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The nurse is giving preoperative instructions to a 14-year old female client who is scheduled for surgery to correct a spinal curvature. Which statement by the client best demonstrates that learning has taken place? A. I will read all the literature you gave me before surgery. B. I have had surg...

The practical nurse (PN) is monitoring a child who is manifesting signs of shock after a motor vehicle collision. Which finding is most important for the PN to report to the charge nurse? a) narrowing pulse pressure b) apprehension c) irritability d) thirst Answer: A Rationale: As shock progr...

The RN is monitoring an infant with CHD closely for SSx of HF. The RN should assess the infant for which early sign of HF? 1.Pallor 2.Cough 3.Tachycardia 4.Slow and shallow breathing 3. tachycardia RATIONALE: HF is the inability of the heart to pump a sufficient amt of blood to meet the O2 an...

A male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the nurse to ask the client? Do you hear voicesa A female client with a history of drinking who was admitted...

At the first meeting of a group at a daycare center for older adults, the nurse asks one of the members what kinds of things the client would like to do with the group. The older adult shrugs and says, "You tell me. You're the leader." What would be the best response for the nurse to make? A....

A male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the nurse to ask the client? Do you hear voices A female client with a history of drinking who was admitted ...

The nurse is discussing the grieving process with the client. Which stages are included in Kubler- Ross' stages of grief? Rank in the correct order. 1. Acceptance 2. Bargaining 3. Denial 4. Anger 5. Depression Answer: 3. Denial 4. Anger 2. Bargaining 5. Depression 1. Acceptance Which si...

Which behavior indicates to the nurse that a client with paranoid ideas is improving? A. Arrives on time for all activities B. Talks more openly about plans to protect his possessions C. Aggressively uses the punching bag in the gym D. Discusses his feelings of anxiety with the nurse Answer: D ...

The nurse is planning care with a Mexican client who is diagnosed with depression. The client believes in "mal ojo" (the evil eye) and uses treatment by a root healer. The nurse should do which of the following? 1. Avoid talking to the client about the root healer. 2. Explain to the client tha...

A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching? A. Take temperature once a day. B. Wash the armpits and genitals with a gentle cleanser daily. C. Change the litter boxes while...

When providing care for a client following a bronchoscopy, which assessment finding should the nurse immediately report to the HCP? a) slight blood-tinged sputum b) dyspnea and dysphagia c) sore throat and hoarseness d) no gag reflex after thirty minutes b) dyspnea and dysphagia To reduce the ...

During a clinic visit, a client reports to the practical nurse (PN) that they felt a solid mass in their breast during self-examination, but it was not painful. What instruction should the PN reinforce with the client? A. Continue to monitor the mass until the next scheduled annual exam. B. Noti...

34. Based on the clinical manifestations of Cushing syndrome, which nursing intervention would be appropriate for a client who is newly diagnosed with Cushing syndrome? A. Monitor blood glucose levels daily. B. Increase intake of fluids high in potassium. C. Encourage adequate rest between activ...

The nurse notices clear nasal drainage in a patient newly admitted with facial trauma, including a nasal fracture. The nurse should: A. test the drainage for the presence of glucose. B. suction the nose to maintain airway clearance. C. document the findings and continue monitoring. D. apply a d...

The nurse is assessing a 48-year-old client with a history of smoking during a routine clinic visit. The client, who exercises regularly, reports having pain in the calf during exercise that disappears at rest. Which of the following findings requires further evaluation? 1. Heart rate 57 bpm. 2...

The nurse is assessing a 48-year-old client with a history of smoking during a routine clinic visit. The client, who exercises regularly, reports having pain in the calf during exercise that disappears at rest. Which of the following findings requires further evaluation? 1. Heart rate 57 bpm. 2...

The nurse is preparing to assist a client with a cuffed tracheostomy tube to eat. What intervention is the priority before the client is permitted to drink or eat? Inflate the cuff Rationale: If a client with a tracheostomy is allowed to eat and the tracheostomy has a cuff, the nurse should infla...

A client with a productive cough has obtained a sputum specimen for culture as instructed. What is the best initial nursing action? A. Administer the first dose of antibiotic therapy B. Observe the color, consistency, and amount of sputum C. Encourage the client to consume plenty of warm liquids...

Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching of the gravid client? a. the client's readiness to learn b. the client's educational background c. the order in which the information is presented d. the extent ...

1. A 12-year-old female is seen by the school nurse after recently experiencing increasing difficulty sitting and paying attention in class, and increasingly illegible handwriting. The nurse observes that the child has protruding eyeballs and a staring expression. What action should the nurse tak...

A client is reporting chest pain. What statement made by the client, helps the nurse to understand this client has a naturalistic belief in the cause of illness? "My life is really out of balance." 2. A nurse is working in a healthcare facility that serves a diverse population. What action(s) by...

A client with cardiogenic shock weighs 220 lb and is receiving dopamine at the rate of 3 mcg/kg/minute. The solution strength available is dopamine 400 mg in 250 ml of D5W. The nurse should set the infusion pump to deliver how many ml/hour? (Enter numeric value only. If rounding is required, roun...

Low GFR and low cardiac output = Elevated BUN COPD intervention Chantix Severe hearing deficit and anxious = provide sensory stimulation Macular degeneration patho and tx loss of central vision in retina OT Normal suction level for adult -20cm RA intervention OT intermittent claudication tx s...

The community health nurses is counseling a group of 14 year olds about safe sexual practices. Which health teaching strategy would be most effective for the nurse to use with this age group. A.Encourage group members to describe personal experiences in practicing safe sex B. Provide the group wi...

At the first meeting of a group of older adults at a daycare center for the elderly, the nurse asks one of the members what kinds of things she would like to do with the group. The older woman shrugs her shoulders and says, "You tell me, you're the leader." What is the best response for the nu...

A 29 year old male client informs the nurse that he came to the clinic to see if, "Maybe I have lung cancer or something," and wants to get checked out since, "I can't seem to get rid of this body-wracking dry cough that has been hanging around for the last six weeks." Which computer documen...

A client who has partial-thickness burns on the chest, abdomen, and right side arrives in the emergency department. Which action will the nurse take first? A. Remove the client's clothing. B. Evaluate whether the client has inhaled smoke. C. Insert a venous access device in an unaffected arm. ...

A client with cardiogenic shock weighs 220 lb and is receiving dopamine at the rate of 3 mcg/kg/minute. The solution strength available is dopamine 400 mg in 250 ml of D5W. The nurse should set the infusion pump to deliver how many ml/hour? (Enter numeric value only. If rounding is required, roun...

1. In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking? A) Note-taking may impede the nurse's observation of the patient's nonverbal behaviors. B) Note-taking allows the patient to continue at his or her ow...

The nurse is performing a thoracic assessment on a client with chronic asthma and hyperinflation of the lungs. Which finding should be expected for this client? Barrel chest The nurse is assessing bowel sounds for a hospitalized client. The nurse has heard bowel sounds in the right upper quadrant...

The nurse is caring for a patient with chronic lower back pain. The nurse knows that the most reliable indicator of pain in this client is: The patient is reporting "6/10" pain. The patient is refusing to get out of bed. The patient is refusing to eat breakfast. The patient's heart rate is 9...

A client presents at a community-based clinic with complaints of shortness of breath, headache, dizziness, and nausea. During the assessment, the nurse learns that the client is a migrant worker who often uses a gasoline-powered pressure washer to clean equipment and farm buildings. Which type of...

A nurse is monitoring a client who is taking spironolactone for the tx of HTN. Which findings denote adverse effects of this med SATA a) constipation b) tall T waves c) hyporeflexia d) shallow resp e) prolonged PR interval f) hyperactive bowel sounds b, e, f a nurse is providing dietary inst...

What instruction should the nurse include in the discharge teaching plan of a client who had a cataract extraction today? Light housekeeping is permitted but avoid heavy lifting. A male adult comes to the urgent care clinic 5 days after being diagnosed with influenza. He is short of breath, febri...

A nurse is showing a student nurse how to care for Tonisha Bennete, a 32-year-old female who has pneumonia. The student nurse asks the nurse to explain why Ms. Bennete is placed in Fowler position. What is the nurse's best response to the student nurse? "It is an intervention for activity intol...

The nurse is evaluating a male client's understanding of diet teaching about DASH (dietary approaches to stop hypertension) eating plan. Which behavior indicates that the client is adhering to the eating plan Enjoys fat free yogurt as an occasional snack food A client with carcinoma of the lung ...

1. During a two-week postoperative follow-up home visit, a female client who had gastric bypass surgery exhibits abdominal tenderness, shoulder pain, and describes feelings of malaise. Her vital signs are: temperature 101.8°F, blood pressure 100/50, heart rate 104 beats/minute, and respirations ...

A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When the PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the RN implemen...

During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the sun coming up the next day. What intervention is most important for the RN to implement during the admission process? A. Assist the client in developing alternative coping skill...

A client with depression remains in bed most of the day, declines activities and refuses meals. Which nursing problem has the greatest priority for this client? a.Loss of interest in diversional activity. b.Social isolation c.Refusal to address nutritional needs d.Low self-esteem C The nurse i...

A client with giardiasis is taking metronidazole (Flagyl) 2 grams PO. Which information should the nurse include in the client's instruction? Take the medication with food. A client is receiving metoprolol (Lopressor SR). What assessment is most important for the nurse to obtain? Blood pressure....

Which data indicate to the nurse that a client is experiencing effective coping following the loss of a spouse? Select all that apply. 1.Looks at old snapshots of family 2.Constantly neglects personal grooming 3.Visits the spouse's grave once a month 4.Visits the senior citizens' center once ...

The nurse is giving pre-op instructions to a 14 yr old female scheduled for surgery to correct a spinal curvature. Which stmt best demonstrates that leaning has taken place? "I understand that I will be in a body cast and I will show you how you taught me to turn" To take the v/s of a 4 month o...

Guaiac Occult Test. What lab is most important? Platelet count Patient had BDP 3 months ago with dehydration. What would warrant the nurse immediate intervention? Positive Gastro Occult A patient with Parkinson's "Freezes". Pretends there is a crack on the floor and carefully lifts leg and st...

1. It is important that the aspirin you administer to Mr. Swan be in which form? Non-enteric- coated 2. Given Mr. Swan's chest pain, it is initially assumed and he is treated as if he is having a myocardial infarction (MI). This is because: Early identification and treatment of MI increases the...

A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last 2 hours. Which action should the nurse take first? A. Irrigate the nasogastric tube with sterile normal saline....

1) A nurse is caring for a client with hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dL. Which medication should the nurse prepare to administer as prescribed to the client? 1. Calcium chloride 2. Calcium gluconate 3. Calcitonin (Miacalcin) 4. Large doses of vit...

Following the administration of sublingual nitroglycerin to a client experiencing an acute anginal attack, which assessment finding indicates to the nurse that the desired effect has been achieved? A. Client states chest pain is relieved B. Client's pulse decreases from 120 to 90 C. Client's s...

1. You care for many patients with leukemia. Leukemia is a malignancy that originates in: Bone marrow 2. Leukemia is thought to occur as result of a combination of factors. Which of the following have been implicated in the development of leukemia? -Smoking -Radiation exposure -Chemical agents ...

The nurse is providing care to a client after a percutaneous transluminal coronary angioplasty (PTCA). What actions will the nurse include in the client's plan of care? (Select all that apply.) A.Frequent vital signs. B.Determine if the client is allergic to aspirin. D.Offer fluids of choice. ...

The nurse reviews the new prescription, phenelzine (Nardil), a monoamine oxidase inhibitor (MAOI), for a client with depression on the psychiatric unit. Which information is most important for the nurse to assess? A. Consumption of any alcohol or tyramine rich foods B. Reports of nausea or vomit...

ELDERLY HAVE DECREASED RENAL FUNCTION EXCRETE DUGS AT A SLOWER RATE THAN YOUNGER ADULTS. ***RISK OF TOXICITY FOR MEDS SCHEDULED CLOSE TOGETHER EXAMPLE Q 4HRS FOR NARCOTICS*** SUCCINYLCHOLINE (ANECTINE) DEPOLARIZING NEUROMUSCULAR BLOCKER USED DURING SURGERY ***MAY CAUSE VENTRICULAR TACHYCARDIA/...

While interviewing a client, the nurse takes notes to assist with accurate documentation later. Which statement is most accurate regarding note-taking during an interview? A. The nurse' ability to directly observe the client's nonverbal communication is limited with note taking. B. Taking note...

A male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst, and the RN finds him attempting to drink water from the bathroom sink faucet. Which intervention should the RN implement? A. Report the client's serum lithium level to the HCP...

Jennifer is a community health nurse in a large metropolitan area. According to the American Nurses Association's Code of Ethics (2001), community health nurses must align themselves with public health programs that promote and preserve the health of populations by influencing: socioeconomic iss...

Fever This can cause dehydration due to excessive fluid loss due to diaphoresis as well as increases metabolism and demand for O2 Clients at High Risk for Pneumonia ALOC, depressed or absent cough/gag reflexes, brain injury, drug overdose, stroke victims, immunocompromised, susceptibility to orop...

A male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst, and the RN finds him attempting to drink water from the bathroom sink faucet. Which intervention should the RN implement? A. Report the client's serum lithium level to the HCP...

5. The nurse is interviewing a patient who has a hearing impairment. What techniques would be most beneficial in communicating with this patient? A) Determine the communication method he prefers. B) Avoid using facial and hand gestures because most hearing-impaired people find this degrading. C...

1. You recall what you know about the pathophysiology of acute pancreatitis. Which of the following best describes acute pancreatitis? Pancreatic enzymes attack pancreatic cells and cause tissue damage. 2. You know that a diagnosis of acute pancreatitis is often made on the basis of symptoms and ...

A client is reporting chest pain. What statement made by the client helps the nurse to understand the client has a naturalistic belief in the cause of illness? A. "My life is really out of balance." B. "I knew I should have changed my diet." C. "I should have gone to church last week." D....

Which glands are located immediately surrounding the urethral meatus on a woman? Skene's glands Which glands are posterior to the vaginal orifice? Bartholin's (vestibular) glands Which ligament suspends the breasts? Coopers ligament Which glands are responsible for keeping areola lubricated? M...

1. In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking? A) Note-taking may impede the nurse's observation of the patient's nonverbal behaviors. B) Note-taking allows the patient to continue at his or her ow...

Which of the following statements from a patient's history is it most important to investigate further? a. "I have an allergy to peanuts." b. "I have lost 30 pounds over the last 4 months." c. "I don't like many vegetables so I take multivitamins." d. "I drink 2 cups of coffee each mor...

A nurse conducting a physical assessment is observing the client's balance and performing tests to determine the client's sense of equilibrium. Which cranial nerve is the nurse assessing? 1. Cranial nerve II 2. Cranial nerve IX 3. Cranial nerve VII 4. Cranial nerve VIII 4. Cranial nerve VIII ...

A 24-year-old female patient has a 2-day history of clear nasal drainage. Based on these data, which question is the most logical for the nurse to ask? 1. "Is there a foul odor coming from your nose?" 2. "Have you recently had nosebleeds?" 3. "Do you snore when sleeping?" 4. "Do you have...