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The 4th of July holiday comes while a client is in the hospital being treated for schizophrenia. She is taking chlorpromazine and has improved to the point of being allowed to go with a group to the park for a picnic. The side effect of chlorpromazine that the nurse needs to keep in mind during this outing is:
A 15-year-old client was diagnosed as having cystic fibrosis at 8 months of age. He is in the hospital for a course of IV antibiotic therapy and vigorous chest physiotherapy. He has a poor appetite. The nurse can best help him to meet the desired outcome of consuming a prescribed number of calories by:
A 55-year-old woman entered the emergency room by ambulance. Her primary complaint is chest pain. She is receiving O2 via nasal cannula at 2 L/min for dyspnea. Which of the following findings in the client’s nursing assessment demand immediate nursing action?
A 48-year-old client presents with a long history of severedepression unrelieved by medication. He is admitted to the hospital for electroconvulsive therapy. Familymembers are very concerned about this therapy and are requesting information about aftereffects of the treatment. The nurse informs the family that he will:
Loss of appetite for a child with leukemia is a major recurrent problem. The plan of care should be designed to:
A 9-year-old child was in the garage with his father, who was repairing a lawnmower. Some gasoline ignited and caused an explosion. His father was killed, and the child has split-thickness and full-thickness burns over 40% of his upper body, face, neck, and arms. All of the following nursing diagnoses are included on his care plan. Which of these nursing diagnoses should have top priority during the first 24–48 hours postburn?
Which of the following nursing orders has the highest priority for a child with epiglottitis?
Diabetes mellitus is a disorder that affects 3.1 out of every 1000 children younger than 20 years old. It is characterized by an absence of, or marked decrease in, circulating insulin. When teaching a newly diagnosed diabetes client, the nurse includes information on the functions of insulin:
A 5-year-old child has suffered second-degree thermal burns over 30% of her body. Forty-eight hours after the burn injury, the nurse must begin to monitor the child for which one of the following complications?
In acute episodes of mania, lithium is effective in 1–2 weeks, but it may take up to 4 weeks, or even a few months, to treat symptoms fully. Sometimes an antipsychotic agent is prescribed during the first few days or weeks of an acute episode to manage severe behavioral excitement and acute psychotic symptoms. In addition to the lithium, which one of the following medications might the physician prescribe?
A female client with major depression stated that “life is hopeless and not worth living.” The nurse should place highest priority on which of the following questions?
A client at 6 months’ gestation complains of tiredness and dizziness. Her hemoglobin level is 10 g/dL, and her hematocrit value is 32%. Her nutritional intake is assessed as sufficient. The most likely diagnosis is:
A common complication of cirrhosis of the liver is prolonged bleeding. The nurse should be prepared to administer?
A child receiving chemotherapeutic drugs experiences a loss of appetite directly related to the therapy. Which of the following strategies should be most effective in encouraging the child to eat?
When planning care for the passive-aggressive client, the nurse includes the following goal:
A 19-year-old client has sustained a C-7 fracture, which resulted in his spinal cord being partially transected. By 2 weeks’ postinjury, his neck has been surgically stabilized, and he has been transferred from the intensive care unit. A potential life-threatening complication the nurse monitors the client for is:
A client presents to the psychiatric unit crying hysterically. She is diagnosed with severe anxiety disorder. The first nursing action is to:
A type I diabetic client delivers a male newborn. The newborn is 45 minutes old. What is the primary nursing goal in the nursery during the first hours for this newborn?
A 4-year-old child has Down syndrome. The community health nurse has coordinated a special preschool program. The nurse’s primary goal is to:
A client calls the prenatal clinic to schedule an appointment. She states she has missed three menstrual periods and thinks she might be pregnant. During her first visit to the prenatal clinic, it is confirmed that she is pregnant. The registered nurse (RN) learns that her last menstrual period began on June 10. According to Nägele’s rule, the estimated date of confinement is:
A 66-year-old female client has smoked 2 packs of cigarettes per day for 20 years. Her arterial blood gases on room air are as follows: pH 7.35; PO2 70 mm Hg; PCO2 55 mm Hg; HCO3 32 mEq/L. These blood gases reflect:
The nurse is assisting a 4th-day postoperative cholecystectomy client in planning her meals for tomorrow’s menu. Which vitamin is the most essential in promoting tissue healing?
Which stage of labor lasts from delivery of the baby to delivery of the placenta?
A 30-year-old client has been admitted to the psychiatric service with the diagnosis of schizophrenia. He tells the nurse that when the woman he had been dating broke up with him, the CIA had replaced her with an identical twin. The client is experiencing:
A client has been diagnosed with congestive heart failure. His fluid intake and output are strictly regulated. For lunch, he drank 8 oz of milk, 4 oz of tea, and 6 oz of coffee. His intake would be recorded as:
A 4 days postpartum client who is gravida 3, para 3, isexamined by the home health nurse during her first postpartum home visit. The nurse notes that she has a pink vaginal discharge with a serosanguineous consistency. The nurse would most accurately chart the client’s lochia as:
A 1-year-old child is to receive an IM injection ordered by his pediatrician. He has fallen asleep in his mother’s arms when the nurse approaches. Which approach is most appropriate at this time?
A female client has experienced varying degrees of depression throughout her life. Now that she is postmenopausal, her depression has increased. She is unable to motivate herself to clean her house or even to get out of bed and get dressed in the morning. The client was begun on fluoxetine (Prozac) therapy. When educating her about fluoxetine, what might the nurse caution her about?
A 35-year-old primigravida comes to the clinic for her first prenatal visit. The midwife, on examining the client, suspects that she is approximately 11 weeks pregnant. The pregnancy is positively confirmed by finding:
Medication is administered to a client who has been placed in restraints after a sudden violent episode, and his EPSs subside. Restraints can be removed when:
Which of the following blood values would require further nursing action in a newborn who is 4 hours old?
A client undergoes a transurethral resection, prostate (TURP). He returns from surgery with a three-way continuous Foley irrigation of normal saline in progress. The purpose of this bladder irrigation is to prevent:
Due to his prolonged history of alcohol abuse, an alcoholic client will most likely have deficiencies of which of the following nutrients?
A male client has heart failure. He has been instructed to gradually increase his activities. Which signs and symptoms of worsening heart failure should the nurse tell him to watch for that would indicate a need for him to lower his activity level?
As soon as a child has been diagnosed as “hearing impaired,” special education should begin. Which of the following special education tasks is the most difficult for a severely hearing-impaired child?
A client who is gravida 1 para 1 vaginally delivered a 7- lb girl. She received a midline episiotomy at delivery. When assessing the level of her uterus immediately following delivery, the nurse would expect the fundus to be located:
An 82-year-old former restaurant owner walks to the nursing station and states, “I have to go. The restaurant opens at 11 am.” Which response by the nurse is the most appropriate?
A client with cirrhosis of the liver becomes comatose and is started on neomycin 300 mg q6h via nasogastric tube. The rationale for this therapy is to:
A 2-day-old infant boy has been diagnosed with an atrial septal defect due to a persistent patent foramen ovale.
When explaining the diagnosis to the mother, the nurse includes in the discussion the function of the foramen ovale. In fetal circulation, the foramen ovale allows a portion of the blood to bypass the:
A 2-year-old child with a scalp laceration and subdural hematoma of the temporal area as a result of falling out of bed should be prevented from:
A client is 2 hours post ventriculoperitoneal shunt placement. How should the nurse position the client?
The physician of a client diagnosed with alcoholism orders neomycin 0.5 g q6h to prevent hepatic coma. Neomycin decreases serum ammonia levels by:
A husband and wife and their two children, age 9 and age 5, are requesting family therapy. Which of the following strategies is most therapeutic for the nurse to use during the initial interaction with a family?
A client is receiving peritoneal dialysis. He has been taught to warm the dialyzing fluid prior to instilling it because:
The most important reason to closely assess circumferential burns at least every hour is that they may result in:
A female client at 37 weeks’ gestation has just undergone a nonstress test. The results were two fetal movements with a corresponding increase in fetal heart rate (FHR) of 15 bpm lasting 15 seconds within a 20-minute period. Her results would be classified as:
A male client has a history of diverticulosis. He has questions about the foods that he should eat. His nurse gives him the following information:
A 2-year-old boy is in the hospital outpatient department for observation after falling out of his crib and hitting his head. The nurse calls the physician to report:
The physician of an alcoholic client places him on a low-protein, high-carbohydrate diet. When choosing his menu, the client’s best choice from the items below would be:
A client’s prenatal screening indicated that she has no immunity to rubella. She is now 10 weeks pregnant. The best time to immunize her is:
On admission to the postpartal unit, the nurse’s assessment identifies the client’s fundus to be soft, 2 fingerbreadths above the umbilicus, and deviated to the right. This is most likely an indication of:
A client who has been diagnosed with anorexia nervosa refuses to eat lunch. The most therapeutic response by the nurse to her refusal is:
A female client admitted to the labor and delivery unit thinks her bag of water “broke” approximately 2 hours ago. She is having mild contractions 5 minutes apart. The most immediate nursing intervention would be to:
A 44-year-old client had an emergency cholecystectomy 3 days ago for a ruptured gallbladder. She complains of severe abdominal pain. Assessment reveals abdominal rigidity and distention, increased temperature, and tachycardia. Diagnostic testing reveals an elevated WBC count. The nurse suspects that the client has developed:
The mother of a preschooler reports to the nurse that he frequently tells lies. The admission assessment of the child indicates possible child abuse. The nurse knows that his:
The nurse writes the following nursing diagnosis for a client in acute renal failure—Impaired gas exchange related to:
A newborn girl’s father expresses concern that the newborn does not have good control of her hands and arms. It is important for the father to realize certain neurological patterns that characterize the newborn:
A mother who is breast-feeding her newborn asks the RN, “How can I express milk from my breasts manually?” The RN tells her that the correct method for manual milk expression includes using the thumb and the index finger to:
At 32 weeks’ gestation, a client is scheduled for a fetal activity test (nonstress test). She calls the clinic and asks the RN, “How do I prepare for the test I am scheduled for?” The RN will most likely inform her of the following instructions to help prepare her for the test:
In client teaching, the nurse should emphasize that fetal damage occurs more frequently with ingestion of drugs during:
A pregnant client during labor is irritable and feels the urge to vomit. The nurse should recognize this as the:
Two hours after the second injection of haloperidol, a client complains to the nurse of a stiff neck and inability to sit still. He is experiencing symptoms consistent with:
A 35-year-old client is admitted to the hospital for elective tubal ligation. While the nurse is doing preoperative teaching, the client says, “The anesthesiologist said she was going to give me balanced anesthesia. What exactly is that?” The best explanation for the nurse to give the client would be that balanced anesthesia:
A 38-year-old female client with a history of chronic schizophrenia, paranoid type, is currently an outpatient at the local mental health and mental retardation clinic. The client comes in once a week for medication evaluation and/or refills. She self-administers haloperidol 5 mg twice a day and benztropine 1 mg once a day. During a recent clinic visit, she says to the nurse, “I can’t stay still at night. I toss and turn and can’t fall asleep.” The nurse suspects that she may be experiencing:
Goal setting for a client with Meniere’s disease should include which of the following?
Often children are monitored with pulse oximeter. The pulse oximeter measures the:
A 2-year-old toddler is hospitalized with epiglottitis. In assessing the toddler, the nurse would expect to find:
To prevent transmission of bacterial meningitis, the nurse would instruct an infected baby’s mother to:
Morphine sulfate 4 mg IV push q2h prn for chest pain was ordered for a client in the emergency room with severe chest pain. The nurse administering the morphine sulfate knows which of the following therapeutic actions is related to the morphine sulfate?
The nurse assesses a postoperative mastectomy client and notes that breath sounds are diminished in both posterior bases. The nurse’s action should be to:
A 43-year-old client is admitted to the hospital with a diagnosis of peripheral vascular disorder. She arrives in her
room via stretcher and requires assistance to move to her bed. The nurse notes that her left leg is cold to touch. She complains of having recently experienced muscle spasms in that leg. To determine if these muscle spasms are indicative of intermittent claudication, the nurse would begin her assessment with the following question:
A 72-year-old male client had the Foley catheter that was inserted during the transurethral resection of his prostate removed today. He is concerned about the urinary incontinence he is having since removal of the Foley catheter. The nurse explains that:
A client is placed on lithium therapy for her manicdepressive illness. When monitoring the client, the nurse assesses the laboratory blood values. Toxicity may occur with lithium therapy when the blood level is above:
A 32-year-old mother of two was brought to the hospital by her husband. He reported that his wife could no longer manage the house and children. She does not sleep and talks day and night. She has purchased some very expensive clothes. The nurse noted that the client speaks rapidly and changes the subject irrationally. This is an example of:
An 18-year-old client enters the emergency room complaining of coughing, chest tightness, dyspnea, and sputum production. On physical assessment, the nurse notes agitation, nasal flaring, tachypnea, and expiratory wheezing. These signs should alert the nurse to:
A client’s renal calculi are identified as consisting of calcium phosphate. Which of the following diets would be appropriate?
A male client receives 10 U of regular human insulin SC at 9:00 AM. The nurse would expect peak action from this injection to occur at:
A 55-year-old man is admitted to the hospital with complaints of fatigue, jaundice, anorexia, and clay-colored stools. His admitting diagnosis is “rule out hepatitis.” Laboratory studies reveal elevated liver enzymes and bilirubin. In obtaining his health history, the nurse should assess his potential for exposure to hepatitis.
Which of the following represents a high-risk group for contracting this disease?
In assessing cardiovascular clients with progression of aortic stenosis, the nurse should be aware that there is typically:
Which of the following nursing orders should be included in the plan of care for a client with hepatitis C?
The physician orders fluoxetine (Prozac) for a depressed client. Which of the following should the nurse remember about fluoxetine?
A six-month-old infant has been admitted to the emergency room with febrile seizures. In the teaching of the parents, the nurse states that:
When inspecting a cardiovascular client, the nurse notes that he needs to sit upright to breathe. This behavior is most indicative of:
A client confides to the nurse that he tasted poison in his evening meal. This would be an example of what type of hallucination?
Dietary planning is an essential part of the diabetic client’s regimen. The American Diabetes Association recommends which of the following caloric guidelines for daily meal planning?
A diagnosis of hepatitis C is confirmed by a male client’s physician. The nurse should be knowledgeable of the differences between hepatitis A, B, and C. Which of the following are characteristics of hepatitis C?
A client with emphysema is placed on diuretics. In order to avoid potassium depletion as a side effect of the drug therapy, which of the following foods should be included in his diet?
The usual treatment for diabetes insipidus is with IM or SC injection of vasopressin tannate in oil. Nursing care related to the client receiving IM vasopressin tannate would include:
Which of the following signs and symptoms indicates a tension pneumothorax as compared to an open pneumothorax?
A client is 6 weeks pregnant. During her first prenatal visit, she asks, “How much alcohol is safe to drink during pregnancy?” The nurse’s response is:
When assessing fetal heart rate status during labor, the monitor displays late decelerations with tachycardia and decreasing variability. What action should the nurse take?
A 27-year-old man was diagnosed with type I diabetes 3 months ago. Two weeks ago he complained of pain, redness, and tenderness in his right lower leg. He is admitted to the hospital with a slight elevation of temperature and vague complaints of “not feeling well.” At 4:30 PM on the day of his admission, his blood glucose level is 50 mg; dinner will be served at 5:00 PM. The best nursing action would be to:
A 26-year-old client has no children. She has had an abdominal hysterectomy. In the first 24 hours postoperatively, the nurse would be concerned if the client:
A 15-year-old child is admitted to the pediatric unit with a diagnosis of thalassemia. Which of the following would be included in educating the mother and child as part of discharge planning?
A male infant is to be discharged home this morning. Which instruction related to his cord care should be included in his mother’s discharge teaching plan?
An 8-year-old boy has been diagnosed with hemophilia. Which of the following diagnostic blood studies is characteristically abnormal in this disorder?
A client is pregnant for the fourth time and has had three normal vaginal deliveries. She is in active labor and fully dilated. Suddenly she calls, “Nurse, the baby is coming.” As the nurse responds to her call, which one of the following observations should the nurse make first?
A male client tells his nurse that he has had an ulcer in the past and is afraid it is “flaring up again.” The nurse begins to ask him specific questions about his symptoms. The nurse knows that a symptom that might indicate a serious complication of an ulcer is:
A young child has been placed in a spica cast. The chief concern of the nurse during the first few hours is:
During the admitting mental health assessment, a client demonstrates involuntary muscular activity. He has a marked facial tic around the mouth that is distracting to the nurse during the interview. The nurse recognizes the behavior and documents it as:
A 12-year-old girl has been diagnosed with insulindependent diabetes mellitus. Which of these principles would best guide her nutritional management?
A premature infant needs supplemental O2 therapy. A nursing intervention that reduces the risk of retrolental fibroplasia is to:
A 79-year-old client with Alzheimer’s disease is exhibiting significant memory impairment, cognitive impairment, extremely impaired judgment in social situations, and agitation when placed in a new situation or around unfamiliar people. The nurse should include the following strategy in the client’s care:
A male client has asthma and his physician has prescribed beclomethasone (Vanceril) 3 puffs tid in addition to his other medications. After taking his beclomethasone, the client should be instructed to:
A client who is 7 months pregnant is diagnosed with pyelonephritis. The nurse anticipates the physician ordering:
A 1000-mL dose of D5W 1⁄2 normal saline is to be infused in 8 hours. The drop factor for the tubing is 60 gtt/min. How many drops per minute should the nurse administer?
A 17-year-old client has a T-4 spinal cord injury. At present, he is learning to catheterize himself. When he says, “This is too much trouble. I would rather just have a Foley.’’ An appropriate response for the RN teaching him would be:
In performing the initial nursing assessment on a client at the prenatal clinic, the nurse will know that which of the following alterations is abnormal during pregnancy?
In addition to changing the mother’s position to relieve cord pressure, the nurse may employ the following measure (s) in the event that she observes the cord out of the vagina:
A male client is scheduled for a liver biopsy. In preparing him for this test, the nurse should:
Which nursing implication is appropriate for a client undergoing a paracentesis?
Which one of the following is considered a reliable indicator for assessing the adequacy of fluid resuscitation in a 3-year-old child who suffered partial- and fullthickness burns to 25% of her body?
A client is taught to eat foods high in potassium. Which food choices would indicate that this teaching has been successful?
When a client with pancreatitis is discharged, the nurse needs to teach him how to prevent another occurrence of acute pancreatitis. Which of the following statements would indicate he has an understanding of his disease?
The nurse provides a male client with diet teaching so that he can help prevent constipation in the future. Which food choices indicate that this teaching has been understood?
The nurse would be concerned if a client exhibited which of the following symptoms during her postpartum stay?
Nursing interventions designed to decrease the risk of infection in a client with an indwelling catheter include:
A client tells the nurse that she has had a history of urinary tract infections. The nurse would do further health teaching if she verbalizes she will:
A 26-year-old client is in a treatment center for aprazolam (Xanax) abuse and continues to manifest moderate levels of anxiety 3 weeks into the rehabilitation program, often requesting medication for “his nerves.” Included in the client’s plan of care is to identify alternate methods of coping with stress and anxiety other than use of medication. After intervening with assistance in stress reduction techniques, identifying feelings and past coping, the nurse evaluates the outcome as being met if:
The nurse would assess the client’s correct understanding of the fertility awareness methods that enhance conception, if the client stated that:
TESTED 06 May 2024