OCTOBER FILE 2 NCLEX RN

NCLEX RN OCTOBER FILE QUESTIONS&ANSWERS 1. A client with a productive cough has obtained a sputum specimen for culture as instructed. What is the best initial nursing action? Answer: Administer the first dose of prescribed antibiotic therapy 2. A client is brought to the Emergency Department by ambulation in cardiac arrest with cardiopulmonary resuscitation (CPR) in progress. The client is intubated and receiving 100% oxygen per self‐inflating (ambu) bag. The nurse determines that the client is cyanotic, cold, and diaphoretic. Which assessment is most important for the nurse to obtain? Answer: deep tendon reflexes. 3. After hospitalization for Syndrome of Inappropriate Antidiuretic hormone (SIADH), a client develops myelinolysis. Which intervention should the nurse implement first? Answer: Reorient client to hisroom. 4. A male client with heart failure (HF) calls the clinic and reports that he cannot put his shoes on because they are too tight. Which additional information should the nurse obtain? Answer: Has his weight changed in the last several days? 5. An older adult woman with a long history of COPD is admitted with progressive shortness of breath and a persistent cough. She is anxious and is complaining of a dry mouth. Which intervention should the nurse implement? Answer: Apply a high‐flow venturi mask. 6. A client with a history of asthma and bronchitis arrives at the clinic with SOB, productive cough with thickened, tenacious mucous, and the inability to walk up flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self‐care? Answer: Increase the daily intake of oral fluids to liquefy secretions. 7. A cardiac catheterization of a client with heart disease indicates the following blockages: 95% LAD, 99% proximal circumflex, and 95% proximal RCA. The client later asks the nurse “what does all that mean for me?” Answer: Three main arteries have major blockage with only 1 to 5% of the blood flow getting through to the heart muscle. 8. A client who weighs 175 pounds is receiving an IV bolus dose of heparin 80 units/kg. The heparin is available in a 2 mL vial, labeled 10,000 units/mL. How many mL should the nurse administer? (enter numeric value only. If rounding, round to nearest tenth.) Answer: 1.3 mL after calculations: the calculator will show 1., but you must round to the nearest tenth. So, the answer is 1.3 mL. 9. What information should the nurse include in the teaching plan of a client diagnosed with gastroesophageal reflux disease (GERD)? Answer: minimize symptoms by wearing loose, comfortable clothing. 10. The nurse is caring for a client with a lower left lobe pulmonary abscess. Which position should the nurse instruct the client to maintain? Answer: Left Lateral. 11. A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare provider? Answer: Yellow Sclera 12. While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse? Answer: Increasing anxiety. 13. The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft to promote burn healing. Which information should the nurse provide this client? Answer: The xenograft is taken from nonhuman sources. 14. A male client who had colon surgery 3 days ago is anxious and request assistance to reposition. The wound dehiscences and eviscerates. The nurse moistens an available sterile dressing and palaces it over the wound. Which intervention should the nurse implement next? answer: prepare the client to return to the operating room. 15. A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117 mEq/L. Which nursing problem should the nurse include in this client’s plan of care? answer: fluid volume excess 16.A female client enters the clinic and insists on being seen. She is weak, nervous, and reports a racing heart beat and recent weight loss of 15 pounds. After ruling out substance withdrawal, the healthcare provider suspects hyperthyroidism. Which action should the nurse implement? answer:space the client’s care to provide periods of rest 17. The nurse is teaching a client with glomerulonephritis about self‐care. Which dietary recommendations should the nurse encourage the client to follow? answer: restrict intake by limiting meats and other high‐protein foods. 18. An overweight, young adult male who has recently diagnosed with type diabetes mellitus is admitted for a hernia repair. He tells the nurse he is feeling very weak and jittery. Which actions should the nurse implement? (select all that apply). Assess hisskin temperature and moisture. Document anxiety on the surgical checklist. Administer a PRN dose of regular insulin 19. A client with Cushing’ssyndrome isrecovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse? answer: irregular apical pulse 20. An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red and the client reports a burning sensation. What action should the nurse take? answer:secure a pulse oximeter to monitor the client’s oxygen saturation. 21. A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital signs are temperature 101° F, heart rate 128 beats/minute, respirations 28 breaths/minute, and blood pressure 122/82, which intervention is most important for the nurse to implement first? Answer: assess lower extremity circulation. 22. The nurse is completing the preoperative assessment of a client who is scheduled for a laparoscopic cholecystectomy under general anesthesia. Which finding warrants notification ofthe healthcare provider prior to proceeding with the scheduled procedure? answer: the client’s blood pressure is 184/88 mm Hg. 23. A client who has a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse? answer: hematocrit of 30% 24. Following surgical repair of the bladder, a female client is being discharged from the hospital to home with an indwelling urinary catheter. Which instruction is most important for the nurse to provide to this client? answer: keep the drainage bag lower than the level of the bladder 25. Which client has the highest risk for developing skin cancer? answer: a 65‐year‐old fairskinned male who is a construction worker. 26. When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain? answer: level of consciousness 27. A female client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). (select all that apply). Verify pedal pulses using a doppler pulse device. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure. Evaluate the application of the splint to the left leg. 28. A male client with herpeszoster (shingles) on his thorax tellsthe nurse that he is having difficulty sleeping. What is the probably etiology of this problem? answer: pain 29. When planning care for a client newly diagnosed with open angle glaucoma, the nurse identifies a priority nursing diagnosis of, “visual sensory/perceptual alterations.” This diagnosis is based on which etiology? answer: decreased peripheral vision. 30. A client who is newly diagnosed with emphysema is being prepared for discharge. Which instruction is best for the nurse to provide the client to assist them with dyspnea self‐management? answer: Allow additional time to complete physical activities to reduce oxygen demand. 31. A client with cancer is receiving chemotherapy with a known vesicant. The client’s IV has been in place for 72 hours. The nurse determines that a new IV site cannot be obtained, and leaves the present IV in place. What is the greatest clinical risk related to this situation? answer: impaired skin integrity. 32. A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the post anesthesia unit. Before selecting which medication to administer, which action should the nurse implement? answer: Compare the client’s pain scale rating with the prescribed dosing. 33. While assisting a female client to the toilet, the client begins to have a seizure and the nurse eases her to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first? answer: Observe for prolonged periods of apnea. 34. A male client with diabetes mellitus istransferred from the hospital to a rehabilitation facility following treatment for a stroke with resulting right hemiplegia. He tells the nurse that his feet are always uncomfortable cool at night, preventing him from falling asleep. Which Action should the nurse implement? answer: Use a bed cradle to old the covers off feet. 35. During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms? answer: a grandson and his new dog recently visited. 36. While planning care for a client with carpal tunnelsyndrome, the nurse identifies a collaborative problem of pain. What is the etiology of this problem? answer: irritation of nerve endings. 37. The nurse assesses a client being treated for Herpes zoster (shingles). Which assessments should the nurse include when evaluating the effectiveness of treatment? (select all that apply). Skin integrity Functional ability Pain scale 38. A male client tells the clinic nurse that he is experiencing burning on urination, and assessment reveals that he had sexual intercourse four days ago with a woman he casually met. Which action should the nurse implement? answer: obtain a specimen of urethral drainage for culture 39.A client with Addison’s disease started taking hydrocortisone in a divided daily dose last week. It is most important for the nurse to monitor which serum laboratory value? answer: Glucose 40. A client with acquired immunodeficiency syndrome (AIDS) has impaired gas exchange from a respiratory infection. Which assessment finding warrants immediate intervention by the nurse? answer: elevated temperature 41. An older male client tells the nurse that he is losing sleep because he has to get up several times at night to go to the bathroom, that he has trouble starting his urinary stream, and that he does not feel like his bladder is ever empty. Which intervention should the nurse implement? answer: collect a urine specimen for culture analysis. 42. Fluids are restricted to 1,500 mL daily for a male client with acute kidney injury (AKI). He isfrustrated and complaining of constant thirst, and the nurse discovers that the family is providing the client with additional fluids. Which intervention of the nurse implement? answer: provide the client with oralswabs to moisten his mouth. 43. During a paracentesis, two liters of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed, and 50 mL of clear, straw‐colored fluid drains within the first hour. What action should the nurse implement? answer: Continue to monitor the fluid output. 44. While assessing a client with degenerative joint disease, the nurse observes Heberden’s nodes large prominences on the client’s fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse take? answer: discuss approaches to chronic pain control with the client. 45. A client who took a camping vacation two weeks ago in a country with a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for the nurse report to the healthcare provider? answer: jaundiced sclera. 46. Ten hours following thrombolysis for an ST elevation myocardial infarction (STEMI), a client is receiving a lidocaine infusion for isolated runs of ventricular tachycardia (VT). Which finding should the nurse document in the electronic medical record as a therapeutic response to the lidocaine infusion? answer: Cessation of chest pain 47. After a computer tomography (CT)scan with intravenous contrast medium, a client returns to the room complaining of SOB and itching. Which intervention should the nurse implement? answer: prepare a dose of epinephrine (adrenalin). 48. The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding? answer: Nuchal rigidity 49. The nurse is preparing to administer enoxaparin (lovenox) 135 mg subcutaneously. The medication is available in a cartridge labeled 150 mg/mL. How many mL should the nurse administer? answer: 0.9 mL After calculations, the answer will show 0.9 mL. If you have to round for some reason in this answer, simply round to the nearest tenth. 50. The nurse is obtaining a client’s fingerstick glucose level. After gently milking the client’s finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take? answer: collect the blood sample 51.A client admitted to a surgical unit is being evaluated for an intestinal obstruction. The healthcare provider prescribes a nasogastric tube (NGT) to be inserted and placed to intermittent low wallsuction. Which intervention should the nurse implemented to facilitate proper tube placement? answer: insert tube with client’s head tilted back. 52. A young female client with seven children is having frequent morning headaches, dizziness, and blurred vision. Her blood pressure (BP) is 168/104 mm Hg. The client reports that her husband recently lost his job and she is not sleeping well. After administering a STAT dose of an antihypertensive IV medication, which intervention is most important for the nurse to implement? answer: Use an automated BP machine to monitor for hypotension. 53. The wife of a client with Parkinson’s disease expresses concern because her husband has lost so much weight. Which teaching is best for the nurse to provide? answer: Invite friends over regularly to share in meal times. 54. A client who was discharge 8 months ago with cirrhosis and ascites is admitted with anorexia and recent hemoptysis. The client is drowsy but responds to verbal stimuli. The nurse programs a blood pressure monitor to take readings every 15 minutes. Which assessment should the nurse implement first? answer: Palpate the abdomen for tenderness and rigidity. 55. A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client’s postoperative discharge instructions? answer: monitor urinary stream for decreases in output. 56. A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority? Pain related to ischemia 57. An 80 year-old client on digitalis (Lanoxin) reports nausea, vomiting, abdominal cramps and halo vision. Which of the following laboratory results should the nurse analyze first? Potassium levels 58. The nurse is giving instructions to the mother of a newborn infant with oral candidiasis. Which statement by the mother would indicate the need for further teaching? "The therapy can be discontinued when the spots disappear." 59. The nurse assigns an unlicensed assistive personnel (UAP) to care for a client with a musculoskeletal disorder. The client ambulates with a leg splint. Which task requires supervision of the UAP? Monitor the client's response to ambulatory activity 60. A polydrug user has been in recovery for 8 months. The client has began skipping breakfast and not eating regular dinners. The client has also started frequenting bars to "see old buddies." The nurse understands that the client’s behavior is a warning sign to indicate that the client may be: headed for relapse 61. The nursing intervention that best describes treatment to deal with the behaviors of clients with personality disorders include: Consistent limit-setting enforced 24 hours per day 62. An adolescent client comes to the clinic 3 weeks after the birth of her first baby. She tells the nurse she is concerned because she has not returned to her pre-pregnant weight. Which action should the nurse perform first? Encourage her to talk about her view of herself 63. A 67 year-old client with non-insulin dependent diabetes should be instructed to contact the out-patient clinic immediately if the following findings are present? An open wound on their heel 64. A nurse is instructing a class for new parents at a local community center. The nurse would stress that which activity is most hazardous for an 8 month-old child? Eating peanuts 65. The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks the nurse why he must wait 6 weeks before having sexual intercourse. What is the best response by the nurse to this question? "When you can climb 2 flights of stairs without problems, it is generally safe." 66. A couple trying to conceive asks the nurse when ovulation occurs. The woman reports a regular 32 day cycle. Which response by the nurse is correct? Days 17-19 67. A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the health care provider ordering: Vena caval interruption 68. While assessing the vital signs in children, the nurse should know that the apical heart rate is preferred until the radial pulse can be accurately assessed at about what age? 2 years of age 69. While the nurse is administering medications to a client, the client states "I do not want to take that medicine today." Which of the following responses by the nurse would be best? "Is there a reason why you don't want to take your medicine?" 70. A nurse entering the room of a postpartum mother observes the baby lying at the edge of the bed while the woman sits in a chair. The mother states," This is not my baby, and I do not want it." The nurse's best response is: ‘You seem upset; tell me what the pregnancy and birth were like for you’ 71. A man diagnosed with epididymitis 2 days ago calls the nurse at a health clinic to discuss the problem. What information is most important for the nurse to ask about at this time? What does the skin on the testicles look and feel like? 72. The family of a 6 year-old with a fractured femur asks the nurse if the child's height will be affected by the injury. Which statement is true concerning long bone fractures in children? Epiphyseal fractures often interrupt a child's normal growth pattern 73. The nurse is planning to administer otic drops to a 6 year-old child. Which of the following is the correct procedure? Hold the pinna up and back to instill the drops 74. The nurse is assessing a client who has taken haldol (Haloperidol) for several months. Which of the following is a side effect of this medication and must be reported immediately to the health care provider? Dystonic reaction 75. A client admits to benzodiazepine dependence for several years. She is now in an outpatient detoxification program. The nurse must understand that a priority during withdrawal is: Avoid alcohol use during this time 76. A victim of domestic violence states, "If I were better, I would not have been beat." Which feeling best describes what the victim may be experiencing? Self-blame 77. The nurse is providing instructions to a new mother on the proper techniques for breast feeding her infant. Which statement by the mother indicates the need for additional instruction? I can switch to a bottle if I need to take a break from breast feeding 78. A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4cm by 7cm, the wound base is red and moist with no exudate and the surrounding skin is intact. Which of the following coverings is most appropriate for this wound? Occlusive moist dressing 79. Which type of accidental poisoning would the nurse expect to occur in children under age 6? Oral ingestion 80. A depressed client who has recently been acting suicidal is now more social and energetic than usual. Smilingly he tells the nurse "I’ve made some decisions about my life." What should be the nurse’s initial response? ‘Are you thinking about killing yourself?’ 81. The nursing care plan for a client with decreased adrenal function should include: Limiting visitors 82. A nurse from the surgical department is reassigned to the pediatric unit. The charge nurse should recognize that the child at highest risk for cardiac arrest and is the least likely to be assigned to this nurse is which child? Prolonged hypoxemia 83. The RN is planning care at a team meeting for a 2 month-old child in bilateral leg casts for congenital clubfoot. Which of these suggestions by the PN should be considered the priority nursing goal following cast application? Tissue perfusion will be maintained 84. When caring for a client with advanced cirrhosis of the liver, which nursing diagnosis should take priority? Risk for injury: hemorrhage 85. A hospitalized child suddenly has a seizure while his family is visiting. The nurse notes whole body rigidity followed by general jerking movements. The child vomits immediately after the seizure. A priority nursing diagnosis for the child is; Risk for aspiration related to loss of consciousness 86. Which one of the following statements, if made by the client, indicates teaching about Inderal (propranolol) has been effective? “ I can have a heart attack if I stop this medication suddenly." 87. A client with hepatitis A (HAV) is newly admitted to the unit. Which action would be the priority to include in the plan of care within the initial 24 hours for this client? Wear gown and gloves during client contact 88. The nurse is providing diet instruction to the parents of a child with cystic fibrosis. The nurse would emphasize that the diet should be: High protein, high calorie, unrestricted fat 89. A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities which: Lead to dehydration 90. A newborn has hyperbilirubinemia and is undergoing phototherapy with a blanket. Which safety measure is most important during this process? Provide water feedings at least every 2 hours 91. The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease? Strep throat went through all the children at the day care last month 92. A client expresses anger when the call light is not answered within 5 minutes. The client demanded a blanket. The best response for the nurse to make is: "I see this is frustrating for you. I have a few minutes so let's talk." 93. Upon completing the admission documents, the nurse learns that the87 year-old client does not have an advance directive. What action should the nurse take? Give information about advance directives 94. A client with Guillain Barre is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition? Glascow Coma Scale 8, respirations regular 95. A hospitalized female client with mania enters the unit community room and says to a client who is wearing a blue shirt, "Boys in blue are fun to do! Boys in blue are fun to do!" What is the appropriate response by the nurse? "Don’t say that. If you can’t control yourself, we’ll help you." 96. A nurse reviews the laboratory results of a hospitalized pregnant client with a diagnosis of sepsis who is at risk for disseminated intravascular coagulopathy (DIC). Which laboratory finding would indicate to the nurse that DIC has developed in the client? Positive result on d-dimer study 97. A nurse has given a client with viral hepatitis instructions about home care. Which of the following statements by the client indicates to the nurse that the client needs further teaching? “I need to eat three meals a day with foods high in protein, fat, and carbs’ 98. A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture? The flow of life is believed to flow through major pathways or nerve clusters in your body. 99. A middle aged woman talks to the nurse in the health care provider’s office about uterine fibroids also called leiomyomas or myomas. What statement by the woman indicates more education is needed? Fibroids that cause no problems still need to be taken out 100. A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug? Improved respiratory status and increased urinary output 101. Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse's priority? Obtain a health and dietary history 102. A 10 year-old child has a history of epilepsy with tonic-clonic seizures. The school nurse should instruct the classroom teacher that if the child experiences a seizure in the classroom, the most important action during the seizure would be to: Place the hands or a folded blanket under the head of the child 103. A 2 day-old child with spina bifida and meningomyocele is in the intensive care unit after the initial surgery. As the nurse accompanies the grandparents for a first visit, which response should the nurse anticipate of the grandparents? Disbelief 104. An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to: open the client's airway 105. The client with amyotrophic lateral sclerosis is scheduled for 160 ml of enteral feeding as a bolus every 4 hours. Before flushing with water the nurse aspirates the feeding tube contents and gets back 180 ml of feeding. What is the next appropriate nursing action? Hold the next feed 106. A nurse is told in report that a client has a positive Chvostek’s sign. What other data would the nurse expect to find on data collection? Select all that apply. 2. Tetany 3. Diarrhea 4. Possible seizure activity 6. Positive Trousseau’s sign 107. A nurse lawyer provides an education session to the nursing staff regarding client rights. A nurse asks the lawyer to describe an example that may relate to invasion of client privacy. A nursing action that indicates a violation of this right is: 3. Taking photographs of the client without consent 108. A nurse notes in the medical record that a client with Cushing’s syndrome is experiencing fluid overload. Which interventions should be included in the plan of care? Select all that apply. 1. Monitoring daily weight 2. Monitoring intake and output 4. Monitoring extremities for edema 5. Maintaining a low-sodium diet 109. A nurse notes in the medical record that a client with Cushing’s syndrome is experiencing fluid overload. Which interventions should be included in the plan of care? Select all that apply. 1. Monitoring daily weight 2. Monitoring intake and output 4. Monitoring extremities for edema 5. Maintaining a low-sodium diet 110. Which instruction should the nurse provide to the client with diabetes mellitus receiving acarbose (Precose)? Select all that apply. 2. “Take the medication with each meal.” 4. “Side effects include abdominal bloating and flatus.” 5. “Take some form of glucose if hypoglycemia occurs.” 6. “Report symptoms such as shortness of breath or tiredness.” 111. A nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Choose the instructions that would be included on the list. Select all that apply. 2. Keep small toys and sharp objects away from the cast. 5. Contact the health care provider if the child complains of numbness or tingling in the extremity. 6. Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling. 112. A nurse reinforces instructions to the mother of a child who has been hospitalized with croup. Which of the following statements, if made by the mother, would indicate the need for further instruction? 1. “I will give my child cough syrup if a cough develops.” 113. The nurse would anticipate the use of which medications in the treatment of the client with heart failure? Select all that apply. 1. Diuretics 4. Cardiac glycosides 5. Phosphodiesterase (PDE) inhibitors 6. Angiotensin-converting enzyme (ACE) inhibitors 114. The parent of a toddler asks a nurse when it is safe to place the car safety seat in a face-forward position. Which of the following is the best nursing response? 1. When the toddler weighs 20 lb and is 1 year old 115. A pregnant woman has a positive history of genital herpes, but she has not had lesions during her pregnancy. The nurse plans to provide which of the following information to the client? 4. “You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are present, a cesarean delivery will be needed.” 116. Which of these clients are most likely to develop fluid (circulatory) overload? Select all that apply. 1. A premature infant 2. A 101-year-old man 3. A client on renal dialysis 6. A client with congestive heart failure 117. An unconscious client who is bleeding profusely is brought to the emergency department after a serious accident. Surgery is required immediately to save the client’s life. With regard to informed consent for the surgical procedure, which of the following is the best action? 4. Transport the client to the operating department immediately, as required by the health care provider without obtaining an informed consent. 118. When caring for a 3-year-old child, the nurse should provide which toy for this child? 2. A wagon 119. When the nurse is collecting data from the older adult, which of the following findings would be considered normal physiological changes? Select all that apply. 2. Decline in visual acuity 5. Increased susceptibility to urinary tract infections 6. Increased incidence of awakening after sleep onset 120. Which data indicates to the nurse that a client may be experiencing ineffective coping? 1. Constantly neglects personal grooming 121. The nurse notes that a client is quite suspicious during an assessment interview and believes that her family is under investigation by the CIA. What would the appropriate nursing interventions be with this client? Select all that apply: 1. Use active listening skills to seek information from the client. 2. Encourage the client to describe the problem as she sees it. 3. Ask the client to tell you exactly what she thinks is happening. 122. Which nursing interventions will assist in reducing pressure points that may lead to pressure ulcers? Check all that apply: 2. Avoid use of donut type devices. 4. Elevate the HOB no more than 30 degrees when possible. 5. When the client is side lying, use the 30 degree lateral inclined position. 6. Avoid uninterrupted sitting in a chair or wheelchair. 123. The nurse is evaluating a client recently diagnosed with primary open angle glaucoma (POAG). What will an important nursing action be? Select all that apply: 1. Review meds the client is currently on to determine whether any of them cause an increased intraocular pressure as a side effect. 5. Have the client demonstrate the use of eye drops. 6. Assess the client for chronic diseases such as diabetes. 124. A nurse understands that a patient may experience pain during peritoneal dialysis because of which of the following? Select all that apply: 2. Too rapid installation 4. Accumulation of dialysate solution under the diaphragm 125. The nurse is evaluating a client’s response to hemodialysis. Which lab results will indicate the dialysis was effective? Select all that apply: 1. Serum potassium level decreases from 5.4 to 4.6 mEq/L 2. Cr decreases from 1.6 to 0.8 mg/dL 5. BUN decreases from 110 to 90 mg/dL 126. The nurse understands that the following clinical findings are indications for dialysis. Select all that apply: 1. Volume overload 2. BUN 18 mg/dL 3. K 5.2 mEq/L 5. Metabolic acidosis 6. Cr 5.0 mg/dL 127. The nurse is assessing a client who had a fractured femur repaired with an external fixator device. Which assessment finding would cause the nurse concern regarding the development of compartment syndrome? Select all that apply: 2. Paresthesia distal to area of injury. 3. Toes on affected leg cool to touch and edematous. 5. Complaints of leg pain unrelieved by analgesics or repositioning. 128. The nurse is preparing discharge for a patient with GERD. What would be important for the nurse to include in this teaching plan? Select all that apply: 1. Elevate the HOB. 2. Decrease intake of caffeine. 3. Discuss strategies for weight loss if overweight. 5. Take ranitidine (Zantac) at hs. 129. The nurse is preparing a client for cardiac catheterization. Which nursing interventions are necessary in preparing the client for this procedure. Select all that apply: 1. Verify consent has been signed. 2. Explain procedure to client. 5. Obtain a 12 lead ECG 6. Obtain history of shellfish allergy. 130. The nurse has been assigned a group of cardiac clients. What would be the most important information for the nurse to check on the initial evaluation of each client? Select all that apply: 1. Presence of cardiac pain. 3. Presence of jugular vein distention. 4. Heart sounds and apical rate. 5. Presence of diaphoresis. 131. The nurse is teaching a client about home care and treatment of venous stasis ulcers in his leg. What should be included in the nurse’s instructions? Select all that apply: 2. Healing will be facilitated by wearing leg compression devices. 3. When the client is in sitting position, he should keep his legs elevated. 4. Avoid standing for long periods of time. 132. A nurse knows the clinical manifestations of a client with Addison’s disease include which of the following? Select all that apply: 1. Nausea 4. Hyperpigmentation 5. Hypotension 133. A licensed practical nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that which of the following is a characteristic of this type of nursing model of practice? 3. Nursing staff are led by a nurse when providing care to a group of clients. 134. A licensed practical nurse is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant? 2. A client who requires frequent ambulation 135. . A nurse assessing the newborn of a mother with diabetes understands that hypoglycemia is related to what pathophysiological process? Disruption of fetal glucose supply 136. The nurse is teaching the mother of a 5 month-old about nutrition for her baby. Which statement by the mother indicates the need for further teaching? I dip his pacifier in honey so he'll take it 137. Which of the following drugs should the nurse anticipate administering to a client before they are to receive electroconvulsive therapy? Succinylcholine (Anectine) 138. To prevent drug resistance common to tubercle bacilli, the nurse is aware that which of the following agents are usually added to drug therapy? Two anti-tuberculosis drugs 139. The charge nurse reviews the charting of a graduate nurse. Which indicates a need for further education on documentation? Charts some actions in advance of performing them 140. The nurse reviews the comprehensive metabolic panel for a client with an electrolyte imbalance. Which data requires the most immediate intervention by the nurse? Sodium level, 125 mEq/L 141. The outpatient clinic nurse is reviewing phone messages from last night. Which client should the nurse call back first? A women at 30 weeks of gestation who has been diagnosed with mild preeclampsia and is unable to relieve her heartburn 142. A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care? Excessive CNS stimulation will be reduced. 143. A nurse is caring for a client who sustained a missed abortion during the second trimester of pregnancy. For which finding indicating the need for further evaluation does the nurse monitor the client? Spontaneous bruising 144. A nurse is planning to teach a crutch gait to a client who will be using wooden axillary crutches. The nurse reviews the physician's instructions, understanding that the gait was selected after assessment of the client's: Physical and functional abilities 145. The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal: S3 ventricular gallop