FLORIDA UNIVERSITY PEDIATRICS NUR 416 CAT 2 KAPLAN 2 LATEST 2021/2022,100% CORRECT

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FLORIDA UNIVERSITY PEDIATRICS NUR 416 CAT 2 KAPLAN 2 LATEST 2021/2022 1. The nurse assess a client who is in the 24th week of gestation. Which finding is a priority for the nurse to follow-up? 1. Fe... tal heart rate of 130 to 140 beats/min. 2. Fundal level at 3 fingers below the umbilicus. 3. Fetal movements felt faintly on lower part of abdomen. 4. Client reports backache and leg cramps when sleeping. Ans: 2 2. The nurse administers carisoprodol to the incorrect client. Which strategy should the nurse use to reduce the risk of malpractice litigation? (Select all that apply.) 1. Ask the charge nurse to reassign the client to a different nurse. 2. Notify the health care provider of the medication error immediately. 3. Report the incident to the manager for appropriate follow-up with the client. 4. Print a copy of the incident report to keep in the nurse’s personal records. 5. Explain to the client that the nurse has a heavier assignment than normal. Ans: 2, 3 3. The nurse provides care for a client who is receiving sitagliptin for type 2 diabetes mellitus. Which assessment finding causes the nurse to suspect the client is experiencing an adverse reaction to the medication? 1. Weight gain. 2. Anemia. 3. Abdominal pain. 4. Edema. Ans: 3 4. The nurse orients a new nurse who inquired about electrical cardioversion. Which statement about cardioversion by the nurse is accurate? (Select all that apply.) 1. “Cardioversion is used to treat ventricular fibrillation.” 2. “Pulseless electrical activity (PEA) responds to cardioversion.” 3. “Cardioversion treats atrial fibrillation and atrial flutter.” 4. “An intravenous sedative is required in elective cardioversion.” 5. “Check for life-threatening dysrhythmia during cardioversion.” Ans: 3, 4, 5 5. A wound located on the foot of a client with type 2 diabetes mellitus (DM) is healing. The nurse teaches the client about the prevention of future foot wounds. Which client statement indicates the teaching is effective? (Select all that apply.) 1. “I should not cross my legs.” 2. “I should wear shoes only when I go outside.” 3. “I should apply lotion between my toes after a shower.” 4. “I should inspect the inside of my shoes before I put them on.” 5. “I should use a mirror to examine the bottom of my feet every day.” Ans: 1, 4, 5 6. The nurse prepares discharge instructions for a client who speaks very little English and is recovering from an emergency appendectomy. Which nursing action best helps this client understand wound care instructions? 1. Asking if the client understands the instruction. 2. Demonstrating the procedure and having the client return the demonstration. 3. Asking an interpreter to replay the instructions to the client. 4. Writing out the instructions and having a family member read them to the client. Ans: 2 7. The family sits at the bedside of a client nearing the end-of-life. Which action is appropriate for the nurse to implement? (Select all that apply.) 1. Teach family members about physical signs of impending death. 2. Encourage the management of adverse signs and symptoms. 3. Assess family coping mechanisms to handle impending loss. 4. Avoid spirituality as nurse’s beliefs may not be congruent with the client’s. 5. Leave the family alone as there is no more need for direct nursing care. Ans: 1, 2, 3 8. The nurse performs an intermittent urinary catheterization for a client who is 2 hours post surgery. Which client observation indicates that the procedure was effective? 1. Reports dribbling of urine. 2. Rests quietly. 3. Notes distention above symphysis pubis. 4. Voids 30 mL every 15 minutes. Ans: 2 9. The nurse directs the nursing assistive personnel (NAP) to provide a back massage to a client. Which action does the nurse emphasize when giving these directions? 1. Warm the lotion in the microwave before use. 2. Wear clean gloves while performing the massage. 3. Place the bed in the lowest position after the massage. 4. Start the massage at the shoulders and work toward the buttocks. Ans: 3 10. The nurse observes a student nurse provide a client with a subcutaneous injection of heparin. For which student action will the nurse intervene? (Select all that apply.) 1. Pinches the skin and inserts the needle 90 degrees. 2. Places the needle in the sharps container. 3. Administers the injection 1/2 inch from the umbilicus. 4. Aspirates after inserting the needle. 5. Massages the site. Ans: 3, 4, 5 11. The nurse provides care to a client who experienced prolonged cold exposure. For which complication does the nurse closely monitor this client? 1. Ventricular fibrillation. 2. Hypertension. 3. Metabolic alkalosis. 4. Shivering. Ans: 1 12. The nurse provides care for clients in a headache clinic. Which client should the nurse assess first? 1. The client reporting pain and neck stiffness. 2. The client reporting abdominal pain and vomiting. 3. The client with difficulty speaking to the receptionist. 4. The client with a headache of 3 weeks’ duration. Ans: 3 13. The nurse is discussing infection control guidelines with a group of student nurses. Which information is most important for the nurse to include in the discussion? 1. “A gown should be worn when measuring the blood pressure of a client with a methicillin-resistant Staphylococcus aureus (MRSA) wound infection.” 2. “The door should be kept closed to the room of a client with a clostridium difficile (C. diff) infection.” 3. “Disposable dishes should be provided for a client with a hepatitis B infection.” 4. “A surgical mask should be worn when providing care for a client with pulmonary tuberculosis.” Ans: 1 14. The nurse uses a paper-based documentation system to write a client care note. The previous nurse’s documentation appears incomplete. Which action should the nurse take next? 1. Draw a line through any empty space and continue documenting. 2. Mark out the previous nurse’s entry, initial, and continue documenting. 3. Complete an incident report for the nurse manager to review. 4. Call the previous nurse at home and ask if the documented entry is complete. Ans: 1 15. While preparing medications, the nurse documents that a client is allergic to penicillin. Which medication will the nurse question before administering to this client? 1. Cefazolin. 2. Doxycycline. 3. Ciprofloxacin. 4. Clarithromycin. Ans: 1 16. The nurse provides care for a client diagnosed with sickle cell crisis. Which sign or symptom should the nurse immediately report to the healthcare provider? 1. Cyanosis of the tongue. 2. Jaundiced skin. 3. Slurred speech. 4. Slow capillary refill. Ans: 3 17. The nurse develops a teaching plan to promote optimal cardiac output during pregnancy. Which information is most important for the nurse include? 1. Take frequent rest periods between activities. 2. Modify aerobic exercise as pregnancy progresses. 3. Avoid resting or sleeping in the supine position. 4. Elevate both lower extremities whenever sitting. Ans: 3 18. The nurse reviews the daily lab results of four clients. Which client does the nurse delegate to the LPN/LVN to provide care? 1. Client with a brain natriuretic peptide (BNP) level of 300 pg/mL. 2. Client with an erythrocyte sedimentation rate of 10 mm/h. 3. Client with a C-reactive protein (CRP) level of 4 mg/L. 4. Client with an international normalized ratio (INR) level of 8.0. Ans: 2 19. The nurse provides care to a client of Native American descent who has traditional beliefs about health and illness. Which action is most appropriate for the nurse to take? 1. Ask if cultural healers should be contacted. 2. Avoid asking questions unless initiated by the client. 3. Obtain further information about the client’s cultural beliefs from the family. 4. Explain the usual hospital routines for mealtimes, care, and family visits. Ans: 1 20. The nurse follows up with a client diagnosed with insomnia. The nurse seeks to determine if treatment was successful. Which response by the client best indicates treatment was successful? 1. “I am sleeping 4 hours a night.” 2. “I fall asleep within 1 to 2 hours at night now.” 3. “I am not napping in the day anymore.” 4. “I am waking up twice a night.” Ans: 3 21. The nurse provides care for a client diagnosed with systemic lupus erythematosus (SLE). Which finding will the nurse find most concerning? 1. Pallor observed on fingers of the right hand. 2. Blood pressure reading of 152/90 mm Hg. 3. Pain reported as severe in the left knee and ankle. 4. Blood urea nitrogen (BUN) level of 40 mg/dL. Ans: 4 22. A preschool-age client experiences a sudden cardiac arrest. Which action will the nurse take when performing cardiopulmonary resuscitation (CPR)? 1. Deliver 12 breaths per minute. 2. Compress the sternum with both hands at a depth of 2 inches (4 to 5 cm). 3. Use the heel of one hand for sternal compressions. 4. Use two fingers for sternal compressions. Ans: 3 23. A client takes a statin as prescribed. Which action does the nurse implement to identify if the client is experiencing any side effects of the medication? 1. Measure height and weight. 2. Check recent cholesterol level. 3. Inquire about the consistency of stool. 4. Assess for muscle tenderness. Ans: 4 24. The nurse provides care for a client with the following arterial blood gas (ABG) results: pH 7.29, pCO231 mmHg, and HCO3 19 mEq/L. Which electrolyte alteration does the nurse monitor for based on this client data? 1. Hypocalcemia. 2. Hypernatremia. 3. Hypomagnesemia. 4. Hyperkalemia. Ans: 4 25. The nurse provides care for a client diagnosed with an acute stroke. Which intervention does the nurse delegate to the nursing assistive personnel (NAP)? (Select all that apply.) 1. Screen the client for thrombolytic therapy. 2. Take vital signs based on stroke protocol. 3. Measure and record urinary output. 4. Assist with positioning the client as needed. 5. Evaluate the client’s motor strength every hour. Ans: 2, 3, 4 26. The health care provider prescribes intramuscular pain medication for a child recovering from an appendectomy. Which is the most appropriate action for the nurse to take? 1. Advocate for the child to see if the medication can be given by an alternate route. 2. Disinfect the injection site and allow it to dry completely. 3. Administer a topical anesthetic at the intended injection site. 4. Administer the medication by the intravenous route. Ans: 1 27. The nurse provides care to victims of a disaster. Which client will the nurse assess first? 1. An 8-month-old client with a laceration over the left eye, a blood pressure of 84/50 mm Hg, and a pulse of 105 beats/min. 2. A 6-year-old client with crush injuries to both legs, fixed and dilated pupils, and an absent pulse. 3. A 20-year-old client with a traumatic left below the knee amputation, a blood pressure of 70/46 mm Hg, and a pulse of 124 beats/min. 4. A 28-year-old client with a hematoma on the forehead, a Glasgow Coma Scale of 11, and is crying. Ans: 3 28. The nurse notes the client’s electrocardiogram (ECG) tracing shows a prolonged PR interval, a wide QRS complex, and tall peaked T waves. Which action does the nurse take next? 1. Palpate the peripheral pulses. 2. Check the serum potassium. 3. Raise the head of the bed. 4. Obtain serum troponin level. Ans: 2 29. The nurse provides care for a client on bed rest. The nurse determines that the client’s right calf is swollen, red, and tender to touch. Which nursing action is most appropriate? 1. Check the client for Homan sign. 2. Massage the area. 3. Notify the health care provider. 4. Teach the client to dangle legs. Ans: 3 30. The nurse prepares to teach a client about measures to prevent falls at home. Which point will the nurse include in the teaching plan? 1. Place a small area rug on the bathroom floor in front of the bathtub. 2. Avoid using step stools. 3. Allow damp areas on the floor to air dry. 4. Do not attempt to do anything beyond reach. Ans: 4 31. The nurse auscultates heart sounds in a school-age client. Where does the nurse place the stethoscope to listen to the aortic area of the heart? 1. Second left intercostal space. 2. Second right intercostal space. 3. Fifth intercostal space left midclavicular line. 4. Fifth right and left intercostal spaces. Ans: 2 32. The nurse teaches a class on suicide prevention to high school students. Which risk factor is accurate with regard to suicide in adolescent clients? (Select all that apply.) 1. Possessions that are given to friends. 2. A low-grade point average. 3. Statements like, “I may not be around anymore.” 4. Access to a gun at home. 5. Frequent thoughts of suicide. Ans: 1, 3, 4, 5 33. The nurse prepares discharge instructions for an overweight client with gastroesophageal reflux disease (GERD). Which instruction does the nurse include in the teaching plan? (Select all that apply.) 1. Elevate the head of the bed. 2. Decrease caffeine intake. 3. Evaluate weight loss strategies. 4. Increase fluid intake at meals. 5. Eat a small bedtime snack. Ans: 1, 2, 3 34. The nurse reviews care needs for a shift assignment. Which client task will the nurse delegate to newly hired nursing assistive personnel (NAP)? (Select all that apply.) 1. Client diagnosed with a fractured hip being discharged tomorrow. 2. Client receiving blood after a total abdominal hysterectomy that was admitted to the care area 10 minutes ago. 3. Client diagnosed with a fractured tibia who had surgery 2 days ago. 4. Client diagnosed with cellulitis to the lower leg. 5. Client who had a resection of the prostate this morning with a 3-way indwelling urinary catheter for irrigation. Ans: 1, 3, 4 35. The nurse prepares to administer fondaparinux to a client. Which laboratory test result will the nurse monitor in the client receiving this medication? 1. International normalized ratio. 2. Prothrombin time. 3. Creatinine level. 4. Partial thromboplastin time. Ans: 3 36. The nurse provides care to a client with a total serum calcium level of 7.0 mg/dL (1.75 mmol/L). Which action will the nurse take first? 1. Withhold antacids containing phosphorus. 2. Educate about calcium-rich foods. 3. Instruct to avoid drinking alcohol. 4. Initiate seizure precautions. Ans: 4 37. The nurse notes that a client's heart rate decreases from 55 to 45 beats/min. Which action does the nurse take first? 1. Notify the health care provider (HCP). 2. Determine if the client is lightheaded. 3. Administer 0.5 mg of intravenous (IV) atropine. 4. Prepare for transcutaneous pacing. Ans: 2 38. When performing a sterile dressing change, the nurse removes the saturated dressing, notes the wound is clean, applies a new dressing, and discards the used gloves. Which action does the nurse take next? 1. Put on sterile gloves. 2. Open the sterile gauze packaging. 3. Perform hand hygiene. 4. Date and initial the new dressing. Ans: 3 39. The nurse provides care for a newly admitted client with chest pain. Which task will the nurse complete instead of delegating to nursing assistive personnel (NAP)? 1. Set up the client's meal tray. 2. Obtain a urine specimen and send it to the laboratory. 3. Remove the client’s oxygen if chest pain is rated as zero. 4. Place the client on the cardiac monitor. Ans: 3 40. The nurse provides care for a client taking warfarin for a mechanical prosthetic heart valve. The client has an international normalized ratio (INR) of 3.1. Which is the correct interpretation by the nurse of this finding? 1. The next dose of warfarin needs to be stopped. 2. The result indicates a sign of warfarin toxicity. 3. The client’s treatment goal has been achieved. 4. The client may require a plasma transfusion. Ans: 3 41. The visiting nurse notes that a client diagnosed with asthma is in the “red zone” of the peak flow meter system. Which action does the nurse take first? 1. Take a detailed medical history. 2. Call the health care provider. 3. Do a medication reconciliation. 4. Repeat the peak flow meter test. Ans: 2 42. A parent asks the nurse about the best time to begin toilet training a 22-month-old child. Which nursing response is most appropriate? 1. “When your child turns 2 years old.” 2. “When your child expresses interest in toilet training.” 3. “When you are ready to begin toilet training.” 4. “When your child turns 3 years old.” Ans: 2 43. The nurse delegates a task to an LPN/LVN. Which action will the nurse make that indicates delegation was appropriate? 1. The nurse follows up with the LPN/LVN to make sure the task was completed. 2. The nurse has the LPN/LVN to ask another LPN/ LVN for help if needed. 3. The nurse gives a brief explanation of the task the LPN/LVN is to do. 4. The nurse has the LPN/LVN complete a task the LPN/LVN has completed once. Ans: 1 44. A client of Asian descent receives information about a recommended surgery from the health care provider yet refuses to sign the consent form. Which response by the nurse is best? 1. "Did you understand what the health care provider said to you about the surgery?" 2. "Why won’t you sign the form after the health care provider recommended the surgery?" 3. "I will have to call the surgeon and have your surgery cancelled until you can make a decision." 4. "Are there other people that you want to talk with before making this decision?" Ans: 4 45. The health care provider prescribes an external urinary catheter for a client with urinary incontinence. Which action does the nurse take after the catheter is rolled onto the penis? 1. Secure the catheter to the tubing. 2. Connect the drainage tube system. 3. Ensure there is 1 to 2 inches of space at the end of the catheter. 4. Observe for urinary drainage to occur within 5 minutes. Ans: 3 46. The nurse provides care for a client diagnosed with head trauma. The client experiences a seizure. Which actions will the nurse implement? (Select all that apply.) 1. Keep the client in a side-lying position. 2. Monitor the client's ability to maintain a patent airway. 3. Arouse the client frequently to assess neurological status. 4. Provide environmental stimuli to help the client awaken. 5. Place suction equipment and an oral airway at the client's bedside. Ans: 1, 2, 5 47. The nurse admits a child with fever, malaise, headache, and a vesicular rash on the scalp, face, and trunk. Which transmission-based precaution does the nurse implement for this child? 1. Contact precautions. 2. Airborne and contact precautions. 3. Airborne and droplet precautions. 4. Droplet precautions. Ans: 2 48. The nurse provides care for a client diagnosed with deep vein thrombosis. The client receives warfarin therapy. Which laboratory test result indicates to the nurse that treatment is successful? 1. International normalized ratio 1 to 2. 2. Partial thromboplastin time 1.5 times the control. 3. International normalized ratio 2 to 3. 4. Partial thromboplastin times 2.5 times the control. Ans: 3 49. The nurse provides care for a client receiving chemotherapy and radiation who has several bruises. Which nursing intervention will be part of the care plan to prevent further injury? (Select all that apply.) 1. Shave with an electric razor. 2. Allow the client to be up without supervision as tolerated. 3. Avoid enemas and suppositories. 4. Administer stool softeners. 5. Place an indwelling catheter. Ans: 1, 3, 4 50. Which activity appropriately demonstrates the nurse’s role as client advocate? (Select all that apply.) 1. Defending client participation in decisions affecting them. 2. Protecting clients from incompetent or unethical practice. 3. Safeguarding the client’s autonomy and independence. 4. Telling clients, they must take all medications prescribed by health care providers. 5. Communicating client needs to the interdisciplinary team. Ans: 1, 2, 3, 5 51. The nurse reviews ways to prevent client medication errors with a student nurse. Which response by the student indicates that additional teaching is necessary? (Select all that apply.) 1. “ I will prepare medications for each client separately." 2. “ I should compare the medication administration record against the drug label at least two times before giving the medication to a client.” 3. “ I should trust the health care provider and not question a medication or dose ordered.” 4. “ I will document all medications as soon as I give them.” 5. “ I should use at least two patient identifiers whenever administering medications.” Ans: 2, 3 52. The nurse reviews prescriptions from a health care provider for a client’s care. Which prescription will the nurse question before implementing? 1. Monitor intake and output. 2. Begin a 2 L/day fluid restriction. 3. Start heparin infusion by 0800 hours. 4. Continue intravenous fluids D5W at 150 mL/hour. Ans: 3 53. The nurse provides care for a client newly diagnosed with a benign brain tumor. The nurse teaches the client about the diagnosis. Which property of benign tumors should the nurse include in the teaching? 1. They are poorly differentiated. 2. They metastasize to other organs. 3. They grow at an aggressive rate. 4. They can cause tissue destruction. Ans: 4 54. The nurse auscultates the heart of a client experiencing increasing shortness of breath. Which finding causes the nurse the most concern? 1. S1 heart sound. 2. S2 heart sound. 3. S3 heart sound. 4. S4 heart sound. Ans: 3 55. The nurse educator plans an educational program to review transmission-based precautions with unit staff. Which substance is included on the list of potential sources of infection as outlined by the Centers for Disease Control and Prevention (CDCP)? (Select all that apply.) 1. Blood. 2. Vaginal secretions. 3. Sputum. 4. Non-intact skin. 5. Sweat. Ans: 1, 2, 3, 4 56. A young adult military veteran who served time in the Gulf War reports headache, sore throat, shortness of breath, a rash, and nausea when exposed to paint and certain air fresheners. Which condition does the nurse suspect is most likely causing the client’s symptoms? 1. Post-traumatic stress disorder. 2. Allergy-induced asthma. 3. Multiple chemical sensitivities. 4. Claustrophobic reaction. Ans: 3 57. The nurse provides care to a school-age child suspected of being sexually abused. Which assessment data best supports this suspicion? 1. Difficulty walking. 2. Bald spots on scalp. 3. Fear of parents. 4. Welts on buttocks. Ans: 1 58. The nurse provides care for a hospitalized client. The client’s room is located close to the nurses station. The client tells the nurse, “I don’t know how anyone can get any rest around here, it is so noisy.” The nurse reports these concerns to the nursing supervisor. Which change to the nursing unit should the nursing supervisor implement? (Select all that apply.) 1. Encourage staff to change shoes to clogs to reduce noise. 2. Reduce the volume of phones and pagers. 3. Turn off all lights in the hallways. 4. Keep conversations quiet. 5. Close the client’s room door if possible. Ans: 2, 4, 5 59. The nurse working in a community hospital’s emergency department provides care to a client with chest pain. Which level of care is the nurse providing? 1. Preventive care. 2. Tertiary care. 3. Restorative care. 4. Continuing care. Ans: 2 60. While administering an intravenous push medication to a client, the nurse notes that the color of the medication changed in the tubing. Which type of response will the nurse identify occurred with this medication? 1. Incompatibility. 2. Additive effect. 3. Synergistic effect. 4. Allergic reaction. Ans: 1 61. The nurse provides care for a client who reports difficulty breathing. Which assessment finding requires immediate action by the nurse? (Select all that apply.) 1. Non-productive cough. 2. Flushed skin appearance. 3. Use of accessory muscles. 4. Oxygen saturation of 78%. 5. A heart rate of 145/minute. Ans: 3, 4, 5 62. The nurse documents care on a client who is 3 hours postoperative after a right leg amputation. Which charting entry indicates a problem with the documentation? 1. Client A/O x 4, gag reflex intact, reports nausea. 2. Client post above the knee amputation, sequential compression device to left leg, scant amount bleeding on dressing. 3. Client A/O x 4, dressing dry and intact, reports incisional pain at 5 on a 10 point scale. 4. Client post above the knee amputation, voids without difficulty, 2+ dorsalis pedis pulses bilaterally. Ans: 4 63. The nurse observes that a client’s peripheral intravenous (IV) dressing has loosened. Which action does the nurse take next? 1. Immediately change the IV dressing. 2. Tape the IV dressing to secure it in place. 3. Replace the IV catheter at another site. 4. Apply a skin adhesive where the IV dressing loosened. Ans: 1 64. The nurse makes assignments for the health care team consisting of three nurses and one LPN/LVN. Which client will the nurse assign to the LPN/ LVN? 1. Client admitted 4 days ago with pulmonary fibrosis. Client is on a venturi mask with 40% oxygen concentration and flow rate at 15 L/min. 2. Client admitted yesterday with lower gastrointestinal bleeding. Client reports lightheadedness and dizziness. 3. Client admitted today with episodic chest discomfort. Initial troponin T level is > 0.1 ng/mL. 4. Client admitted 3 days ago with upper gastrointestinal bleeding. Yellowish green drainage noted in nasogastric suction container. Ans: 4 65. The nurse instructs a client receiving intramuscular cyanocobalamin injections. Which client statement indicates that teaching is effective? 1. “I should limit eating egg yolks and red meat.” 2. “I should avoid eating organ meats and shellfish.” 3. “This medication does not interact with any other medications.” 4. “I should not drink any alcohol while receiving these injections.” Ans: 4 66. The nurse provides care for a client with a serum sodium level of 120 mEq/L. Which nursing action is a priority? 1. Monitor for neurological changes. 2. Check the client’s serum creatinine level. 3. Assess the client’s functional status. 4. Obtain a prescription for intravenous dextrose 5%. Ans: 1 67. The nurse teaches parents about the nutritional needs of their 6-month-old infant. Which statement by a parent indicates a need for further teaching? 1. “Fruit juice should be limited to 2 to 4 ounces per day.” 2. “I’ll make sure I offer more fruit juice than fruit.” 3. “Fruit juice is not necessary in my baby’s diet.” 4. “I’ll avoid offering a no-spill sippy cup to prevent tooth decay.” Ans: 2 68. The charge nurse supervises the care of several clients. Which situation requires immediate intervention by the charge nurse? 1. A nurse puts on an isolation gown and gloves before entering the room of a client with localized herpes zoster. 2. An LPN/LVN gathers all necessary supplies before entering the room of a client needing a sterile dressing change. 3. A nurse talks with family about a client’s condition after receiving the client’s permission. 4. A nursing assistive personnel (NAP) changes the linens on a client’s bed while the client with Meniere disease ambulates in the hall. Ans: 4 69. The nurse provides care for a client who has undergone detoxification of long-term opioid use. The nurse plans discharge teaching for the client. Which medication does the nurse include in the discharge teaching? 1. Diazepam. 2. Vareninclin. 3. Naltrexone. 4. Disulfiram. Ans: 3 70. The nurse identifies the nursing diagnosis of Stress Urinary Incontinence related to weakened pelvic musculature for a client. Which goal is most appropriate for this client? 1. Engage in a bladder retraining program. 2. Reduce the frequency of urinary incontinence episodes through exercises. 3. Use adaptive clothing for quick removal. 4. Undergo urodynamic testing to assess urine speed and volume. Ans: 2 71. The nurse provides care for a client with a nasogastric (NG) tube attached to wall suction. The nurse notes large amounts of gastric secretions in the suction canister. Which arterial blood gas (ABG) result does the nurse expect to observe? 1. PaCO2 50 mmHg, pH 7.20. 2. PaCO2 40 mmHg, pH 7.40. 3. HCO3 28 mEq/L (28 mmol/L), pH 7.50. 4. HCO3 20 mEq/L (20 mmol/L), pH 7.30. Ans: 3 72. The nurse plans to assess a client with acquired immune deficiency syndrome (AIDS). Which question provides the least amount of information to plan this client's care? 1. What method of birth control do you use? 2. Do you use intravenous drugs? 3. How many sexual partners do you have? 4. How old were you when you became sexually active? Ans: 4 73. A client recovers from general anesthesia. Which medication will the nurse identify as causing respiratory depression? (Select all that apply.) 1. Ketorolac. 2. Hydromorphone hydrochloride. 3. Ibuprofen. 4. Codeine sulfate. 5. Hydrocodone. Ans: 2, 4, 5 74. The nurse provides care to a client diagnosed with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which goal is most appropriate to include in the nursing care plan? 1. Improve gas exchange. 2. Perform activities of daily living without dyspnea. 3. Obtain flu and pneumonia vaccinations. 4. Sleep for 8 hours without interruption. Ans: 1 75. A client with injuries from a motor vehicle accident is unconscious from a severe head injury. The client's identity is unknown, but the client needs emergency surgery to stabilize fractures. Which action is the best for the nurse to take when obtaining informed consent for the operative procedure? 1. Ask the emergency services team to sign the informed consent. 2. Obtain an emergency court order for the surgical procedure. 3. Transport the client to the operating room for surgery. 4. Ask the police to identify the client and locate the family. Ans: 3 76. The nurse attends a staff development conference on transfusion reactions. Which statement by the nurse indicates the need for further teaching? 1. “I will keep the intravenous line open with normal saline after I stop the transfusion.” 2. “I will obtain a urine specimen to determine the presence of hemoglobin.” 3. “I will discard the blood bag and transfusion set in a waterproof bag.” 4. “I will notify the blood bank if a client has a transfusion reaction.” Ans: 3 77. A client diagnosed with a terminal disease questions the nurse about the purpose of diagnostic tests. Which action should the nurse take next? 1. Encourage the client to have the testing performed to validate the diagnosis. 2. Contact the radiology department to reschedule the diagnostic tests. 3. Inform the health care provider that the client is refusing diagnostic tests. 4. Ask the health care provider to discuss the diagnostic tests with the client. Ans: 4 78. The nurse observes a student assess an older client with dehydration. Which assessment requires the nurse to intervene? 1. Measures orthostatic blood pressure. 2. Reviews serial daily weight readings. 3. Checks skin turgor on the hand. 4. Reviews serum sodium values. Ans: 3 79. The nurse provides care for a client receiving external radiation to the chest wall. Which action by the nurse is best? 1. Perform a thorough assessment and ongoing monitoring of the client’s skin. 2. Isolate the client from people with infections such as the cold virus. 3. Prevent the client from eating or drinking for 2 hours after radiation. 4. Dispose of the client’s excretions in a specific lead-lined container. Ans: 1 80. The nurse teaches a group of students about measures to reduce the risk for medical device- related accidents. Which point does the nurse include in the teaching? (Select all that apply.) 1. Bend electric cords for storage. 2. Be alert for wet surfaces near electric cords. 3. Handle medical equipment with care. 4. Avoid using equipment that is unfamiliar. 5. Use two-prong electrical plugs when possible. Ans: 2, 3, 4 81. The nurse provides care for a 65-year-old client with no high-risk factors. The nurse evaluates the client’s immunization status. Which of the client’s immunizations should the nurse determine are current? (Select all that apply.) 1. Last tetanus booster at age 60. 2. Has not received the hepatitis A vaccine. 3. Received the herpes zoster vaccine at age 60. 4. Has not received the hepatitis B vaccine. 5. Receives a flu shot every year. Ans: 1, 3, 5 82. The nurse provides care for a client who reports a sexual and physical assault by a friend. Which action should the nurse take first? 1. Place a referral for a psychiatric provider consult. 2. Call the hospital chaplain to offer prayer and support. 3. Clean the client’s wounds and provide a clean gown. 4. Stay with the client during the physical examination. Ans: 4 83. The nurse teaches the parent of a child diagnosed with celiac disease. Which statement does the nurse identify as an indication that the parent understands the teaching? 1. “I will give my child barley soup for lunch.” 2. “I will make my child sandwiches on rye bread." 3. “I will make my child popcorn as a snack.” 4. “I will give my child oatmeal for breakfast." Ans: 3 84. The nurse provides care to a client with a terminal illness and discusses withdrawal of care. The family expresses concern related to discontinuation of the therapy. Which statement by the nurse is most appropriate? 1. “I understand your concerns. We will give the client enough morphine to promote a painless death.” 2. “You will need to talk to the lawyer. I am not legally allowed to participate in the withdrawal of life support.” 3. “I realize this is a difficult decision. Discontinuation of therapy will allow the client to die a more natural death.” 4. “There is no need to worry. Most religious organizations support the client’s decision to stop medical treatment.” Ans: 3 85. The nurse cares for a client receiving nasogastric tube feedings. Which method will the nurse use when administering the client’s medications? 1. Crush the medications and add them to client’s tube feeding. 2. Flush the nasogastric tube with 15 mL of water between medications. 3. Crush the medications and pour them into the nasogastric tube. 4. Place crushed medications together and dissolve with water. Ans: 2 86. The nurse provides care for a client in the final stage of chronic kidney disease. The client’s serum calcium level is 7.5 mg/dL (1.8 mmol/L) and the phosphate level is 6.0 mg/dL (1.9 mmol/L). Which priority nursing diagnosis does the nurse use to plan care for this client? 1. Activity intolerance. 2. Risk for injury. 3. Imbalanced nutrition. 4. Failure to thrive. Ans: 2 87. The nurse provides care for a client who has a body mass index of 16.2. Which health problem will the nurse identify as being most affected by this assessment finding? 1. Seasonal allergies. 2. Rheumatoid arthritis. 3. Sacral pressure injury. 4. Elevated blood pressure. Ans: 3 88. The nurse provides discharge teaching to the parents of an infant recovering from gastroenteritis and dehydration who is approaching the first birthday. After instructing on dietary and fluid requirements, which topic will the nurse teach the parents next? 1. Toilet training. 2. Introduction to solid foods. 3. Safety guidelines. 4. Glucose testing. Ans: 3 89. The nurse prioritizes the needs of several assigned clients. Which client need will the nurse address first? 1. Comforting a client who received a cancer diagnosis. 2. Instituting precautions for a client identified at risk for falling. 3. Assessing a client with a reported blood glucose level of 60 mg/dL (3.33 mmol/L). 4. Implementing precautions for a client identified at risk for aspiration. Ans: 3 90. The nurse provides care for a client with type 2 diabetes mellitus who experienced a large brain concussion. Which medication does the nurse expect to be prescribed for this client? 1. Metoprolol. 2. Mannitol. 3. Morphine. 4. Metformin. Ans: 2 91. The nurse is assisting in the care of a client with ventricular fibrillation. The “code” leader called to shock the client uses a biphasic defibrillator. The nurse sets the defibrillator at which energy level? 1. 80 to 100 Joules. 2. 100 to 110 Joules. 3. 120 to 200 Joules. 4. 300 to 360 Joules. Ans: 3 92. The nurse provides care for a client who reports fatigue, has dry skin, and a poorly healing wound. Which health problem will the nurse consider the client to be experiencing? 1. Anemia. 2. Malnutrition. 3. Activity intolerance. 4. Peripheral vascular disease. Ans: 2 93. The nurse plans to fax health information to a facility in which a client is being transferred. Which action is appropriate for the nurse to take? (Select all that apply.) 1. Remove all identifiers on all the documents to be faxed. 2. Fax documents during the least busy time in the other facility. 3. Confirm that fax numbers are correct before sending. 4. Use a cover sheet with the name of the recipient printed. 5. Fax the information that is required for immediate needs. Ans: 3, 4, 5 94. The nurse assesses a client with obsessive compulsive personality disorder. Which finding will the nurse expect to observe? (Select all that apply.) 1. Requires excessive support from others when making decisions. 2. Believes is able to know what others are thinking. 3. Possesses exaggerated feelings of helplessness when alone. 4. Demonstrates unwillingness to delegate tasks unless others follow strict rules. 5. Imposes perfectionism in own completion of tasks. Ans: 4, 5 95. The client states to the nurse, “I am a lacto-vegetarian.” Which food will the nurse expect the client to eat? (Select all that apply.) 1. Fish. 2. Milk. 3. Eggs. 4. Cheese. 5. Yogurt. Ans: 2, 4, 5 96. The nurse provides care for a client in the post-operative anesthesia care unit (PACU). The client’s vital signs are respirations 16 breaths per minute, pulse 90 beats per minute, and blood pressure 110/68 mm Hg. The pulse oximeter shows 87% with 2 L of oxygen per nasal cannula. Which nursing diagnosis is a priority? 1. Impaired gas exchange. 2. Ineffective airway clearance. 3. Ineffective peripheral tissue perfusion. 4. Ineffective breathing pattern. Ans: 1 97. The nurse is teaching a group of nursing assistive personnel (NAP) about infection control practices. Which statement by a NAP indicates that the teaching is effective? 1. “I’ll be sure to clean the least soiled areas first.” 2. “I’ll place soiled bed linens on the floor.” 3. “I’ll discard liquids by pouring them over the sink.” 4. “I’ll carry soiled items close to me to prevent them from dropping.” Ans: 1 98. The nurse provides care to a client receiving intravenous heparin. Which laboratory test result causes the nurse to be most concerned? 1. Platelet count 50 mm3/L (50×109/L). 2. Sodium level 130 mEq/L (130 mmol/L). 3. Potassium level 3.2 mEq/L (3.2 mmol/L). 4. Partial thromboplastin time 70 seconds. Ans: 1 99. The nurse is teaching a client diagnosed with end stage renal disease about hemodialysis. Which statement indicates that teaching has been effective? 1. “I should have a treatment once a week.” 2. “I might have muscle cramps after a treatment.” 3. “The treatment could make my blood clot faster.” 4. “The treatments reduce my risk of getting infections.” Ans: 2 100. The supervisor observes the nurse delegate a dressing change on a client with a fever, positive blood cultures, and a blood pressure of 86/42 mm Hg to the LPN/LVN. Which action will the supervisor take next? 1. Encourage the LPN/LVN to complete the dressing change as assigned. 2. Assign another LPN/LVN who is more comfortable with dressings to complete the dressing change. 3. Discuss with the nurse that the dressing change should not be delegated to the LPN/LVN. 4. Ensure that the nurse follows up with the LPN/LVN after the dressing change is complete. Ans: 3 101. The nurse prepares to instruct a client diagnosed with diabetes mellitus on self-injection of insulin. Which gauge and needle length does the nurse teach the client to choose? 1. 23-gauge syringe with a 1 inch needle. 2. 28-gauge syringe with a 0.5 inch needle. 3. 18-gauge syringe with a 1 1/2 inch needle. 4. 20-gauge syringe with a 2 inch needle. Ans: 2 102. A newly admitted client experiences a cardiac arrest and does not have a "do not resuscitate" order. Nursing assistive personnel (NAP) relate that the client stated to family earlier the desire to not be resuscitated. Which action will the nurse perform next? 1. Respect the client's wishes and do not perform cardiopulmonary resuscitation. 2. Tell the health care provider the client asked to be have a "do not resuscitate" order. 3. Determine who has the durable medical power of attorney. 4. Start cardiopulmonary resuscitation. Ans: 4 103. The nurse provides care for a client diagnosed with a duodenal ulcer. The client asks how a stomach infection can cause a duodenal ulcer. Which response by the nurse is best? 1 “Bacteria in the duodenum deteriorate the area, causing an ulceration.” 2 “The bacteria enter the lining of the intestines and changes the protective layer.” 3 “There is no explanation for how this occurs in a vast majority of people.” 4 “Medication for the stomach infection causes the duodenal lining to break down.” Ans: 2 104. The nurse receives reports on several clients. Which client will the nurse assess first? 1 9-month-old client with a barking cough, not eating or drinking, with an oxygen saturation of 92% on room air. 2 14-month-old client with an oral temperature of 1020 F, green nasal drainage, and is pulling at the ears. 3 6-month-old client with a harsh cough, mild audible wheezes, and retractions noted in the ribs. 4 2-year-old client with a sore throat, sitting upright, refusing to swallow, and drooling. Ans: 4 105. During an assessment the nurse suspects that an injured child is a victim of physical abuse. Which action is the nurse’s primary legal responsibility in this situation? 1 Refer the family to the hospital social worker. 2 Call the hospital attorney to report the suspicion. 3 Report the case to the local law enforcement authorities. 4 Document the physical assessment of the child accurately and thoroughly. Ans: 3 106. A client relieves severe abdominal pain that radiates to the back by sitting forward with the knees bent. Which laboratory test will the nurse expect to be prescribed for this client? 1 Creatinine. 2 Serum amylase. 3 Creatinine kinase. 4 Blood urea nitrogen. Ans: 2 107. The nurse provides care for a client who is confused and reports a headache. The client's vital signs are as follows: temperature 101.0°F (38.3°C), BP 150/64 mm Hg, pulse 58 beats/min, and irregular respirations of 12 breaths/min. Which action does the nurse take next? 1 Lower the head of the bed to a flat position. 2 Prepare for a lumbar puncture (LP). 3 Administer morphine 4 mg intravenously. 4 Prepare for a head computerized tomography (CT) scan. Ans: 4 108. The nurse provides care for a toddler who is a ward of the state. The toddler requires surgery. Who is authorized to give written, informed consent for the procedure? 1 Primary care health care provider. 2 Nurse manager. 3 Foster parent. 4 Social worker who placed the child in the foster home. Ans: 3 109. A client may be developing side effects from an anticholinergic medication. Which question does the nurse ask the client to further assess for side effects to this medication? (Select all that apply.) 1 “Do you have blurred vision?” 2 “Does your mouth feel dry?” 3 “Do you have needles and pins sensation?” 4 “When was the last time you voided?” 5 “When was your last bowel movement?” Ans: 1, 2, 4, 5 110. The nurse provides care for a client diagnosed with trigeminal neuralgia. The client reports severe burning and shooting pain. Which understanding does the nurse have about managing this type of pain? 1 It is usually well controlled with salicylates or nonsteroidal anti-inflammatory drugs (NSAIDs). 2 It is acute and will require short-term treatment. 3 Treatment will include low or moderate regular doses of oral opioids. 4 Treatment will include the use of adjuvant analgesics. Ans: 4 111. The nurse works with a nursing assistive personnel (NAP) to care for several clients. Which NAP action should cause the nurse to immediately intervene? 1 The NAP explains signs and symptoms of hypoglycemia to a client. 2 The NAP reports a blood pressure of 88/52 mm Hg to the nurse. 3 The NAP collects a midstream urinalysis from a client. 4 The NAP obtains a fasting capillary blood sugar on a client. Ans: 1 112. The nurse teaches a client with peptic ulcer disease about the prescribed therapy. Which client statement indicates to the nurse that teaching has been effective? 1 “I can stop taking the prescribed medications as soon as I feel better.” 2 “I’m glad I can still take ibuprofen for my arthritis pain.” 3 “I have to take antibiotics to get rid of bacteria responsible for my ulcer.” 4 “I’m glad I don’t have to cut down my coffee consumption.” Ans: 3 113. The nurse teaches a group of nursing students about informed consent for medical treatment. The nurse includes teaching about informed consent involving minors. Which statement is correct for the nurse to include in the teaching? 1 Minors with cognitive impairment may consent with a parent. 2 Minors in active military service may consent without a parent. 3 Minors who need emergency surgery may sign the consent. 4 Minors who are orphans cannot sign their informed consent. Ans: 2 114. The nurse teaches a client about prescribed vaginal suppositories for use at home. Which client statement indicates a need for further instructions? 1 “I should insert the suppository about a half inch into my vagina.” 2 “I should plan to lie on my back with my hips elevated for 5 to 10 minutes after inserting the suppository.” 3 “I should wear a perineal pad if I have some of the melted medication come out.” 4 “If I reuse an applicator, I should wash it with soap and water before I use it again.” Ans: 1 115. The nurse provides care for a client newly admitted to the post-operative anesthesia care unit (PACU). The client is drowsy with a respiratory rate of 8 and an oxygen saturation of 86%. Which action does the nurse take first? 1 Place the client in a supine position. 2 Assess lung sounds. 3 Remove the oral airway. 4 Raise the head of the bed to semi-Fowler’s. Ans: 4 116. The nurse provides teaching to a client diagnosed with tuberculosis about the most common means of transmitting the tubercle bacillus to others. Which method of transmission will the nurse include in the teaching? 1. Droplet nuclei 2. Contaminated food 3. Hands 4. Eating utensils Ans: 1 117. The nurse provides care for a newly admitted client diagnosed with Alzheimer disease. Which action from the nurse is appropriate? 1 Ask the client the date and the day of the week. 2 Assign a different nurse to provide care for each day to introduce the client to the staff. 3 Ask the family to step out of the room while the nurse assesses the client. 4 Place the client in a private room away from the nurses’ station. Ans: 1 118. The nurse provides care for a client diagnosed with chronic constipation and diverticulosis who was recently admitted to the hospital with a rectal impaction. The nurse teaches the client about strategies to manage constipation. Which statement made by the client indicates to the nurse a need for further teaching? 1 “I will begin an exercise program and exercise daily.” 2 “I will eat foods like corn, popcorn, or sunflower seeds to increase my fiber.” 3 “I will drink about 2 liters of fluid a day.” 4 “I will give myself as much privacy as I can when having a bowel movement.” Ans: 2 119. The nurse prepares to discard a partial dose of hydromorphone. Which action by the nurse is most correct? 1 Asks a second nurse to witness the discarding. 2 Discards the medication and documents the discarding in the control record. 3 Asks a second nurse to witness the discarding and countersign the control record. 4 Asks a second nurse to countersign the control record. Ans: 3 120. The nurse provides care for a client who has received gentamicin intravenously for the past 6 days. Which finding indicates the client is experiencing adverse effects? 1 Heart rate of 92 beats per minute. 2 Urine output of 110 mL for 8 hours. 3 White blood cell (WBC) count of 12,000 per mm3. 4 Blood pressure (BP) of 149/78 mm Hg. Ans: 2 121. The nurse provides care for a client who exhibits shortness of breath and a pulse oximeter reading of 87% on 2 liters oxygen via nasal cannula. The client’s respiratory rate is 28 breaths/min. The nurse assesses rales in both lower lobes bilaterally. Which nursing diagnosis does the nurse assign the highest priority? 1 Decreased cardiac output. 2 Fluid volume excess. 3 Impaired gas exchange. 4 Ineffective tissue perfusion. Ans: 3 122. The nurse provides care for the client who had an extracorporeal shock-wave lithotripsy to treat a kidney stone. Which observation requires intervention by the nurse? 1 Urine output is 10 to 15 mL per hour. 2 Urine is pinkish in color. 3 Urine contains sand-like particles. 4 Urine has red blood cells of >2. Ans: 1 123. The nurse learns that the twin sibling of a toddler with a Staphylococcus skin infection has developed the same infection. Which behavior by the children is most likely to have caused the transmission of this infection? 1 Using the same pacifiers. 2 Coughing on each other. 3 Sharing eating utensils. 4 Bathing with one another. Ans: 4 124. A client recovering from anesthesia receives a dose of intravenous nalaxone. Which response indicates to the nurse that the medication is effective? 1 Blood pressure is 88/50 mm Hg. 2 Heart rate is 55 beats/min. 3 Respiratory rate is 13 breaths/min. 4 Pulse oximeter is 86% on 2 liters per nasal cannula. Ans: 3 125. Upon entering the room, the nurse notices the client is visibly short of breath. Which nursing action does the nurse perform first? 1 Obtain the client’s oxygen saturation. 2 Place the client in a high-Fowler position. 3 Assess the client’s lung sounds. 4 Notify the health care provider of the client's assessment data. Ans: 2 126. The nurse develops a dietary teaching plan for a pregnant client. Which information will the nurse include? 1 Protein requirements will triple. 2 The need for calories will increase by 1200 kcal/day. 3 There is an increased need for iron. 4 Sodium needs will decrease. Ans: 3 127. A client was found on the floor lying in a pool of blood next to the client’s bed at 0500. The medical examiner determined that the client died 3 to 4 hours before being found by the nurse. Hospital policy states that hourly rounding is done in all client care areas. Which charge will the family use when seeking legal action against the hospital and the nurse? 1 Negligence. 2 Slander. 3 Battery. 4 Abandonment of care. Ans: 1 128. The nurse provides care for a client who was just informed about a cancer diagnosis. Which statement by the nurse demonstrates empathy? 1 “Tomorrow will be better.” 2 “This must be difficult news to hear.” 3 “What are your fears about this diagnosis?” 4 “I believe you can overcome this.” Ans: 2 129. The nurse selects a walker to assist an adult client with ambulation. Which finding supports the selection of a walker with wheels? 1 Generalized weakness and problems with balance. 2 Use of multiple throw rugs in the client’s environment. 3 Weakness that requires frequent leaning on the walker. 4 Inability of the client to lift and advance the walker. Ans: 4 130. The nurse teaches a new parent about umbilical cord care. Which statement by the parent requires follow-up teaching by the nurse? 1 “I will call my child's doctor if the cord becomes brownish black in color.” 2 “The cord usually falls off when my baby is about ten days old.” 3 “I will fold the diaper below the cord to keep it dry and free of urine.” 4 “Yellow or green drainage or redness at the base of the cord may mean infection.” Ans: 1 131. The nurse teaches the parents of a 14-month-old about car seat safety. Which parent statement requires the nurse to immediately intervene? 1 “I use a front-facing car seat.” 2 “I will make sure safety straps are tight.” 3 “I check the restraint straps before each trip.” 4 “I allow my child to hold his favorite toy while in the car seat.” Ans: 1 132. The nurse provides care to a client with acetaminophen toxicity. Which medication does the nurse administer as the antidote for an acetaminophen overdose? 1 Protamine sulfate. 2 N-acetylcysteine. 3 Naloxone. 4 Deferoxamine mesylate. Ans: 2 133. The nurse performs pre-operative teaching for a client diagnosed with end stage colon cancer. The client is scheduled for colostomy placement to relieve a bowel obstruction. Which statement by the nurse most accurately explains the purpose of this surgery? 1 “The surgery is curative and will remove the remaining visible cancer.” 2 “The colostomy placement is palliative and will relieve the bowel obstruction.” 3 “The surgery is reconstructive and will restore bowel tract function.” 4 “The colostomy placement is prophylactic and will prevent the cancer from growing.” Ans: 2 134. The nurse provides care for a client. The intent of the care is to avoid deliberate harm, risk of harm, and any type of harm to the assigned clients during the performance of nursing actions. Which ethical principle is guiding the nurse in this care? 1 Beneficence. 2 Justice. 3 Fidelity. 4 Nonmaleficence. Ans: 4 135. The nurse reviews medications prescribed for a newly admitted client. Which question will the nurse ask before administering the medication? (Select all that apply.) 1 “What is your full name?” 2 “What is today’s date?” 3 “What is your date of birth?” 4 “What time is it now?” 5 “What is your room number?” Ans: 1, 3 136. The nurse provides care for a client recovering from total hip replacement surgery. The client reports severe pain after physical therapy. The nurse notes that the operative limb is 2 cm shorter than the other limb. Which health care provider should the nurse notify immediately? 1 Surgeon. 2 Physical therapist. 3 Nursing supervisor. 4 Nursing assistive personnel (NAP). Ans: 1 137. The nurse provides care for a client with diabetes insipidus (DI). Which nursing diagnosis is most appropriate for this client? 1 Fluid volume deficit related to excess urine output. 2 Hyponatremia related to increased sodium excretion. 3 Risk for fluid overload related to low urine output. 4 Hyperglycemia related to reduced insulin production. Ans: 1 138. The nurse provides care for a post-operative client with an abdominal incision. The client reports feeling the wound give way, and the nurse visualizes a separation in the incision. Which risk factor can contribute to the client’s condition? 1 Vomiting. 2 Uncontrollable pain. 3 Early ambulation after surgery. 4 Splinting with coughing. Ans: 1 139. A nursing assistive personnel (NAP) asks the nurse when contact precautions should be used for client care. Which response by the nurse is best? 1 “Use contact precautions for a client who has a disease transmitted by tiny airborne droplet nuclei.” 2 “Use contact precautions for a client who has a disease transmitted by blood- borne pathogens.” 3 “Use contact precautions for a client who has a disease transmitted by inhaling large particle droplets.” 4 “Use contact precautions for a client who has a disease transmitted by touching a contaminated object.” Ans: 4 140. The nurse instructs a client with asthma about the treatment plan. Which statement from the nurse teaches the client how to evaluate a response to therapy at home? 1 “Keep a daily diary to record symptoms and interventions.” 2 “Measure your chest circumference every week.” 3 “Note your symptoms when you don’t take your home medications.” 4 “Use proper technique and sequence with the metered dose inhaler.” Ans: 1 141. The nurse suspects that a client receiving hospice care is in the depression stage of the Kubler-Ross coping with loss model. Which client action causes the nurse to make this determination? 1 The client ignores family members. 2 The client throws clothes on the floor. 3 The client states repeatedly “this can’t be happening to me.” 4 The client states the desire to see a grandchild get married. Ans: 1 142. The nurse observes a client walk with a cane. The nurse reevaluates the size of the cane being used. Which observation caused the nurse to make this decision? 1 The client moves the weaker leg with the cane. 2 The client bends the elbow at a 90-degree angle. 3 The client holds the cane on the stronger side. 4 The client places the stronger leg ahead of the cane. Ans: 2 143. The nurse provides care for a group of clients in a mental health facility. Which task does the nurse delegate to the nursing assistive personnel (NAP)? (Select all that apply.) 1 Observe a client with bulimia for 30 minutes after each meal. 2 Help a client with depression to complete a craft project. 3 Assist a client to identify coping skills to manage stress. 4 Lead a group therapy session for clients with bipolar disorder. 5 Complete an Abnormal Involuntary Movement Scale for a client. Ans: 1, 2 144. A client with a blood type of B Rhesus factor (Rh) negative is prescribed a blood transfusion. Which type of donated blood will the nurse expect to be provided for this client? 1 B+. 2 AB-. 3 A+. 4 O-. Ans: 4 145. The nurse provides care for a pediatric client diagnosed with otitis media. Which statement by the parent will cause the nurse to immediately intervene? 1 “I will continue giving my child antibiotics, even after symptoms resolve.” 2 “I clean drainage from my child’s outer ear canal with cotton swabs.” 3 “ 4 “I have been giving my child ibuprofen.” Ans: 3 146. The nurse notes that a client has a 2 cm area of skin breakdown on the coccyx. Which action will the nurse take first? 1 Stage the wound. 2 Apply a dry gauze dressing to the wound. 3 Notify the health care provider. 4 Place lamb’s wool under affected the area. Ans: 1 147. The nurse teaches a group of nursing students about infection. Which condition does the nurse list as a primary defense against infection? 1 Inflammation. 2 Elevated temperature. 3 Lethargy. 4 Intact skin. Ans: 4 148. Prior to delegating a client's surgical dressing change to an LPN/LVN, the nurse notes the dressing is saturated with blood. What action will the nurse take next? 1 Instruct the LPN/ LVN to complete the dressing change. 2 Reinforce the dressing. 3 Remove the dressing to assess the incision. 4 Notify the health care provider. Ans: 3 149. The nurse provides care to a client with deep vein thrombosis (DVT). Which medication requires monitoring of the activated partial thromboplastin time (aPTT)? 1 Enoxaparin. 2 Heparin. 3 Rivaroxaban. 4 Warfarin. Ans: 2 150. The nurse provides care for a client who received an inhalation anesthetic agent during surgery. Which assessment finding requires the nurse to intervene immediately? 1 Blood pressure 144/80 mm Hg. 2 Urine output 30 mL/hour. 3 Generalized muscle rigidity. 4 Increased cardiac output. Ans: 3 [Show More]

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