81-year-old mother of Jonathan, who is 54 years old. Jonathan has had schizophrenia since he was 16 years old. Which of Mrs. Owens’s concerns is likely to predominate?
Which type of exercises might be prescribed to strengthen the pelvic floor muscles of a client with urinary incontinence?
A client who recently lost 50 pounds just received news that she is pregnant. A possible nursing diagnosis is:
All of the following are clinical manifestations indicating male climacteric except:
Which of the following nursing diagnoses is most appropriate for the client experiencing acute pancreatitis?
For which condition might a client’s antidiuretic hormone (ADH) level be increased?
A female client complains to the nurse at the health department that she has fatigue, shortness of breath, and lightheadedness. Her history reveals no significant medical problems. She states that she is always on a fad diet without any vitamin supplements. Which tests should the nurse expect the client to have first?
The parents of a 2-year-old child ask the nurse how they can teach their child to quit taking toys away from other children. Which of the following statements by the nurse offers the parents the best explanation of their child’s behavior?
A nurse is caring for a client with an elevated urine osmolarity. The nurse should assess the client for:
When assessing a client in the Emergency Department whose membranes have ruptured, the nurse notes that the fluid is a greenish color. What is the cause of this greenish coloration?
A client is to have an enema to reduce flatus. The enema tube should be inserted:
Which of the following blood pressure parameters indicates PIH? Elevation over a baseline of:
The chemotherapeutic agent 5-fluorourcacil (5-FU) is ordered for a client as an adjunct measure to surgery. Which statement about chemotherapy is true?
A nurse is setting up a vision-screening program for a new school. At what age will vision be 20/20 in children?
A mother that has never breast-feed a child before is having trouble getting the baby to latch on to the breast. The baby has lost 3% of its’ birth weight within the first 2 days of life. The best statement is:
A client who has a known history of cardiac problems and is still smoking enters the clinic complaining of sudden onset of sharp, stabbing pain that intensifies with a deep breath. The pain is occurring on only one side and can be isolated upon general assessment. The nurse concludes that this description is most likely caused by:
A nurse is instructing a patient about the warning signs of (Digitalis) side effects. Which of the following side effects should the nurse tell the patient are sometimes associated with excessive levels of Digitalis?
A 13 year old girl is admitted to the ER with lower right abdominal discomfort. The admitting nursing should take which the following measures first?
The acts enacted by states to provide immunity from liability to persons who provide emergency care at an accident scene are called:
A two-year old has been in the hospital for 3 weeks and seldom seen family members due to isolation precautions. Which of the following hospitalization changes is most like to be occurring?
A nurse is caring for a 10 year-old boy who has just been diagnosed with a congenital heart defect. Which of the following clinical signs does not indicate CHF?
Which of the following syndromes associated with incomplete lesions of the spinal cord is a result of damage to one-half of the spinal cord?
A mother brings her 1-year-old child to the clinic. The child has no record of previous immunizations, and the mother confirms the child has not been immunized. Teaching by the nurse should include which of the following?
An 85-year-old client is eligible for Medicarereimbursable home care services. Referral is contingent on meeting which of the following criteria?
The charge nurse on a cardiac unit tells you a patient is exhibiting signs of right-sided heart failure. Which of the following would not indicate right-sided heart failure?
A high school nurse observes a 14 year-old female rubbing her scalp excessively in the gym. The most appropriate course of action for the nurse to do is:
A nurse working a surgical unit, notices a patient is experiencing SOB, calf pain, and warmth over the posterior calf. All of these may indicate which of the following medical conditions?
A nurse is covering a pediatric unit and is responsible for a 15 year-old male patient on the floor. The mother of the child states, “I think my son is sexually interested in girls.” The most appropriate course of action of the nurse is to respond by stating:
If a client is suffering from thyroid storm, the PN can expect to find on assessment:
A young female teenager describes a brutal assault and rape to the nurse on duty. Which of the following actions should the nurse take first?
Which of the following arterial blood gas values indicates a patient may be experiencing a condition of metabolic acidosis?
A client admitted to the medical nursing unit has classic symptoms of tuberculosis (TB) and tests positive on the purified protein derivative (PPD) skin test. Several months later, the nurse who cared for the client also tests positive on an annual TB skin test for work. The most likely course of treatment if the chest X-ray (CXR) is negative is to:
Why is it often necessary to draw a complete blood count and differential (CBC/differential) when a client is being treated with an antiepileptic drug (AED)?
When a client describes their family as having multiple wives, all of whom are sisters, married to one man, the nurse documents the family structure as?
A nurse is teaching a client newly diagnosed with Emphysema about the disease process. Which of the following statements best explains the problems associated with emphysema and could be adapted for use in the nurse’s discussion with the client?
A client diagnosed with Borderline Personality Disorder frequently attempts to burn herself. The best intervention to facilitate behavior change is:
A 64 year-old Alzheimer’s patient has exhibited excessive cognitive decline resulting in harmful behaviors. The physician orders restraints to be placed on the patient. Which of the following is the appropriate procedure?
A case management clinical pathway for congestive heart failure might include all of the following except:
A client was involved in a motor vehicle accident in which the seat belt was not worn. The client is exhibiting crepitus, decreased breath sounds on the left, complains of shortness of breath, and has a respiratory rate of 34/min. Which of the following assessment findings should concern the nurse the most?
A nurse is working in a pediatric clinic and a 25 year-old mother comes in with a 4 week-old baby. The mother is stress out about loss of sleep and the baby exhibits signs of colic. Which of the following techniques should the nurse teach the mother?
Metformin (Glucophage) is administered to clients with type II diabetes mellitus. Metformin is an example of:
A client needs to rapidly achieve a therapeutic plasma drug concentration of a medication. Rather than wait for steady state to be achieved, the physician might order:
A 55 year-old female asks a nurse the following, “Which mineral/vitamin is the most important to prevent progression of osteoporosis. The nurse should state:
A nurse is caring for a patient who has recently been diagnosed with fibromyalgia and COPD. Which of the following tasks should the nurse delegate to a nursing assistant?
A nurse is reviewing a patient’s current Lithium levels. Which of the following values is outside the therapeutic range?
An nurse is instructing a patient on the order of sensations with the application of an ice water bath for a swollen right ankle. Which of the following is the correct order of sensations experienced with an ice water bath?
Two staff nurses were considered for promotion to head nurse. The promotion is announced via a memo on the unit bulletin board. The nurse who was not promoted tells a friend, “Oh, well, I really didn’t want the job anyway.” This is an example of:
Which of the following nursing diagnoses might be appropriate as Parkinson’s disease progresses and complications develop?
While undergoing fetal heart monitoring, a pregnant Native-American woman requests that a medicine woman be present in the examination room. Which of the following is an appropriate response by the nurse?
A client with dumping syndrome should ___________ while a client with GERD should ___________.
A client is having a seizure; his blood oxygen saturation drops from 92% to 82%. What should the nurse do first?
All of the following factors, when identified in the history of a family, are correlated with poverty except:
The nurse is teaching parents of a newborn about feeding their infant. Which of the following instructions should the nurse include?
Which of the following is most likely to impact the body image of an infant newly diagnosed with Hemophilia?
For which of the following conditions might blood be drawn for uric acid level?
For a client with suspected appendicitis, the nurse should expect to find abdominal tenderness in which quadrant?
Which of the following terms refers to soft-tissue injury caused by blunt force?
A young boy is recently diagnosed with a seizure disorder. Which of the following statements by the boy’s mother indicates a need for further teaching by the nurse?
Following a classic cholecystectomy resection for multiple stones, the PACU nurse observes a serosanguious drainage on the dressing. The most appropriate intervention is to:
Assessment of the client with an arteriovenous fistula for hemodialysis should include:
The nurse teaching about preventable diseases should emphasize the importance of getting the following vaccines:
A safety measure to implement when transferring a client with hemiparesis from a bed to a wheelchair is:
Which of the following foods should be avoided by clients who are prone to develop heartburn as a result of gastroesophgeal reflux disease (GERD)?
A 20-year-old obese female client is preparing to have gastric bypass surgery for weight loss. She says to the nurse, “I need this surgery because nothing else I have done has helped me to lose weight.” Which response by the nurse is most appropriate?
What do the following ABG values indicate: pH 7.38, PO2 78 mmHg, PCO2 36mmHg, and HCO3 24 mEq/L?
Which of the following is likely to increase the risk of sexually transmitted disease?
Which of the following injuries, if demonstrated by a client entering the Emergency Department, is the highest priority?
Which of the following is an appropriate nursing goal for a client at risk for nutritional problems?
Diagnostic genetic counseling, for procedures such as amniocentesis and chorionic villus sampling, allows clients to make all of the following choices except:
Ashley and her boyfriend Chris, both 19 years old, are transported to the Emergency Department after being involved in a motorcycle accident. Chris is badly hurt, but Ashley has no apparent injuries, though she appears confused and has trouble focusing on what is going on around her. She complains of dizziness and nausea. Her pulse is rapid, and she is hyperventilating. The nurse should assess Ashley’s level of anxiety as:
A client who is immobilized secondary to traction is complaining of constipation. Which of the following medications should the nurse expect to be ordered?
How often should the nurse change the intravenous tubing on total parenteral nutrition solutions?
Which of the following medications is a serotonin antagonist that might be used to relieve nausea and vomiting?
Which of the following physical findings indicates that an 11–12-month-old child is at risk for developmental dysplasia of the hip?
A client’s postoperative pain seems to be getting worse instead of better. When the nurse asks the client, “Why do you think it’s getting worse?” the client replies, “My wife died last month. It’s all I can think about.” The nurse must now consider:
A client with Parkinson’s disease has difficulty performing voluntary movements. This is known as:
Which of the following strategies should the nurse include when planning care for children of migrant workers?
A preschooler has successfully completed the test item “counts 5 blocks” on the Denver II test. This pass is evidence of which of the following developmental concepts?
Which of the following should not be included in the teaching for clients who take oral iron preparations?
The nurse is caring for a postpartum woman who has relinquished her baby for adoption. The care plan for the client should include which of the following priority strategies?
A man reports his wife is constantly cleaning. The activity has interfered with the family life. Friends have stopped visiting because she makes them uncomfortable. He states he has awakened in the middle of the night and found her cleaning. The nurse should consult with the couple and recommend the husband help with therapy by:
Which of the following procedures describes an opening between the colon and abdominal wall?
A client is admitted with a diagnosis of Multiple Drug Use. The nurse should plan care based on knowledge that:
Pulling is easier than pushing. So pulling a client rather than pushing him or her has which of the following advantages?
Which instruction should be given in a health education class regarding testicular cancer?
Which of the following conditions has a severe complication of respiratory failure?
Which of the following foods present a problem for a client diagnosed with Celiac Disease?
Which of the following NSAIDS is most commonly used for a brief time for acute pain?
A client is having problems with her ankles. To assess her ankles’ ROM, which ROM exercises should the nurse have her perform?
Two staff nurses were considered for promotion to head nurse. The promotion is announced via a memo on the unit bulletin board. When the nurse who was not promoted first read the memo and learned that the other nurse had received the promotion, she left the room in tears. This behavior is an example of:
Which of the following statements by a client with gastroesophageal reflux disease (GERD) indicates adequate understanding?
Which of the following client groups should the nurse recognize as the fastest-growing segment of the homeless population?
When working with multicultural populations, the nurse should consider all of the following when planning care for a client with an altered sexuality pattern except:
When teaching parents how their children learn sex role identification, the nurse should include which of the following statements?
Clients who take iron preparations should be warned of the possible side effects, which might include:
While performing a physical assessment on a 6-month-old infant, the nurse observes head lag. Which of the following nursing actions should the nurse perform first?
In managing nausea related to Morphine epidural analgesia, the nurse should administer:
To ensure proper immobilization and increase client comfort when using a rigid splint:
An Rh-negative woman with previous sensitization has delivered an Rh-positive fetus. Which of the following nursing actions should be included in the client’s care plan?
An effective intervention for a client diagnosed with Obsessive-Compulsive Disorder is:
A client with a nasogastric (NG) tube begins vomiting. What action should the nurse take?
The best lab test to diagnose disseminated intravascular coagulation (DIC) is:
When a client with a major burn experiences body image disturbance, which of the following is an appropriate nursing intervention classification?
A client newly diagnosed with Diabetes Mellitus needs education. Which of the following statements should the nurse include in this education?
A client had a colostomy done one day ago. Which of the following is an abnormal finding when assessing the stoma?
A client who is newly diagnosed with Parkinson’s disease and beginning medication therapy asks the nurse, “How soon will I see improvement ?” The nurse’s best response is:
Which of the following describes the stages of domestic violence in an intimate relationship?
Laboratory tests reveal the following electrolyte values for Mr. Smith: Na 135 mEq/L, Ca 8.5 mg/dL, Cl 102 mEq/L, and K 2.0 mEq/L. Which of the following values should the nurse report to the physician because of its potential risk to the client?
A client with asthma develops respiratory acidosis. Based on this diagnosis, what should the nurse expect the client’s serum potassium level to be?
A 17-year-old female was raped by a young man in her neighborhood. She is in the Emergency Department for evaluation and tests. After the procedure is completed, a rape crisis counselor (nurse specialist) talks to the client in a conference room regarding the rape. Implementing counseling by the nurse specialist for the raped victim represents:
Fat emulsions are frequently administered as a part of total parenteral nutrition. Which statement is true regarding fat emulsions?
A nurse is planning a brief treatment program for a client who was raped. A realistic, short-term goal is to:
The nurse is teaching a client about erythema infectiosum. Which of the following factors are not correct?
A 45-year-old client with type I diabetes is in need of support services upon discharge from a skilled rehabilitation unit. Which of the following services is an example of a skilled support service?
The nurse should teach parents of small children that the most common type of first-degree burn is:
A client is diagnosed with HIV. Which of the following are antiviral drug classes used in the treatment of HIV/AIDS?
The chemotherapeutic DNA alkylating agents such as nitrogen mustards are effective because they:
Which of the following ethnic groups is at highest risk in the United States for pesticide-related injuries?
Ethical and moral issues concerning restraints include all of the following except:
A 35-year-old Latin-American client wishes to lose weight to reduce her chances of developing heart disease and diabetes. The client states, “I do not know how to make my diet work with the kind of foods that my family eats.” What should the nurse do first to help the client determine a suitable diet for disease prevention?
A corporate executive works 60–80 hours a week. The client is experiencing some physical signs of stress. The nurse teaches the client biofeedback techniques. This is an example of which of the following health-promotion interventions?
A client begins a regimen of chemotherapy. Her platelet counts falls to 98,000. Which action is least likely to increase the risk of hemorrhage?
In a disaster situation, the nurse assessing a diabetic client on insulin assesses for all of the following except:
The physician orders the antibiotics ampicillin (Omnipen) and gentamicin (Garamycin) for a newly admitted client with an infection. The nurse should:
Central venous access devices (CVADs) are frequently utilized to administer chemotherapy. What is an advantage of using CVADs for chemotherapeutic agent administration?
The client’s lab culture report is negative for a suspected infection. A test that can correctly identify those who do not have a given disease is:
What is the primary theory that explains a family’s concept of health and illness?
A 4-year-old client is unable to go to sleep at night in the hospital. Which nursing intervention best promotes sleep for the child?
Ms. Petty is having difficulty falling asleep. Which of the following measures promote sleep?
A hospitalized client has just been informed that he has terminal cancer. He says to the nurse, “There must be some mistake in the diagnosis.” The nurse determines that the client is demonstrating which of the following?
Mr. H. is upset regarding being in the hospital for another day because he states it costs too much. The rights he is likely to demand include all of the following except:
Which is the best way to position a client’s neck for palpation of the thyroid?
In performing a psychosocial assessment, the nurse begins by asking questions that encourage the client to describe problematic behaviors and situations. The next step is to elicit the client’s:
A child comes to the clinic with a skin rash. The maculopapular lesions are distributed around the mouth and have honey-colored drainage. The caregiver states that the rash is getting worse and seems to spread with the child’s scratching. Which of the following advisory comments should be given?
As part of a routine health screening, the nurse notes the play of a 2-year-old child. Which of the following is an example of age-appropriate play at this age?
The most effective nursing strategy to assist a client in recognizing and using personal strength includes:
All of the following are common reasons that nurses are reluctant to delegate except:
One day postoperative, the client complains of dyspnea, and his respiratory rate (RR) is 35, slightly labored, and there are no breath sounds in the lower-right base. The nurse should suspect:
A nurse discharge planner is preparing a client for discharge from an acute care setting. The nurse assesses that skilled home care services are clinically indicated. This assessment is based on all of the following indicators except:
During surgery, it is found that a client with adenocarcinoma of the rectum has positive peritoneal lymph nodes. What is the next most likely site of metastasis?
A client asks the nurse if all donor blood products are cross-matched with the recipient to prevent a transfusion reaction. Which of the following always requires cross-matching?
The advanced directive in a client’s chart is dated August 12, 1998.The client’s daughter produces a Power of Attorney for Health Care, dated 2003, which contains different care direction(s). The nurse is supposed to:
Which of the following clients should refrain from therapy with the thiazide diuretic hydrochlorothiazide (HCTZ)?
The nurse’s first action upon discovery of an electrical fire should be which of the following?
The nurse acts as an advocate for the nursing profession by performing all of the following activities except:
A community health nurse is asked to organize a health promotion project that plans to provide glucose screening. This activity is most beneficial within what realm?
When assessing a client with early impairment of oxygen perfusion, such as pulmonary embolus, the nurse should expect to find restlessness and which of the following symptoms?
The intravenous route is potentially the most dangerous route of drug administration because:
A risk management program within a hospital is responsible for all of the following except:
Some drugs are excreted into bile and delivered to the intestines. Prior to elimination from the body, the drug might be absorbed. This process is known as:
When questioning an elder about suspected abuse, the nurse should keep the questions:
In the United States, several definitions of death are currently being used. The definition that uses apnea testing and pupillary responses to light is termed:
The emergency triage nurse should perform which action upon receiving the history that a client has a severe cough, fever, night sweats, and body wasting?
A hospitalized adult client who routinely works from midnight until 8 a.m. has a temperature of 99.1° F at 4 a.m. The nurse determines that this is most likely due to:
Which of the following factors can impact an individual’s ability to give informed consent?
A visitor accidentally knocks over a plastic pleural drainage system connected to a client, and it cracks. What should the nurse do first?
Activities of effective supervisors can be taskrelated or people-related activities. An example of a task-related supervisory activity is:
A complication of total parenteral nutrition (TPN) is the development of cholestasis. What is this condition?
The nurse is teaching a client about sleep and gives background information on normal sleep patterns. Which of the following substances promotes sleep?
The nurse suspects an elderly client has been the victim of abuse. The client denies abuse and declines assistance. The nurse’s next action should be to:
When medications have an additive, synergistic, or antagonistic effect on a tissue, a ________ reaction has occurred.
The nurse is preparing to administer IV Vancomycin to a client. Which of the following nursing actions
should be taken first?
The school nurse is conducting health screenings on schoolchildren. During the screening, she identifies a child with the behavioral characteristics of attention deficit disorder. Which of the following behaviors is consistent with this disorder?
When caring for a Native-American family, the nurse needs to consider which of the following?
TESTED 17 May 2024