COMMUNITY HEALTH NURSING EXAM QUESTIONS AND COMMUNITY HEALTH NURSING EXAM QUESTIONS AND •, Exams of Nursing

Download COMMUNITY HEALTH NURSING EXAM QUESTIONS AND COMMUNITY HEALTH NURSING EXAM QUESTIONS AND • and more Exams Nursing in PDF only on Docsity! COMMUNITY HEALTH NURSING EXAM QUESTIONS AND • ANSWERS 2023 A+ • Following discharge teaching, a male client with duodenal ulcer tells the nurse he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow- up action by the nurse? Review with the client the need to avoid foods that are rich in milk and cream. • During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate firs? Respiratory apnea of 30 seconds. • Which client should the nurse assess frequently because of the risk for overflow incontinence? A client who is confused and frequently forgets to go to the bathroom? • A client with pneumonia has arterial blood gases levels at: PH 7.33; PaCO2 49 mm/hg; HCO3 25 mEq/L; PaO2 95. What intervention should the nurse implement based on these results? Institute coughing and deep breathing protocols. • A client with hyperthyroidism is admitted to the postoperative after subtotal thyroidectomy. Which of the client's serum laboratory values requires intervention by the nurse? Total calcium 5.0 mg/dl. • In assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the fracture site, and recognizes that hematoma formation at the bone fragment site has occurred. What action should the nurse implement? Document the extend of the bruising in the medical record. • During a left femoral artery arteriogram, the healthcare provider inserts an arterial sheath and initiate. Through the sheath to dissolve an occluded artery. Which interventions should the nurse implement? SATA. -Instruct the client to keep the left leg straight. -Observe the insertion site for a hematoma. -Circle first noted drainage on the dressing. • A male client who was admitted with an acute myocardial infarction receives a cardiac diet with sodium restriction and complains that his hamburger is flavorless. Which condiment should the nurse offer? Fresh horseradish. • While completing an admission assessment for a client with unstable angina, which closed questions should the nurse ask about the client's pain? Does your pain occur when walking short distances? • An adult man reports that he recently experienced an episode of chest pressure and breathlessness when he was jogging in the neighborhood. He expresses concern because both of his deceased parents had heart disease and his father was a diabetic. He lives with his male partner, is a vegetarian, and takes atenolol which maintain his blood pressure at 138/74. Which risk factors should the nurse explore further with the client? Select all that apply: -History of hypertension. -Family heath history. • Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse that the client is experiencing a complication? "I have a headache that gets worse when I sit up." • A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child's foot. Which action should the nurse implement first? Cleanse the foot with soap and water and apply an antibiotic ointment. • A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences Palpitations and shortness of breath. • The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete? Auscultate the client's bowel sounds. • After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse? Capillary refill of 8 seconds. • The client with which type of wound is most likely to need immediate intervention by the nurse? Laceration. -White blood cell (WBC) count -Sputum culture and sensitivity • A client is admitted to isolation with the diagnosis of active tuberculosis. Which infection control measures should the nurse implement? Negative pressure environment. • A school nurse is called to the soccer field because a child has a nosebleed (epistaxis). In what position should the nurse place the child? Sitting up and leaning forward. • A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma? Altered consciousness within the first 24 hours after injury. • A female client with breast cancer who completed her first chemotherapy treatment today at an out-patient center is preparing for discharge. Which behavior indicates that the client understands her care needs? Rented movies and borrowed books to use while passing time at home. • Which instruction should the nurse provide a pregnant client who is complaining of heartburn? Eat small meal throughout the day to avoid a full stomach. • A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely? Hypokalemia. • A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amount of liquid stool. Which action should the nurse implement? Digitally check the client for a fecal impaction. • After changing to a new brand of laundry detergent, an adult male report that he has a fine itchy rash. Which assessment finding warrants immediate intervention by the nurse? Bilateral Wheezing. • The nurse should teach the parents of a 6-year-old recently diagnosed with asthma that the symptom of acute episode of asthma are due to which physiological response? Inflammation of the mucous membrane & bronchospasm. • A 10-year-old who has terminal brain cancer asks the nurse, "What will happen to my body when I die?" How should the nurse respond? "The heart will stop beating & you will stop breathing." • The nurse is assessing a 3-month-old infant who had a pleurotomy yesterday. This child should be medicated for pain based on which findings? Select all that apply: -Restlessness -Clenched Fist -Increased pulse rate -Increased respiratory rate. • The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, ptosis, mouth drooping and aspiration pneumonia. What is the priority nursing assessment that should be done before administering this medication? Determine which side of the body is weak. • The nurse who is working on a surgical unit receives change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse? Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills. • The nurse is caring for a client who had gastric bypass surgery yesterday. Which intervention is most important for the nurse to implement during the first 24 postoperative hours? Measure hourly urinary output. • When preparing to discharge a male client who has been hospitalized for an adrenal crisis, the client expresses concern about having another crisis. He tells the nurse that he wants to stay in the hospital a few more days. Which intervention should the nurse implement? Schedule an appointment for an out-patient psychosocial assessment. • An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her; she keeps hoping that he will change. What action should the nurse take first? Explore client's readiness to discuss the situation. • In caring for a client with Cushing syndrome, which serum laboratory value is most important for the nurse to monitor? Glucose. • Azithromycin is prescribed for an adolescent female who has lower lobe pneumonia and recurrent chlamydia. What information is most important for the nurse to provide to this client? Use two forms of contraception while taking this drug. • A client in the emergency center demonstrates rapid speech, flight of ideas, and reports sleeping only three hours during the past 48h. Based on these finding, it is most important for the nurse to review the laboratory value for which medication? Divalproex. • A male client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the healthcare provider? Serum lithium level of 1.6 mEq/L or mmol/l (SI). • A client was admitted to the cardiac observation unit 2 hours ago complaining of chest pain. On admission, the client's EKG showed bradycardia, ST depression, but no ventricular ectopy. The client suddenly reports a sharp increase in pain, telling the nurse, "I feel like an elephant just stepped on my chest" The EKG now shows Q waves and ST segment elevations in the anterior leads. What intervention should the nurse perform? Administer prescribed morphine sulfate IV and provide oxygen at 2 L/min per nasal cannula. • The nurse is developing a teaching program for the community. What population characteristic is most influential when choosing strategies for implementing a teaching plan? Literacy level. • A client is being discharged with a prescription for warfarin (Coumadin). What instruction should the nurse provide this client regarding diet? Eat approximated the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent. • A client who had a small bowel resection acquired methicillin resistant staphylococcus aureus (MRSA) while hospitalized. He treated and released but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention. Maintain contact transmission precaution Reposition the restraint tie onto the bedframe. • A female client with acute respiratory distress syndrome (ARDS) is chemically paralyzed and sedated while she is on as assist-control ventilator using 50% FIO2. Which assessment finding warrants immediate intervention by the nurse? Diminished left lower lobe sounds. • Following a motor vehicle collision, an adult female with a ruptured spleen and a blood pressure of 70/44, had an emergency splenectomy. Twelve hours after the surgery, her urine output is 25 ml/hour for the last two hours. What pathophysiological reason supports the nurse's decision to report this finding to the healthcare provider? Oliguria signals tubular necrosis related to hypoperfusion. • A nurse-manager is preparing the curricula for a class for charge nurses. A staffing formula based on what data ensures quality client care and is most cost- effective? Skills of staff and client acuity. • When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD), which approach should the nurse use? Explain that the client may be placed in five positions. • A client presents in the emergency room with right-sided facial asymmetry. The nurse asks the client to perform a series of movements that require use of the facial muscles. What symptoms suggest that the client has most likely experience a Bell's palsy rather than a stroke? Inability to close the affected eye, raise brow, or smile. • The nurse is teaching a client how to perform colostomy irrigations. When observing the client's return demonstration, which action indicated that the client understood the teaching? Keeps the irrigating container less than 18 inches above the stoma. • The nurse should teach the client to observe which precaution while taking dronedarone? Avoid grapefruits and its juice. • A client who sustained a head injury following an automobile collision is admitted to the hospital. The nurse includes the client's risk for developing increased intracranial pressure (ICP) in the plan of care. Which signs indicate to the nurse that ICP has increased? Confusion and papilledema. • The nurse is caring for a client receiving continuous IV fluids through a single lumen central venous catheter (CVC). Based on the CVC care bundle, which action should be completed daily to reduce the risk for infection? Confirm the necessity for continued use of the CVC. • During an annual physical examination, an older woman's fasting blood sugar (FBS) is determined to be 140 mg/dl or 7.8 mmol/L (SI). Which additional finding obtained during a follow-up visit 2 weeks later is most indicative that the client has diabetes mellitus (DM)? Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI). • A new mother tells the nurse that she is unsure if she will be able to transition into parenthood. What action should the nurse take? Determine if she can ask for support from family, friend, or the baby's father. • A client who was admitted yesterday with severe dehydration is complaining of pain a 24 gauge IV with normal saline is infusing at a rate of 150 ml/hour. Which intervention should the nurse implement first? Stop the normal saline infusion. • An elderly female is admitted because of a change in her level of sensorium. During the evening shift, the client attempts to get out bed and falls, breaking her left hip. Buck's skin traction is applied to the left leg while waiting for surgery. Which intervention is most important for the nurse to include in this client's plan care? Ensure proper alignment of the leg in traction. • An Unna boot is applied to a client with a venous stasis ulcer. One week later, when the Unna boot is removed during a follow-up appointment, the nurse observes that the ulcer site contains bright red tissue. What action should the nurse take in response to this finding? Document the ongoing wound healing. • At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." What is the priority nursing diagnosis for this client? Anxiety. • The nurse note a visible prolapse of the umbilical cord after a client experiences spontaneous rupture of the membranes during labor. What intervention should the nurse implement immediately? Elevate the presenting part off the cord. • A client who had a right hip replacement 3 day ago is pale has diminished breath sound over the left lower lung fields, a temperature of 100.2 F, and an oxygen saturation rate of 90%. The client is scheduled to be transferred to a skilled nursing facility (SNF) tomorrow for rehabilitative critical pathway. Based on the client's symptoms, what recommendation should the nurse give the healthcare provider? Reassess readiness for SNF transfer. • A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client's teaching plan? (Select all that apply.) -Recognize signs and symptoms of hypoglycemia. -Report persist polyuria to the healthcare provider. -Take Glucophage with the morning and evening meal. • The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the educational materials include which characteristics? Select all that apply: -Contains a list with definitions of unfamiliar terms -Uses common words with few Syllables -Uses pictures to help illustrate complex ideas • An older male comes to the clinic with a family member. When the nurse attempts to take the client's health history, he does not respond to questions in a clear manner. What action should the nurse implement first? Assess the surroundings for noise and distractions. • The nurse caring for a client with acute renal fluid (ARF) has noted that the client has voided 800 ml of urine in 4 hours. Based on this assessment, what should the nurse anticipate, that client will need? Large amounts of fluid and electrolyte replacement. • Which intervention should the nurse include in the plan of care for a child with tetanus? Minimize the amount of stimuli in the room. • Suicide precautions are initiated for a child admitted to the mental health unit following an intentional narcotic overdose. After a visitor leaves, the nurse finds a package of cigarettes in the client's room. Which intervention is most important for the nurse to implement? -Note signs of swelling and edema. • When implementing a disaster intervention plan, which intervention should the nurse implement first? Identify a command center where activities are coordinated. The nurse is auscultating a client's lung sounds. Which description should the nurse use to document this sound? High pitched or fine crackles. • A young adult client is admitted to the emergency room following a motor vehicle collision. The client's head hit the dashboard. Admission assessment include Blood pressure 85/45 mm Hg, temperature 98.6 F, pulse 124 beat/minute and respirations 22 breath/minute. Based on these data, the nurse formulates the first portion of nursing diagnosis as " Risk of injury" What term best expresses the "related to" portion of nursing diagnosis? Shock. • The healthcare provider prescribes the antibiotic Cefdinir (cephalosporin) 300mg PO every 12 h for a client with postoperative wound infections. Which foods should the nurse encourage this client to eat? Yogurt and/or buttermilk. • The charge nurse is making assignment on a psychiatric unit for a practical nurse (PN) and newly license register nurse (RN). Which client should be assigned to the RN? A young male with schizophrenia who said voices is telling him to kill his psychiatric. • The nurse is auscultating a client's heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio file to select the option that applies.) Murmur. • The public nurse health received funding to initiate primary prevention program in the community. Which program the best fits the nurse's proposal? Vitamin supplements for high-risk pregnant women. • When assessing and adult male who presents as the community health clinic with a history of hypertension, the nurse note that he has 2+ pitting edema in both ankles. He also has a history of gastroesophageal reflex disease (GERD) and depression. Which intervention is the most important for the nurse to implement? Review the client's use of over the counter (OTC) medications. • An older client is admitted to the intensive care unit with severe abdominal pain, abdominal distention, and absent bowel sound. The client has a history of smoking 2 packs of cigarettes daily for 50 years and is currently restless and confused. Vital signs are temperature 96`F, heart rate 122 beats/minute, respiratory rate 36 breaths/minute, mean arterial pressure (MAP) 64 mmHg and central venous pressure (CVP) 7 mmHg. Serum laboratory findings include hemoglobin 6.5 grams/dl, platelets 6o, 000, and white blood cell count (WBC) 3,000/mm3. Based on these findings this client is at greatest risk for which pathophysiological condition? Multiple organ dysfunction syndrome (MODS). • A client experiencing withdrawal from the benzodiazepines alprazolam (Xanax) is demonstrating severe agitation and tremors. What is the best initial nursing action? Initiate seizure precautions. • The nurse is caring for a client who is taking a macrolide to treat a bacterial infection. Which finding should the nurse report to the healthcare provider before administering the next dose? Jaundice. • A client with Alzheimer's disease (AD) is receiving trazodone (Desyrel), a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the client's mood and sleep patterns are improved, but there is no change in cognitive ability. How should the nurse respond to this information? Confirm the desired effect of the medication has been achieved. • A client with diabetic peripheral neuropathy has been taking pregabalin (Lyrica) for 4 days. Which finding indicates to the nurse that the medication is effective? Reduced level of pain. • A group of nurse-managers is asked to engage in a needs assessment for a piece of equipment that will be expensed to the organization's budget. Which question is most important to consider when analyzing the cost-benefit for this piece of equipment? How many departments can use this equipment? • While receiving a male postoperative client's staples de nurse observe that the client's eyes are closed, and his face and hands are clenched. The client states, "I just hate having staples removed". After acknowledgement the client's anxiety, what action should the nurse implement? Attempt to distract the client with general conversation. • A male client is admitted for the removal of an internal fixation that was inserted for the fracture ankle. During the admission history, he tells the nurse he recently received vancomycin (vancomycin) for a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which action should the nurse take? (Select all that apply.) -Collect multiple site screening culture for MRSA -Place the client on contact transmission precautions -Continue to monitor for client sign of infection. • The nurse plans to collect a 24- hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client? Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours. • The nurse assesses a client with new onset diarrhea. It is most important for the nurse to question the client about recent use of which type of medication? Antibiotics. • A neonate with a congenital heart defect (CHD) is demonstrating symptoms of heart failure (HF). Which interventions should the nurse include in the infant's plan of care? SATA -Give O2 at 6 L/nasal cannula for 3 repeated oximetry screens below 90% -Evaluate heart rate for effectiveness of cardio tonic medications -Use high energy formula 30 calories/ounce at Q3 hours feeding via soft nipples -Ensure Interrupted and frequent rest periods between procedures. • An elderly male client is admitted to the mental health unit with a sudden onset of global disorientation and is continuously conversing with his mother, who died 50 years ago. The nurse reviews the multiple prescriptions he is currently taking and assesses his urine specimen, which is cloudy, dark yellow, and has foul odor. These findings suggest that his client is experiencing which condition? Delirium. • Following an esophagogastroduodenoscopy (EGD) a male client is drowsy and difficult to arouse, and his respiration are slow and shallow. Which action should the nurse implement? Select all that apply. -Prepare medication reversal agent. -Check oxygen saturation level. -Apply oxygen via nasal cannula. • The nurse is planning preoperative teaching plan of a 12-years old child who is scheduled for surgery. To help reduce the child anxiety, which action is the best for the nurse to implement? Peripheral vasodilation. • A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide (Amphogel) is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention? Allopurinol (Zyloprim). • A male client's laboratory results include a platelet count of 105,000/ mm3 Based on this finding the nurse should include which action in the client's plan of care? Encourage him to use an electric razor. • A client is admitted to the hospital after experiencing a brain attack, commonly referred to as a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding? Persistent coughing while drinking. • At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the client's medical record. Based on date contained in the record, what action should the nurse take before assisting the client with ambulation: Remove sequential compression devices. • Which assessment finding for a client who is experiencing pontine myelinolysis should the nurse report to the healthcare provider? Sudden dysphagia. • A client is scheduled to receive an IW dose of ondansetron (Zofran) eight hours after receiving chemotherapy. The client has saline lock and is sleeping quietly without any restlessness. The nurse caring for the client is not certified in chemotherapy administration. What action should the nurse take? Administer the Zofran after flushing the saline lock with saline. • When providing diet teaching for a client with cholecystitis, which types of food choices the nurse recommend to the client? Low fat • A client with a history of cirrhosis and alcoholism is admitted with severe dyspnea and ascites. Which assessment finding warrants immediate intervention by the nurse? Muffled heart sounds. • When entering a client's room, the nurse discovers that the client is unresponsive and pulseless. The nurse initiate CPR and Calls for assistance. Which action should the nurse take next? Place cardiac monitor leads on the client's chest. • A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. What intervention should the nurse implement? Redress the abdominal incision. • An adult male client is admitted to the emergency room following an automobile collision in which he sustained a head injury. What assessment data would provide the earliest that the client is experiencing increased intracranial pressure (ICP)? Lethargy. • In preparing a diabetes education program, which goal should the nurse identify as the primary emphasis for a class on diabetes self-management? Enable clients to become active participating in controlling the disease process. • To reduce staff nurse role ambiguity, which strategy should the nurse manager implemented? Review the staff nurse job description to ensure that it is clear, accurate, and recurrent. • The nurse is assisting a new mother with infant feeding. Which information should the nurse provide that is most likely to result in a decrease milk supply for the mother who is breastfeeding? Supplemental feedings with formula. • Which assessment is more important for the nurse to include in the daily plan of care for a client with a burned extremity? Distal pulse intensity. • When assessing a 6-month-old infant, the nurse determines that the anterior fontanel is bulging. In which situation would this finding be most significant? Sitting upright. • A client with angina pectoris is being discharge from the hospital. What instruction should the nurse plan to include in this discharge teaching? Avoid all isometric exercises but walk regularly. • What is the priority nursing action when initiating morphine therapy via an intravenous patient-controlled analgesia (PCA) pump? Initiate the dosage lockout mechanism on the PCA pump. • The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn's survival? Heat loss. • A male client, who is 24 hours postoperative for an exploratory laparotomy, complains that he is "starving" because he has had no "real food" since before the surgery. Prior to advancing his diet, which intervention should the nurse implement? Auscultate bowel sounds in all four quadrants. • A male client with a long history of alcoholism is admitted because of mild confusion and fine motor tremors. He reports that he quit drinking alcohol and stopped smoking cigarettes one month ago after his brother died of lung cancer. Which intervention is most important for the nurses to include in the client's plan of care? Observe for changes in level of consciousness. • An older adult female admitted to the intensive care unit (ICU) with a possible stroke is intubated with ventilator setting of tidal volume 600, PlO2 40%, and respiratory rate of 12 breaths/minute. The arterial blood gas (ABG) results after intubation are PH 7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To normalize the client's ABG finding, which action is required? Increase ventilator rate. • The mother of the 12- month-old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice a day and has also experiences a loss of appetite. What instruction should the nurse provide? CPT should be performed more frequently, but at least an hour before meals. • A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale with insulin apart q6h are prescribed. What action should the nurse include in this client's plan of care? (PLP) and ask the nurse if mirror therapy will make the pain stop. Which response by the nurse is likely to be most helpful? Research indicates that mirror therapy is effective in reducing phantom limb pain. • An older adult client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant, heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement? Notify healthcare provider to prepare for pericardiocentesis. • A new member joins the nursing team spreads books on the table, puts items on two chairs, and sits on a third chair. The members of the group are forced to move closer and remove their possessions from the table what action should the nurse leader take? Ask the new person to move belonging to accommodate others. • The nurse is caring for a one-week-old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which findings are an indication of a postoperative complication? -Poor feeding and vomiting -Leakage of CSF from the incisional site -Abdominal distention • In monitoring tissue perfusion in a client following an above the knee amputation (aka), which action should the nurse include in the plan of care? Evaluate closet proximal pulse. • The leg of a client who is receiving hospice care have become mottled in appearance. When the nurse observes the unlicensed assistive personal (UAP) place a heating pad on the mottled areas, what action should the nurse take? Remove the heating pads and place a soft blanket over the client's leg and feet. • A client who underwent an uncomplicated gastric bypass surgery is having difficult with diet management. What dietary instruction is most important for the nurse to explain to the client? Plan volume-controlled evenly-space meal thorough the day. • If the nurse is initiating IV fluid replacement for a child who has dry, sticky mucous membranes, flushed skin, and fever of 103.6 F. Laboratory finding indicate that the child has a sodium concentration of 156 mEq/L. What physiologic mechanism contributes to this finding? Insensible loss of body fluids contributes to the hemoconcentration of serum solutes. • During a Woman's Health fair, which assignment is the best for the Practical Nurse (PN) who is working with a register nurse (RN) Prepare a woman for a bone density screening. • An adult client present to the clinic with large draining ulcers on both lower legs that are characteristics of Kaposi's sarcoma lesions. The client is accompanied by two family members. Which action should the nurse take? Send family to the waiting area while the client's history is taking • An adult client is exhibiting the maniac stage of bipolar disorder is admitted to the psychiatric unit. The client has lost 10 pounds in the last two weeks and has no bathed in a week "I'm trying to start a new business and "I'm too busy to eat". The client is oriented to time, place, person but not situation. Which nursing problem has the greatest priority? Imbalance nutrition. • The nurse is preparing a discharge teaching plan for a client who had a liver transplant. Which instruction is most important to include in this plan? Avoid crowds for first two months after surgery. • A client who had a percutaneous transluminal coronary angioplasty (PTCA) two weeks ago returns to the clinic for a follow up visit. The client has a postoperative ejection fraction ejection fraction of 30%. Today the client has lungs which are clear, +1 pedal edema, and a 5pound weight gain. Which intervention the nurse implement? Assess compliance with routine prescriptions. • The RN is assigned to care for four surgical clients. After receiving report, which client should the nurse see first? The client who is Three days postoperative colon resection receiving transfusion of packed RBCs. • The nurse is preparing an older client for discharge following cataract extraction. Which instruction should be included in the discharge teaching? Avoid straining at stool, bending, or lifting heavy objects. • At 40-week gestation, a laboring client who is lying is a supine position tells the nurse that she has finally found a comfortable position. What action should the nurse take? Place a wedge under the client's right hip. • A client with a history of diabetes and coronary artery disease is admitted with shortness of breath, anxiety, and confusion. The client's blood pressure is 80/60 mmHg, heart rate 120 beats/minute with audible third and fourth heart sounds, and bibasilar crackles. The client's average urinary output is 5 ml/hour. Normal saline is infusing at 124 ml/hour with a secondary infusion of dopamine at mcg/kg/minute per infusion pump. With intervention should the nurse implement? Titrate the dopamine infusion to raise the BP. • The nurse ends the assessment of a client by performing a mental status exam. Which statement correctly describes the purpose of the mental status exam? Evaluate the client's mood, cognition, and orientation. • An older adult resident of a long-term care facility has a 5-year history of hypertension. The client has a headache and rate the pain 5 on a pain scale 0 to 10. The client's blood pressure is currently 142/89. Which interventions should the nurse implement? (Select all that apply) -Administer a daily dose of lisinopril as scheduled. -Provide a PRN dose of acetaminophen for headache • When conducting diet teaching for a client who is on a postoperative soft diet, which foods should eat? (Select all that apply) -Pasta, noodles, rice. -Egg, tofu, ground meat. -Mashed, potatoes, pudding, milk. • The nurse is preparing a 4-day-old I infant with a serum bilirubin level of 19 mg/dl (325 micromol/L) for discharge from the hospital. When teaching the parents about home phototherapy, which instruction should the nurse include in the discharge teaching plan? A. Reposition the infant every 2 hours. B. Perform diaper changes under the light. C. Feed the infant every 4 hours. D. Cover with a receiving blanket. A. Reposition the infant every 2 hours. • When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority? Withhold food and fluid intake. • Assessment by the home health nurse of an older client who lives alone indicates that client has chronic constipations. Daily medications include furosemide for hypertension and heart failure and laxatives. To manage the client's constipation, which suggestions should the nurse provide? (Select all that apply) student stated she did not receive vaccination because she has asthma. How should the nurse respond? Offer to provide the influenza vaccination to the student while she is at the clinic. 225. A client with eczema is experiencing severe pruritus. Which PRN prescriptions should the nurse administer? (Select all that apply) -Topical corticosteroid. -Oral antihistamine 226. An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies. What is the best response by the nurse? Explain that the client will start to lose consciousness and his body system will slow down. 227. When should intimate partner violence (IPV) screening occur? As a routine part of each healthcare encounter. 228. A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge? Instructions about how much fluid the child should drink daily. 229. What action should the school nurse implement to provide secondary prevention to a school-age children? Initiate a hearing and vision screening program for first graders. 230. While assisting a client who recently had a hip replacement into a bed pan, the nurse notices that there is a small amount of bloody drainage on the surgical dressing, the client's skin is warm to the touch, and there is a strong odor from the urine. Which action should the nurse take? Measure the client's oral temperature. 231. While making rounds, the charge nurse notices that a young adult client with asthma who was admitted yesterday is sitting on the side of the bed and leaning over the bed-side-table. The client is currently receiving at 2 litters/minute via nasal cannula. The client is wheezing and is using pursed-lip breathing. Which intervention should the nurse implement? Administer a nebulizer Treatment. 232. A client with emphysema is being discharged from the hospital. The nurse enters the client's room to complete discharge teaching. The client reports feeling a little short of breath and is anxious about going home. What is the best course of action? Provide only necessary information in short, simple explanations with written instructions to take home. 233. An older adult male who had an abdominal cholecystectomy has become increasingly confused and disoriented over the past 24 hours. He is found wandering into another client's room and is return to his room by the unlicensed assistive personnel (UAP). What actions should the nurse take? (Select all that apply). -Report mental status change to the healthcare provider -Assess the client's breath sounds and oxygen saturation -Review the client's most recent serum electrolyte values 234. A client is admitted to a medical unit with the diagnosis of gastritis and chronic heavy alcohol abuse. What should the nurse administered to prevent the development of Wernicke's syndrome? Thiamine (Vitamin B1). 235. When conducting diet teaching for a client who was diagnosed with nutritional anemia in pregnancy, which foods should the nurse encourage the client to eat? (Select all that apply) -Fortified whole wheat cereals, whole-grain pasta, brown rice -Spinach, kale, dried raisins and apricots 236. A client with type 2 diabetes mellitus is admitted for antibiotic treatment for a leg ulcer. To monitor the client for the onset of hyperosmolar hyperglycemic nonketotic syndrome (HHNS), what actions should the nurse take? (Select all that apply) -Measure blood glucose -Monitor vital signs -Assessed level of consciousness 237. After receiving report, the nurse can most safely plan to assess which client last? The client with... No postoperative drainage in the Jackson-Pratt drain with the bulb compressed 238. The nurse instructs unlicensed assistive personnel (UAP) to turn an immobilized elderly client with an indwelling urinary catheter every two hours. What additional action should the nurse instruct the UAP to take each time the client is turned? Offer the client oral fluids. 239. The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendations should the nurse provide this client? (Select all that apply) -Inspect skin for redness -Use a residual limb shrinker -Wash the stump with soap and water 240. When assessing the surgical dressing of a client who had abdominal surgery the previous day, the nurse observes that a small amount of drainage is present on the dressing and the wound's Hemovac suction device is empty with the plug open. How should the nurse respond? Recompress the wound suction device and secure to plug. 241. A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus and tells the nurse the quarter is supposed to fix her child's hernia. Which explanations should the nurse provide? This hernia is a normal variation that resolves without treatment. 242. A client who is admitted to the intensive care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first? Evaluate swallow. 243. A client with possible acute kidney injury (AKI) is admitted to the hospital and mannitol is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement? Obtain vital signs and breath sounds. 244. A male client with COPD smokes two packs of cigarettes per day and is admitted to the hospital for a respiratory infection. He complains that he has trouble controlling respiratory distress at home when using his rescue inhaler. Which comment from the client indicates to the nurse that he is not using his inhaler properly? "After I squeeze the inhaler and swallow, I always feel a slight wave of nausea, bit it goes away" 245. A 6-years-old who has asthma is demonstrating a prolonged expiratory phase and wheezing and has 35% personal best peak expiratory flow rate (PEFR). Based on these finding, which action should the nurse implement first? Administer a prescribed bronchodilator. 246. A client is receiving lactulose (Portalac) for signs of hepatic encephalopathy. To evaluate the client's therapeutic response to this medication, which assessment should the nurse obtain? An older adult who is unable to communicate elimination needs. 263. A client with acute renal failure (ARF) is admitted for uncontrolled type 1 diabetes Mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is the most important for the nurse to include in this client's plan of care? Monitor the client's cardiac activity via telemetry. 264. A client with C-6 spinal cord injury rehabilitation. In the middle of the night the client reports a severe, pounding headache, and has observable piloerection or "goosebumps". The nurse should assess for which trigger? Full bladder. 265. A nurse working on an endocrine unit should see which client first. A client taking corticosteroids who has become disoriented in the last two hours. 266. Four hours after surgery, a client reports nausea and begins to vomit. The nurse notes that the client has a scopolamine transdermal patch applied behind the ear. What action should the nurse take? Notify the healthcare provider of the vomiting. 267. A client is receiving, and oral antibiotic suspension labeled 250 mg/2ml. The healthcare provider prescribes 200mg every 6 hours. How many ml should the nurse administer at each dose? (Enter numerical value only. If rounding is required, round to the nearest tenth) Answer: 1.6 268. The nurse identifies an electrolyte imbalance, an elevated pulse rate, and elevated BP for a client with chronic kidney disease. Which is the most important action for the nurse to take? Auscultate for irregular heart rate. 269. A client with persistent low back pain has received a prescription for electronic stimulator (TENS) unit. After the nurse applies the electrodes and turns on the power, the client reports feeling a tingling sensation. How should the nurse respond? Determine if the sensation feels uncomfortable. 270. A female client is extremely anxious after being informed that her mammogram was abnormal and needs to be repeated. Client is tearful and tells the nurse her mother died of breast cancer. What action should the nurse take? Encourage the client to continue expressing her fears and concerns. 271. The psychiatric nurse is talking to a newly admitted client when a male client diagnosed with antisocial behavior intrudes on the conversation and tells the nurse, "I have to talk to you right now! It is very important!" how should the nurse respond to this client? Inform him that the nurse is busy admitting a new client and will talk to him later. 272. The charge nurse is planning for the shift and has a registered nurse (RN) and a practical nurse (PN) on the team. Which client should the charge nurse assign to the RN? A 30-year-old depressed client who admits to suicide ideation. 273. A female client presents in the Emergency Department and tells the nurse that she was raped last night. Which question is most important for the nurse to ask? Has she taken a bath since the raped occurred? 274. While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values? Culture for sensitive organisms. 275. The nurse is demonstrating correct transfer procedures to the unlicensed assisted personnel (UAP) working on a rehabilitation unit. The UAPs ask the nurse how to safely move a physically disabled client from the wheelchair to a bed. What action should the nurse recommended? Place a client's locked wheelchair on the client's strong side next to the bed. 276. A client who is experiencing musculoskeletal pain receives a prescription for ketorolac 15mg IM q6 hours. The medication is depended in a 39mg/ml pre-filled syringe. Which action should the nurse implement when giving the medication? Waste 0.5 ml from the pre-filled syringe and inject the medication in the ventrogluteal site. 277. A client with a lower respiratory tract infection receives a prescription for ciprofloxacin 500mg PO q 12hours. When the client requests an afternoon snack, which dietary choice should the nurse provide? Cinnamon applesauce. 278. The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection would indicate to the nurse the client understands they prescribed diet? Roasted turkey canned vegetables. 279. An adult client with schizophrenia begins treatment three days ago with the Antipsychotic risperidone. The client also received prescription for trazodone as needed for sleep and clonazepam as needed for severe anxiety. When the client reports difficulty with swallowing, what action should the nurse take? Obtain a prescription for an anticholinergic medication. 280. One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in the clients plan of care? Teach need for dietary and supplementary vitamin D3. 281. When teaching a group of school-age children how to reduce the risk of Lyme disease which instruction should the camp nurse include? Wear long sleeves and pants. 282. A native-American male client diagnosed with pneumonia, states that in addition to his prescribed medical treatment of IV antibiotics he wishes to have a spiritual cleaning performed. Which outcome statement indicates that the best plan of care was followed? Participated actively in all treatment’s regimens. 283. A male client with cancer is admired to the oncology unit and tells the nurse that he is in the hospital for palliative care measures. The nurse notes that the client's admission prescription include radiation therapy. What action should the nurse implement? Ask the client about his expected goals for the hospitalization. 284. A client with myasthenia Gravis (MG) is receiving immunosuppressive therapy. Review recent laboratory test results show that the client's serum magnesium level has decreased below the normal range. In addition to contacting the healthcare provider, what nursing action is most important? Observe rhythm on telemetry monitor. 285. A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider? Last menstrual period was 7 weeks ago. 286. A 154-pound client with diabetic ketoacidosis is receiving an IV of normal saline 100 ML with regular insulin 100 units. The healthcare provider prescribes a rate of 0.1 units/kg/hour. To 302. The nurse is triaging clients in an urgent care clinic. The client with which symptoms should be referred to the health care provider immediately? Headache, photophobia, and nuchal rigidity. 303. An adult male is brought to the emergency department by ambulance following a motorcycle accident. He was not wearing a helmet and presents with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse? Nausea and projectile vomit 304. After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the x-ray findings that indicate the CVC tip is in the client's superior vena cava. Which action should the nurse implement? Initiate intravenous fluid as prescribed. 305. The nurse has received funding to design a health promotion project for African American women who are at risk for developing breast cancer. Which resource is most important in designing this program? Participation of community leaders in planning the program. 306. The home care nurse provides self-care instruction for a client chronic venous insufficiency cause by deep vein thrombosis. Which instructions should the nurse include in the client's discharge teaching plan? Select all that apply -Avoid prolonged standing or sitting -Use recliner for long period of sitting -Continue wearing elastic stocking 307. The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention? Muscle spasms of the back and neck. 308. A male client was transferred yesterday from the emergency department to the telemetry unit because he had ST depression and resolved chest pain. When his EKG monitor alarms for ventricular tachycardia (VT), what action should the nurse take first? Determine the client's responsiveness and respirations. 309. A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which assessment finding warrants immediate intervention by the nurse? The client has asymmetrical chest wall expansion. 310. A client is receiving an IV solution labeled Heparin Sodium 20,000 Units in 5% dextrose injection 500 ml at 25 ml/hour. How many units of heparin is the client receiving each hour? 1000 units/hour. 311. The nurse is preparing a client for discharge from the hospital following a liver transplant. Which instruction is most important for the nurse to include in this client's discharge teaching plan? Monitor for an elevated temperature. 312. The nurse is conducting health assessments. Which assessment finding increases a 56- year- old woman's risk for developing osteoporosis? 20 pack-year history of cigarette smoking. 313. A young couple who has been unsuccessful in conceiving a child for over a year is seen in the family planning clinic. During an initial visit, which intervention is most important for the nurse to implement? Determine current sexual practice. 314. The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse report to the health care provider? Elevated liver function tests. 315. A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first? Auscultated bilateral breath sounds. 316. The nurse makes a supervisory home visit to observe unlicensed assistive personnel (UAP) who is providing personal care for a client with Alzheimer's disease. The nurse observes that whenever the client gets upset, the UAP changes the subject. What action should the nurse take in response to this observation? Affirm that the UAP is using and effective strategy to reduce the client's anxiety. 317. An older female who ambulated with a quad-cane prefer to use a wheelchair because she has a halting and unsteady gait at times. Which interventions should the nurse implement? (Select all that apply) -Move personal items within client's reach -Lower bed to the lower possible position -Give directions to call for assistance -Assist client to the bathroom in 2 hours. 318. In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete? Observe both lower extremities for redness and swelling. 319. A school-age child who weighs 42 pounds receives a post-tonsillectomy prescription for promethazine (Phenergan) 0.5 mg/kg IM to prevent postoperative nausea. The medication is available in 25 mg/ml ampules. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth). 0.4 320. A nurse stops at the site of a motorcycle accident and finds a young adult male lying face down in the road in a puddle of water. It is raining, no one is available to send for help, and the cell phone is in the car about 50 feet away. What action should the nurse take first? Stabilize the victim's neck and roll over to evaluate his status. 321. During a well-baby, 6-month visit, a mother tells the nurse that her infant has had fewer ear infections than her 10-year-old daughter. The nurse should explain that which vaccine is likely to have made the difference in the siblings' incidence of otitis media? Hemophilic Influenza Type B (HiB) vaccine. 322. The healthcare provider prescribes Morphine Sulfate Oral Solution 38 mg PO q4 hours for a client who is opioid-tolerant. The available 30 mL bottle is labeled, 100 mg/5 mL (20mg/mL) and is packaged with a calibrated oral syringe to provide to provide accurate dose measurements. How many mL should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest tenth.) 1.9. 323. Which medication should the nurse anticipate administering to a client who is diagnosed with myxedema coma? Intravenous administration of thyroid hormones. 324. The nurse who works in labor and delivery is reassigned to the cardiac care unit for the day because of a low census in labor and delivery. Which assignments is best for the nurse to give this nurse? 341. When five family members arrive at the hospital, they all begin asking the nurse questions regarding the prognosis of their critically ill mother. What intervention should the nurse implement first? Ask the family to identify a specific spokesperson. 342. The nurse reviews the signs of hypoglycemia with the parents of a child with Type I diabetes mellitus. The parents correctly understand signs of hypoglycemia if they include which symptoms? Diaphoresis. 343. The nurse is caring for a client with hypovolemic shock who is receiving two units of packed red blood cells (RBCs) through a large bore peripheral IV. What action promotes maintenance of the client's cardiopulmonary stability during the blood transfusion? Increase the oxygen flow via nasal cannula if dyspnea is present. 344. Which information is more important for the nurse to obtain when determining a client's risk for (OSAS)? Body mass index. 345. During the transfer of a client who had major abdominal surgery this morning, the post anesthesia care unit (PACU) nurse reports that the client, who is awake and responsive continues to report pain and nausea after receiving morphine 2 mg IV and ondansetron 4 mg IV 45 mints ago. Which elements of SBAR communication are missing from the report given by the PACU nurse? (Select all that apply) -Background -Assessment -Recommendation 346. The nurse is triaging victims of a tornado at an emergency shelter. An adult woman who has been wandering and crying comes to the nurse. What action should the nurse take? Delegate care of the crying client to an unlicensed assistant. 347. A client in septic shock has a double lumen central venous catheter with one liter of 0.9% Normal Saline Solution infusing at 1 ml/hour through one lumen and TPN infusing at 50 ml/hr. through one port. The nurse prepared newly prescribed IV antibiotic that should take 45 mints to infuse. What intervention should the nurse implement? Use a secondary port of the Normal Saline solution to administer the antibiotic. 348. A male client returns to the mental health clinic for assistance with his anxiety reaction that is manifested by a rapid heartbeat, sweating, shaking, and nausea while driving over the bay bridge. What action I the treatment plan should the nurse implement? Teach client to listen to music or audio books while driving. 349. Which intervention should the nurse include in the plan of care for a client with leukocytosis? Monitor temperature regularly. 350. The nurse is teaching a client about the antiulcer medications ranitidine which was... statement best describes the action of this drug? It blocks the effects of histamine, causing decreased secretion of acid 351. A client with superficial burns to the face, neck, and hands resulting from a house fire...which assessment finding indicates to the nurse that the client should be monitored for carbon monoxide...? Mucous membranes cherry red color. 352. A female client who was mechanically ventilated for 7 days is extubated. Two hours later...productive cough, and her respirations are rapids and shallow. Which intervention is most important? Prepare the client for intubation. 353. The nurse is assessing the emotional status of a client with Parkinson's disease. Which client finding is most helpful in planning goals to meet the client's emotional needs? Cries frequently during the interview. 354. When changing a diaper on a 2-day-old infant, the nurse observes that the baby's legs are... this finding, what action should the nurse take next? Notify the healthcare provider. 355. The nurse is presenting information about fetal development to a group of parents with...when discussing cephalocaudal fetal development, which information should the nurse gives the parents? Development progress from head to rump. 356. A client has a prescription for lorazepam 2mg for alcohol withdrawal symptoms. Which finding... the client? Blood pressure 149/101. 357. A male client is discharged from the intensive care unit following a myocardial infarction, and the healthcare provider low-sodium diet. Which lunch selection indicates to the nurse that this client understands the dietary restrictions? Turkey salad sandwich. 358. A client is receiving continuous bladder irrigation via a triple-lumen suprapubic catheter that was placed during prostatectomy. Which report by the unlicensed assistive personnel (UAP) requires intervention by the nurse? Leakage around catheter insertion site. 359. One day after abdominal surgery, an obese client complains of pain and heaviness in the right calf. What action should the nurse implement? Observe for unilateral swelling. 360. While removing staples from a male client's postoperative wound site, the nurse observes that the client's eyes are closed, and his face and hands are clenched. The client states, "I just hate having staples removed." After acknowledging the client's anxiety, what action should the nurse implement? Attempt to distract the client with general conversation. 361. Which assessment is more important for the nurse to include in the daily plan of care for a client with a burned extremity? Distal pulse intensity. 362. A client is scheduled to receive an IW dose of ondansetron (Zofran) eight hours after receiving chemotherapy. The client has saline lock and is sleeping quietly without any restlessness. The nurse caring for the client is not certified in chemotherapy administration. What action should the nurse take? Administer the ondansetron (Zofran) after flushing the saline lock with saline 363. The nurse notes a visible prolapse of the umbilical cord after a client experiences spontaneous rupture of the membranes during labor. What intervention should the nurse implement immediately? Elevate the presenting part off the cord. 364. The healthcare provider prescribes heparin protocol at18 units/kg/hr for a client with a possible pulmonary embolism. This client weighs 144 pounds. The available solution is labeled, 18 381. The nurse notes the client receiving heparin infusion labeled, Heparin Na 25,000 Units in 5% Dextrose injection 500 ml at 50ml/hr. What dose of Heparin is the client receiving per hour? 2,500 382. A male client is returned to the surgical unit following a left nephrectomy and is medicated with morphine. His dressing has a small amount of bloody drainage, and a Jackson- Pratt bulb surgical drainage device is in place. Which interventions is most important for the nurse to include in this client’s plan of care? Monitor urine output hourly. 383. A primigravida client is 36 weeks gestation is admitted to labor and delivery unit because her membranes ruptured 30minutes ago. Initial assessment indicates 2cm dilation, 50% effaced, -2 station, vertex presentation greenish colored amniotic fluid, and contractions occurring 3-5 minutes with a low FHR after the last contraction peaks: Administer Oxygen via face mask. 384. Following a motor vehicle collision (MCV), a male adult in severe pain is brought to the emergency department via ambulance. His injured left leg is edematous, ecchymotic around the impact of injury on the thigh, and shorter than his right leg. Based on these findings, the client is at greatest risk for which complication? Fat embolism. 385. A 2-year-old is bleeding from a laceration on the right lower extremity that occurred as the result of a motor vehicle collision. The nurse is selecting supplies to start an IV access. Which assessment finding is most significant in the nurse's selection of catheter size? Thready brachial pulse. 386. A client with a recent colostomy expresses concern about the ability to control flatus. Which intervention is most important for the nurse to include in the client's plan of care? Avoid foods that caused gas before the colostomy. 387. A male client arrives at the clinic with a severe sunburn and explains that he did not use sunscreen because it was an overcast day. Large blisters are noted over his back and chest and his shirt is soaked with serosanguinous fluid. Which assessment finding warrants immediate intervention by the nurse? Hypotension. 388. A client with polycystic kidney disease (PKD) receiving antibiotics for an infected cyst is experiencing severe pain. What action should the nurse implement? Teach the client how to use a dry heating pad over the painful area. 389. Which statement is accurate regarding the pathological changes in the pulmonary system associated with acute (adult) respiratory distress syndrome (ARDS)? Capillary hydrostatic pressure exceeds colloid osmotic pressure, producing interstitial edema. 390. The nurse mixes 250 mg of debutamine in 250 ml of D5W and plans to administer the solution at rate client weighing 110 pounds. The nurse should set the infusion pump to administer how many ml per hour only. If rounding is required, round the nearest whole number.). 45 391. An adult male who was admitted two days ago following a cerebrovascular accident (CVA) is confused and experiencing left-side weakness. He has tried to get out of bed several times but is unable to ambulate without assistance. Which intervention is most important for the nurse to implement? Install a bed exit safety monitoring device. 392. A client in her first trimester of pregnancy complains of nausea. Which complementary therapy should the nurse recommend? Drink chamomile tea at breakfast and in the evening. 393. When gathering for a group therapy session at 1400 hours, a female client complains to the nurse that a smoking break has not been allowed all day. The nurse responds that 15-minute breaks were called over the unit intercom after breakfast and after lunch. The nurse is using what communication technique in responding to the client? Reflection. 394. A female client with rheumatoid arthritis (RA) comes to the clinic complaining of joint pain and swelling. The client has been taking prednisone (Deltasone) and ibuprofen (Motrin Extra Strength) every day. To assist the client with self-management of her pain, which information should the nurse obtain? Therapeutic exercise included in daily routine. 395. The charge nurse of the Intensive Care Unit is making assignments for the permanent staff and one RN who was floated from a medical unit. The client with which condition is the best to assign to the float nurse? Diabetic ketoacidosis and titrated IV insulin infusion. 396. A client admitted to the emergency center had inspiratory and expiratory wheezing, nasal flaring, and thick, tenacious sputum secretions observed during the physical examination. Based on these assessment findings, what classification of pharmacologic agents should the nurse anticipate administering? Bronchodilators. 397. The home health nurse is assessing a male client who has started peritoneal dialysis (PD) 5 days ago. Which assessment finding warrants immediate intervention by the nurse? Cloudy dialysate output and rebound abdominal pain. 398. A client's telemetry monitor indicates ventricular fibrillation (VF). What should the nurse do first? Provide immediate defibrillation. 399. In conducting a health assessment, the nurse determines that both parents of a child with asthma smoke cigarettes. What recommendation is best to the nurse to recommend to the parents? Avoid smoking in the house. 400. The nurse is developing a plan of care for a middle-aged woman who is diagnosed with type 2 diabetes mellitus (DM). To lower her blood glucose and increase her serum high- density lipoprotein (HDL) levels, which instruction is most important for the nurse to provide? at least three times weekly. 401. A client who has been in active labor for 12 hours suddenly tells the nurse that she has a strong urge to have a bowel movement. What action should the nurse take? Perform a sterile vaginal exam. 402. The nurse assesses a 78-year-old male client who has left sides heart failure. Which symptoms would the nurse expect this client to exhibit? Dyspnea, cough, and fatigue. 403. A female client comes to the clinic complaining of fatigue and inability to sleep because she is the full-time caretaker for 22-year-old son who was paralyzed by a motor vehicle collision. She adds that her husband left her because he says he can't take her behavior any more since all she does is care for their son. What intervention should the nurse implement? Acknowledge the client's stress and suggest that she consider respite care. 420. What is the nurse's priority goal when providing care for a 2-year-old child experiencing a seizure? Manage the airway. 421. The nurse is preparing to discharge an older adult female client who is at risk for hy...nurse include with this client's discharge teaching? -Report any muscle twitching or seizures -Take vitamin D with calcium daily -Low fat yogurt is a good source of calcium -Keep a diet record to monitor calcium intake 422. The daughter of an older female client tells the clinic nurse that she is no longer able to care for her mother since her mother has lost the ability to perform activities of daily living (ADLs) due to aging. Which options should the nurse discuss with the daughter? -Long-term care facility -Home health agency 423. A male client with cancer, who is receiving antineoplastic drugs, is admitted to the...what findings is most often manifest this condition? Ecchymosis and hematemesis. 424. A 7-year-old boy is brought to the clinic because of facial edema. He reports that he has been voiding small amounts of dark, cloudy, tea-colored urine. The parents state that their son had a sore throat 2 weeks earlier, but it has resolved. After assessing the child's vital signs and weight, what intervention should the nurse implement next? Collect a urine specimen for routine urinalysis. 425. The nurse observes an adolescent client prepare to administer a prescribed corticosteroid medication using a metered dose inhaler as seen in the picture. What action should the nurse take? Remind the client to hold his breath after inhaling the medication 426. The nurse teaches an adolescent male client how to use a metered dose inhaler. Seen in the picture. What instruction should the nurse provide? Move the device one to two inches away from the mouth. 427. A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother...During the assessment, the mother asks the nurse why her child is at the 5th percent...response is best for the nurse to provide? "His smaller size is probably due to the heart disease" 428. A client with hypertension receives a prescription for enalapril, an angiotensin...instruction should the nurse include in the medication teaching plan? Report increased bruising of bleeding. 429. When administering ceftriaxone sodium (Rocephin) intravenously to a client before...most immediate intervention by the nurse? Stridor. 430. The nurse is assessing a client with a small bowel obstruction who was hospitalized 24 hours ago. Which assessment finding should the nurse report immediately to the healthcare provider? Rebound tenderness in the upper quadrants. 431. An adult female client is admitted to the psychiatric unit because of a complex handwashing ritual she performs daily that takes two hours or longer to complete. She worries about staying clean and refuses to sit on any of the chairs in the day area. This client's handwashing is an example of which clinical behavior? Compulsion. 432. A female client reports that she drank a liter of a solution to cleanse her intestines...immediately. How many ml of fluid intake should the nurse document? Whole number. 760 433. Following routine diagnostic test, a client who is symptom-free is diagnosed with Paget's disease. Client teaching should be directed toward what important goal for this client? Reduce the risk for injury. 434. After removing a left femoral arterial sheath, which assessment finding warrant immediately interventions by the nurse? (Select all that applied.) -Unrelieved back and flank pain. -Cool and pale left leg and foot. -Left groin egg-size hematoma. 435. A client with urticaria due to an environmental allergies is taking diphenhydramine... Which complaint should the nurse identify to the client as a side effect of the OTC medication? Nausea and indigestion. 436. In caring for a client with a PCA infusion of morphine sulfate through the right cephalic vein, the nurse assesses that the client in lethargic with a blood pressure of 90/60, pulse rate of 118 beats per minute, and respiratory rate of 8 breaths per minutes. What assessment should the nurse perform next? Observe the amount and dose of morphine in the PCA pump syringe. 437. Which instruction is most important for the nurse to provide a client who is being discharge following treatment for Guillain-Barre syndrome? Avoid exposure to respiratory infections. 438. The nurse assesses a female client with obstructive sleep apnea syndrome (OSAS) who is 5 feet tall (152 cm) and weighs 155 pounds (70 kg), the client's 24-hour diet history includes: no breakfast, cheeseburger, and fries for lunch; lasagna, chocolate ice cream and a cola drink for dinner, and 2 glasses of wine in the evening before going to bed for a total caloric intake of 3500 calories. What instructions should the nurse provide? (Select all that apply) -Avoid use of alcohol as a sleep aide at bedtime -Start a weight loss program 439. The health care provider prescribes atenolol 50 mg daily for a client with angina pectoris...to the health care provider before administering this medication? Irregular pulse. 440. A male Korean American client looks away when asked by the nurse to describe his problem. What is the best initial nursing action? Allow several minutes for the client to respond. 441. The nurse provides feeding tube instructions to the wife of a client with end stage cancer. The client's wife performs a return demonstration correctly, but begins crying and tells the nurse, "I just don't think I can do this every day." The nurse should direct further teaching strategies toward which learning domain? Affective. 442. A woman who takes pyridostigmine for myasthenia gravis (MG) arrives at the emergency department complaining of extreme muscle weakness. Her adult daughter tells the nurse that since yesterday her mother has been unable to smile, which assessment finding warrants immediate intervention by the nurse? Uncontrollable drooling. 458. A client's telemetry monitor indicates ventricular fibrillation (VF). After delivering one counter shock, the nurse resumes chest compression, after another minute of compression, the client's rhythm converts to supraventricular tachycardia (SVT) on the monitor, at this point, what is the priority intervention for the nurse? Give IV dose of adenosine rapidly over 1-2 seconds. 459. A client with a history of using illicit drugs intravenously is admitted with Kaposi's sarcoma. Which intervention should the nurse include in this client's admission plan of care? Monitor for secondary infections. 460. After an elderly female client receives treatment for drug toxicity, the HCP prescribes a 24- hour creatinine clearance test. Prior to starting the urine collection, the nurse notes that the client's serum creatinine is 0.3mg/dl. What action should the nurse implement? Notify the HCP of the results. 461. Immediately after extubating, a client who has been mechanically ventilated is placed on a 50% non-rebreather. The client is hoarse and complaining of a sore throat. Which assessment finding should the nurse report to the healthcare provider immediately? Upper airway stridor. 462. The nurse is collecting sterile sample for culture and sensitivity from a disposable three chamber water-seal drainage system connected to a pleural chest tube. The nurse should obtain the sample from which site on the drainage system? Plastic tubing located at the chest insertion site. 463. While the nurse is preparing a scheduled intravenous (IV) medication, the client states that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement? Discontinue the painful IV after a new IV is inserted. 464. During a staff meeting, a nurse verbally attacks the nurse manager conducting the meeting, stating, "you always let your favorites have holidays off give then easier assignments. You are unfair and prejudiced" how should the nurse-manager respond? Give me specific examples to support your statements. 465. An adult is admitted to the emergency department following ingestion of a bottle of antidepressants secondary to chronic paint. A nasogastric tube and a left subclavian venous catheter are placed. The nurse auscultates audible breath sounds on the right side, faint sounds procedure should the nurse prepare for first? Insertion of a left- sided chest tube. 466. A male client is admitted with a severe asthma attack. For the last 3 hours he has experienced increased shortness of breath. His arterial blood gas results are: pH 7.22 PaCO2 55 mmHg; HCO3 25 mEq/L or mmol/L (SI). Which intervention should the nurse implement? Administer PRN dose of albuterol. 467. A young adult female with chronic kidney disease (CKD) due to recurring pyelonephritis is hospitalized with basilar crackles and peripheral edema. She is complaining of severe nausea and the cardiac monitor indicates sinus tachycardia with frequent premature ventricular contraction. Her blood pressure is 200 /110 mm Hg, and her temperature is 101 F which PRN medication should the nurse administers first? Furosemide. 468. When entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which actions should the nurse implement? Leave the room and close the door quietly. 469. A child with heart failure (HF) is taking digitalis. Which signs indicates to the nurse that the child may be experiencing digitalis toxicity? Vomiting. 470. An antacid is prescribed for a client with gastroesophageal (GERD). The client asks the nurse, "How does this help my GERD?" What is the best response by the nurse? Antacids will neutralize the acid in your stomach. 471. A male adult is admitted because of an acetaminophen overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan? Avoid exposure to large crowds. 472. A client arrives in the emergency center with a blood alcohol level of 500 mg/dl. When transferred to the observation unit, the client becomes demanding, aggressive, and shouts at the staff. Which assessments finding is most important for the nurse to identify in the first 24 hours? Agitation and threats to harms staff. 473. To reduce the risk of symptoms exacerbation for a client with multiple sclerosis (MS), which instructions should the nurse include in the client's discharge plan? (Select all that apply). -Space activities to allow for rest periods -Take warm baths before starting exercise 474. A preoperative client states he is not allergic to any medications. What is the most important nursing action for the nurse to implement next? Assess client's knowledge of an allergy response. 475. During a visit to the planned parenthood clinic, a young woman tells the nurse that she is going to discontinue taking the oral contraceptives she has taken for three years because she wants to get pregnant. History indicates that her grandfather has adult-onset diabetes and that she was treated for chlamydia six months ago, which factor in this client's history poses the greatest risk for this woman's pregnancy? Three-year history of taking oral contraceptives. 476. When conducting diet teaching for a client who was diagnosed with a myocardial infarction, which snack foods should the nurse encourage the client to eat? (Select all that apply). -Fresh turkey slices and berries -Chicken bouillon soup and toast -raw unsalted almonds and apples 477. A mother brings her 3-week-old son to the clinic because he is vomiting "all the time." In performing a physical assessment, the nurse notes that the infant has poor skin turgor, has lost 20% of his birth weight, and has a small palpable oval-shaped mass in his abdomen. What intervention should the nurse implement first? Initiate a prescribed IV for parental fluid. 478. An older woman who was recently diagnosed with end stage metastatic breast cancer is admitted because she is experiencing shortness of breath and confusion. The client refuses to eat and continuously asks to go home. Arterial blood gases indicate hypoxia. Which intervention is most important for the nurse to implement? Clarify end of life desires. 479. The nurse is triaging several children as they present to the emergency room after an accident. Which child requires the most immediate intervention by the nurse? An 11-year-old with a headache, nausea, and projectile vomiting. 480. An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasms when taking the blood pressure using the same arm. After confirming the presence of spams what action should the nurse take? Review the client's serum calcium level. 497. In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider? Watery diarrhea. 498. An 11-year-old client is admitted to the mental health unit after trying to run away from home and threatening self-harm. The nurse establishes a goal to promote effective coping and plans to ask the client to verbalize three ways to deal with stress. Which activity is best to establish rapport and accomplish this therapeutic goal? Play a board game with the client and begin taking about stressors. 499. An adult male with schizophrenia who has been noncompliant in taking oral antipsychotic medications refuses a prescribed IM medication. Which action should the nurse take? Notify the healthcare provider of the client's refusal. 500. An older male client with a history of diabetes mellitus, chronic gout, and osteoarthritis comes to the clinic with a bag of medication bottles. Which intervention should the nurse implement first? Identify pills in the bag. 501. A male client with an antisocial personality disorder is admitted to an in-patient mental health unit for multiple substance dependency. When providing a history, the client justifies to the nurse his use of illicit drugs. Based on this pattern of behavior this client's history is most likely to include which finding? Multiple convictions for misdemeanors and class B felonies. 502. An adult male who fell from a roof and fractures his left femur is admitted for surgical stabilization after having a soft cast applied in the emergency department. Which assessment finding warrants immediate intervention by the nurse? Weak palpable distal pulses. 503. A client who has a suspected brain tumor is schedules for a computed (CT) scan. When preparing the client for the client for the CT scan, which intervention should the nurse implement? Obtain the client's food allergy history. 504. A client who is at 10-weeks gestation calls the clinic because she has been vomiting for the past 24 hours. The nurse determines that the client has no fever. Which instructions should the nurse give to this client? Come to the clinic to be seen by a healthcare provider. 505. The nurse is preparing to gavage feed a premature infant through an orogastric tube. During insertion of the tube, the infant's heart rate drops to 60 beats / minute. Which action should the nurse take? Postpone the feeding until the infant's vital signs and stable. 506. A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first? Ensure client takes a diuretic q AM. 507. The nurse and an unlicensed assistive personnel (UAP) are providing care for a client with a nasogastric tube (NGT) when the client begins to vomit. How should the nurse manage this situation? Direct the UAP to measure the emesis while the nurse irrigates the NGT. 508. A preschooler with constipation needs to increase fiber intake. Which snack suggestion should the nurse provide? Oatmeal cookies. 509. The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement? Instruct the mother to change the child's diaper more often. 510. After multiple attempts to stop drinking, an adult male is admitted to the medical intensive care unit (MICU) with delirium tremens. He is tachycardic, diaphoretic, restless, and disoriented. Which finding indicates a life- threatening condition? Widening QRS complexes and flat waves. 511. The home health nurse is preparing to make daily visits to a group of clients. Which client should the nurse visit first? A client with congestive heart failure who reports a 3-pound weight gain in the last two days. 512. A female client is admitted for diabetic crisis resulting from inadequate dietary practices. After stabilization, the nurse talks to the client about her prescribed diet. What client characteristic is most import for successful adherence to the diabetic diet? Demonstrates willingness to adhere to the diet consistently. 513. A client currently receiving an infusion labeled Heparin Sodium 25,000 Units in 5% Dextrose Injection 500 mL at 14 mL/hour. A prescription is received to change the rate of the infusion to 900 units of Heparin per hour. The nurse should set the infusion pump to deliver how many mL/hour? (Enter numeric value only). 700 514. Oxygen at 5l/min per nasal cannula is being administered to a 10-year-old child with pneumonia. When planning care for this child, what principle of oxygen administration should the nurse consider? Avoid administration of oxygen at high levels for extended periods. 515. The nurse is caring for a client with acute kidney injury (AKI) secondary to gentamicin therapy the client's serum blood potassium is elevated, which finding requires immediate action by the nurse? Anuria for the last 12 hours. 516. During orientation, a newly hired nurse demonstrates suctioning of a tracheostomy in a skills class, as seen in the video. After the demonstration, the supervising nurse expresses concern that the demonstrated procedure increased the client's risk for which problem? Infection. 517. A male client with diabetes mellitus type 2, who is taking pioglitazone PO daily, reports to the nurse the recent onset of nausea, accompanied by dark-colored urine, and a yellowish cast to his skin. What instructions should the nurse provide? "You need to seek immediate medical assistance to evaluate the cause of these symptoms" 518. A male client with ulcerative colitis received a prescription for a corticosteroid last month, but because of the side effect he stopped taking the medication 6 year ago. Which finding warrants immediate intervention by the nurse? Anxiety and restlessness. 519. A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, an exhibiting sign of restlessness. Which action should the nurse take fist? Auscultate bilateral breath sounds. 520. A young adult female client with recurrent pelvic pain for 3 year returns to the clinic for relief of severe dysmenorrhea. The nurse reviews her medical record which indicates that the client has endometriosis. Based on this finding, what information should the nurse provide this