In an effort to improve cardiac output, a positive inotropic drug is given to: Group of answer choices increase the contractility of the heart. increase the conduction velocity. increase the heart rate. increase the automaticity of the heart.

increase the contractility of the heart.

Which risk factor(s) regarding fall prevention and safety for older adults would the nurse manager include in a presentation to a group of nurses? (SATA) Medications Visual changes Urinal Orthostatic hypotension

Medications Visual changes Orthostatic hypotension

Which instruction would the nurse provide to an older client using ice and heat to treat pain from back strain? Select all that apply. One, some, or all responses may be correct. Switch positions every 4 hours. Use a heating pad for the first 24 hou

Apply for 30-minute time intervals.

The parents of a toddler ask why they should not keep syrup of ipecac for poison treatment in the home. Which response would the nurse provide the parent? "Syrup of ipecac can increase the damage to the mucosa." "Syrup of ipecac does not stop the po

"Syrup of ipecac is only used after evaluation of the toxicity of the poisoning."

A newborn is admitted to the nursery with a spiral scalp electrode from an internal monitor in place. How would the nurse remove the electrode? Giving the electrode a quick jerk Turning the electrode clockwise until it is free Untwisting the wire

Twisting the electrode counterclockwise until it is free

Which intervention promotes safe movement of objects to protect the back? Select all that apply. One, some, or all responses may be correct. Pull rather than push objects. Use handles or grips on the object. Do not twist the back during movement.

Use handles or grips on the object.

Which nursing assessment finding is most indicative of a systemic infection? White blood cell (WBC) count of 8200/mm3 (8.2 × 109/L) Bilateral 3+ pitting pedal edema Oral temperature of 101.3°F (38.5°C) Pale skin and nail beds

Oral temperature of 101.3°F (38.5°C)

A parent reports that his or her child just ate several multivitamins with iron. Which statement would the nurse say to the parent? "Give your child orange juice." "Call the Poison Control Center." "Iron-fortified multivitamins are safe for your

"Call the Poison Control Center."

Which nursing action is most effective in controlling the spread of infection for an infant with diarrhea? Wearing a gown/gloves during care Allowing only registered nurses to give direct care Washing hands before/after contact with infant

Washing hands before and after contact with the infant

Identify the role of plasma cells in the antigen-antibody response. Makes an antigen harmless without destroying it Produces antibodies against the sensitizing antigen Produces antibodies after an exposure to a known antigen

Produces antibodies against the sensitizing antigen

Which public health risk became a major focus for hospitals after the September 11, 2001, terrorist attacks? Anthrax exposure Multicasualty incidents Mass casualty incidents (MCIs) Weapons of mass destruction (WMD)

Weapons of mass destruction (WMD)

Which parental statement would the nurse recognize as requiring additional education about drowning prevention? "My baby likes to take a bath in the kitchen sink." "My baby loves to watch the birds play in the birdbath."

"My baby loves to watch the birds play in the birdbath."

Which factors would the nurse consider when assessing a client’s increased risk for suicide? Select all that apply. One, some, or all responses may be correct. Impulsivity Panic attacks Unemployment Religious beliefs Substance use

Impulsivity Panic attacks Unemployment Substance use

Which parental statement would the nurse recognize as a knowledge deficit when discussing the care of an infant with a severe diaper rash? "I expose the buttocks to the air." "I direct a heat lamp at the buttocks." "I don’t use soap to clean".

"I direct a heat lamp at the buttocks."

Which scenario is an internal disaster that might delay a specialist from providing on-time treatment to a client? A tornado near the hospital An earthquake near the hospital premises Severe flooding Lack of communication because of a damaged

Lack of communication because of a damaged telephone system in the hospital

A 2-year-old child is admitted with multiple fractures and bruises, and abuse is suspected. Which nursing assessment findings support this suspicion? SATA Bedwetting Thumb-sucking Difficulty consoling Underdevelopment for age

Difficulty consoling Underdevelopment for age

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NCLEX Practice Quest

NCLEX Practice Questions

Question	Answer
A common form of combined nutrition deficit among hospitalized patients is protein-caloric malnutrition (PCM). Which finding is a sign of marasmus? Loss of subcutaneous fat High creatinine excretion in the urin Low transferrin Low albumin	Loss of subcutaneous fat
Which disorder is characterized by a loss of exocrine and endocrine function related to the destruction of acinar and islet cells, resulting in malabsorption and glucose intolerance? Chronic pancreatitis End-stage renal failure Hepatic encephalop	Chronic pancreatitis
A patient with facial trauma is unable to eat after surgery. His albumin level is 1.5. Which nutritional alteration is the patient experiencing? Negative nitrogen balance Positive nitrogen balance Nitrogen equilibrium Nitrogen disequilibrium	Negative nitrogen balance
A patient has low albumin, prealbumin, and transferrin levels with a decreased total lymphocyte count. Which nursing diagnosis is a priority for this patient? Altered nutrition, less than body requirement Risk for infection Fluid volume overload	Risk for infection
Because of the losses that occur with peritoneal dialysis, patients with chronic renal failure require a dietary increase (more than usual) of which nutrient? Protein Potassium Carbohydrate Phosphorus	Protein
When a papillary muscle in the left ventricle ruptures, the mitral valve leaflets do not close completely, resulting in which condition? Cardiac murmur Systemic venous congestion Acute myocardial infarction Aortic valve failure	Cardiac murmur
Aortic valve dysfunction pathologically alters the which structure of the heart? Right ventricle Mitral valve Left ventricle Left atrium	Left ventricle
The time from the beginning of the cardiac action potential (AP) until the time when the fiber can accept another AP is known as which period? Absolute refractory Relative refractory Depolarization Excitability	Absolute refractory
The nurse auscultates a murmur at the fifth intercostal space at the midclavicular line on the left side. The nurse realizes that this is caused by which incompetent heart valve? Mitral Aortic Pulmonic Tricuspid	Mitral
Pulse pressure is the difference between systolic pressure and diastolic pressure. What will happen to the patient’s pulse pressure if the patient becomes volume depleted? Narrow Widen Remain unchanged Increase	Narrow
Cardiac output is the amount of blood ejected from the heart in 1 minute. If a patient’s heart rate (HR) is 72 beats/min and the stroke volume (SV) is 70 mL/beat, what is the patient’s cardiac output? 120 L/min 142 L/min 5.04 L/min 2 L/min	5.04 L/min
In an effort to improve cardiac output, a positive inotropic drug is given to: Group of answer choices increase the contractility of the heart. increase the conduction velocity. increase the heart rate. increase the automaticity of the heart.	increase the contractility of the heart.
What part of the arterial system contains the greatest amount of elastin? Group of answer choices Aorta Pulmonary artery Arterioles Common carotids	Aorta
Which structure of the microcirculation allows for solute diffusion across the endothelium? Group of answer choices Capillary Venule Precapillary sphincter Arteriole	Capillary
Which intracellular structure, essential for cardiac contraction, stores calcium ions for release and use after depolarization? Group of answer choices Transverse tubules Sarcoplasmic reticulum Sarcolemma Sarcomere	Sarcoplasmic reticulum
Which myocardial structure is supplied by the left anterior descending artery? Group of answer choices Atrioventricular (AV) node Posterior wall Sinus node Intraventricular septum	Intraventricular septum
A patient is reported to have an ejection fraction of 30%. What is this finding most likely a sign of? Group of answer choices Pulmonic valve regurgitation Ventricular dysrhythmia Poor ventricular function Coronary artery disease	Poor ventricular function
Which finding could be described as visibly dilated, superficial, and cutaneous small blood vessels found on the face and thighs? Tenting Angioma Varicosity Telangiectasia	Telangiectasia
Which finding is a clinical manifestation of left-sided heart failure? Group of answer choices Cool, pale extremities Vasodilatation of the arterial bed Increased cardiac output Decreased systemic vascular resistance	Cool, pale extremities
Which location of a myocardial infarction (MI) poses the greatest risk of heart failure and cardiogenic shock? Group of answer choices Right ventricular Anterior Inferior Lateral	Anterior
Education for a patient with chronic heart failure would include which information? Appropriate diet choices All answers apply The need for accurate daily weights Signs of negative changes in cardiac symptoms and when	All answers apply
In the early stages of pulmonary edema, which arterial blood gas pH would the nurse expect to find? Group of answer choices pH of 7.50 pH of 7.34 pH of 7.26 pH of 7.38	pH of 7.50
An inferior myocardial infarction (MI) occurs with an occlusion to the right coronary artery. In which leads would the electrocardiograph (ECG) changes be evident? Group of answer choices II, III, and a VF V1 to V4 V1 to V2 I, aVL, V5, and V6	II, III, and a VF
Which action would the nurse take to protect against radiation exposure while caring for a client receiving radiation therapy via internal implant? Wear a dosimeter badge. Place caution sign on the client's bed. Limit care to 2 hours a day.	Wear a dosimeter badge.
Which risk factor(s) regarding fall prevention and safety for older adults would the nurse manager include in a presentation to a group of nurses? (SATA) Medications Visual changes Urinal Orthostatic hypotension	Medications Visual changes Orthostatic hypotension
Which instruction would the nurse provide to an older client using ice and heat to treat pain from back strain? Select all that apply. One, some, or all responses may be correct. Switch positions every 4 hours. Use a heating pad for the first 24 hou	Apply for 30-minute time intervals.
The nurse is preparing to administer an acid-labile prescription to an 18-month-old. Which rate of medication absorption would the nurse need to be mindful of to administer the medication safely to this client? Increased Decreased Unpredictable	Increased
The parents of a toddler ask why they should not keep syrup of ipecac for poison treatment in the home. Which response would the nurse provide the parent? "Syrup of ipecac can increase the damage to the mucosa." "Syrup of ipecac does not stop the po	"Syrup of ipecac is only used after evaluation of the toxicity of the poisoning."
A newborn is admitted to the nursery with a spiral scalp electrode from an internal monitor in place. How would the nurse remove the electrode? Giving the electrode a quick jerk Turning the electrode clockwise until it is free Untwisting the wire	Twisting the electrode counterclockwise until it is free
Which intervention promotes safe movement of objects to protect the back? Select all that apply. One, some, or all responses may be correct. Pull rather than push objects. Use handles or grips on the object. Do not twist the back during movement.	Use handles or grips on the object.
Which nursing assessment finding is most indicative of a systemic infection? White blood cell (WBC) count of 8200/mm3 (8.2 × 109/L) Bilateral 3+ pitting pedal edema Oral temperature of 101.3°F (38.5°C) Pale skin and nail beds	Oral temperature of 101.3°F (38.5°C)
Which technique would the nurse employ for an obstetrical client with a foreign body airway obstruction? Back blows Chest thrusts Suprapubic thrusts Abdominal thrusts	Chest thrusts
A parent reports that his or her child just ate several multivitamins with iron. Which statement would the nurse say to the parent? "Give your child orange juice." "Call the Poison Control Center." "Iron-fortified multivitamins are safe for your	"Call the Poison Control Center."
Which action is the priority when the nurse is establishing a therapeutic environment for a client? Ensuring the client's safety Accepting the client's individuality Promoting the client's independence Explaining to the client what is being do	Ensuring the client's safety
Which nursing action is most effective in controlling the spread of infection for an infant with diarrhea? Wearing a gown/gloves during care Allowing only registered nurses to give direct care Washing hands before/after contact with infant	Washing hands before and after contact with the infant
Which nursing action is the priority to include in a disaster plan for the radioactive dust and smoke that can cause illness from a radiological dispersal device? Covering the nose Protecting the eyes Decontaminating the skin Administering pro	Covering the nose
Identify the role of plasma cells in the antigen-antibody response. Makes an antigen harmless without destroying it Produces antibodies against the sensitizing antigen Produces antibodies after an exposure to a known antigen	Produces antibodies against the sensitizing antigen
Which public health risk became a major focus for hospitals after the September 11, 2001, terrorist attacks? Anthrax exposure Multicasualty incidents Mass casualty incidents (MCIs) Weapons of mass destruction (WMD)	Weapons of mass destruction (WMD)
Why is an infection caused by Neisseria gonorrhoeae particularly troublesome for a female client? The medication is expensive. The infection is difficult to treat with antibiotics. Symptoms are often overlooked. Treatment has many adverse effe	Symptoms are often overlooked.
Which parental statement would the nurse recognize as requiring additional education about drowning prevention? "My baby likes to take a bath in the kitchen sink." "My baby loves to watch the birds play in the birdbath."	"My baby loves to watch the birds play in the birdbath."
Which factors would the nurse consider when assessing a client’s increased risk for suicide? Select all that apply. One, some, or all responses may be correct. Impulsivity Panic attacks Unemployment Religious beliefs Substance use	Impulsivity Panic attacks Unemployment Substance use
Which parental statement would the nurse recognize as a knowledge deficit when discussing the care of an infant with a severe diaper rash? "I expose the buttocks to the air." "I direct a heat lamp at the buttocks." "I don’t use soap to clean".	"I direct a heat lamp at the buttocks."
Which is a primary goal for organized athletics for preadolescent children? Improved socialization Promotion of teamwork Development of safety skills Development of fine motor skills	Promotion of teamwork
Which precaution would the nurse identify as a prevention for transmission of human immunodeficiency virus (HIV) and other bloodborne illnesses? Barrier Droplet Contact Standard	Standard
At which height is it no longer safe for a toddler to sleep in a crib? 26 inches 28 inches 33 inches 36 inches	36 inches
Which scenario is an internal disaster that might delay a specialist from providing on-time treatment to a client? A tornado near the hospital An earthquake near the hospital premises Severe flooding Lack of communication because of a damaged	Lack of communication because of a damaged telephone system in the hospital
The nurse is assessing a client with Crohn disease who is scheduled for an upper gastrointestinal series. Which condition would necessitate the cancellation of the procedure? Hemorrhoids Hyperkalemia Inflamed colon Colon perforation	Colon perforation
A 2-year-old child is admitted with multiple fractures and bruises, and abuse is suspected. Which nursing assessment findings support this suspicion? SATA Bedwetting Thumb-sucking Difficulty consoling Underdevelopment for age	Difficulty consoling Underdevelopment for age
Which complication is caused by a rising reticulocyte count in a newborn? Bacterial infection Significant jaundice Aplastic anemia Adequate oxygenation	Significant jaundice
Which hormone elevations indicate Turner syndrome? Select all that apply. One, some, or all responses may be correct. Lutropin Prolactin Follitropin Testosterone Progesterone	Lutropin Follitropin
Which manifestations are associated with syndrome of inappropriate antidiuretic hormone (ADH)? Select all that apply. One, some, or all responses may be correct. Polyuria Weight gain Hypotension Hyponatremia Decreased specific gravity	Weight gain Hyponatremia
Which Korotkoff sound represents the diastolic blood pressure in toddlers? First Third Fourth Fifth	Fourth
The nurse is assessing a client who has a head injury. Which movement of the client’s arm after the nurse applies nailbed pressure would cause the most concern? Flexing Localizing Extending Withdrawing	Extending
Which test result would the nurse anticipate in the laboratory reports of a client with a diagnosis of end-stage renal disease? Arterial pH of 7.5 Hematocrit of 54% Potassium of 6.3 mEq/L (6.3 mmol/L) Creatinine of 1.2 mg/dL (106 mcmol/L)	Potassium of 6.3 mEq/L (6.3 mmol/L)
The client’s cervical biopsy reveals a stage 0 lesion. Which statement explains this finding? The lesion is carcinoma in situ. There is early stromal invasion. There is parametrial involvement. The cancer is confined to the cervix.	The lesion is carcinoma in situ.
Which arterial blood gas report is indicative of diabetic ketoacidosis? Pco2: 49, HCO3: 32, pH: 7.50 Pco2: 26, HCO3: 20, pH: 7.52 Pco2: 54, HCO3: 28, pH: 7.30 Pco2: 28, HCO3: 18, pH: 7.28	Pco2: 28, HCO3: 18, pH: 7.28
Which stage of Piaget’s theory of cognitive development would the nurse observe in a preschooler? Sensorimotor Preoperational Formal operations Concrete operations	Preoperational
Which intrinsic factor is associated with the fall of an older adult? Wet floors Poor lighting Lack of exercise Inappropriate footwear	Lack of exercise
Which ethical principle is violated when the nurse forgets to give a painkiller to a client as promised? Justice Fidelity Veracity Nonmaleficence	Fidelity
Which behavior by the client exhibits denial after a recent diagnosis? Attempts to minimize the illness Lacks an emotional response to the illness Refuses to discuss the condition with the client’s spouse Expresses displeasure with the prescri	Attempts to minimize the illness
Which stage of a client’s grieving is the family likely to require more emotional nursing care than the client? Anger Denial Depression Acceptance	Acceptance
Which component of cultural competence is being demonstrated when the nurse motivates the immigrant to accept differences in the way a pregnant women is cared for in her current residence? Cultural desire Cultural awareness Cultural knowledge	cultural desire
Which instruction by the nurse is correct for a client with a fractured leg? Double the intake of vitamin C. Remove loose rugs from the environment. Avoid taking showers until the cast is removed. Increase weight bearing on the injured leg gra	remove loose rugs from the environment
The nurse finds that a client with bilateral oral swelling, pain, and trismus underwent surgical extraction of an impacted tooth 5 days ago. To which type of nursing diagnosis would the documentation of acute pain refer? Syndrome diagnosis Risk nurs	Actual nursing diagnosis
Which action would the nurse take first when caring for a postoperative client who reports incisional pain? Provide an ice bag. Administer pain medication as prescribed. Perform a focused assessment of the client. Document the complaint	Perform a focused assessment of the client.
The nurse notes that the victim of an automobile crash is in need of cardiopulmonary resuscitation (CPR). Which factors would the nurse remember before performing CPR? Select all that apply. One, some, or all responses may be correct. Emergency treatme	Emergency treatment that is provided without a client’s consent Not performed on adult clients who have already consented to a do-not-resuscitate order either verbally or in writing Performed on appropriate clients unless a do-not-resuscitate orde
Which situation would the nurse address first according to Maslow’s hierarchy? History of getting injured from sudden falls Complains of sleeplessness due to pain postsurgery Reports that he or she feels lonely and socially isolated	Complains of sleeplessness due to pain postsurgery
Which type of theory is the Neuman systems model? Grand theory Descriptive theory Prescriptive theory Middle-range theory	Grand theory
Which intervention would the nurse implement to develop a caring relationship with the client’s family? Deciding health care options for the client Identifying the client’s family members and their roles Declining to inform the client’s family	Identifying the client’s family members and their roles
The nurse is working in a hospital that receives most of its payment from Medicare and Medicaid services. In the annual assessment of The Joint Commission, the hospital had not met all the standards set forth in the Centers of Medicare and Medicaid Servic	The Joint Commission would conduct an unannounced follow-up survey in the hospital.
Which nursing professional has the maximum span of control? Nurse manager Registered nurse (RN) Patient care associate (PCA) Licensed vocational nurse (LVN)	Nurse manager
Who undertakes the responsibility of identifying the need for and calling of different specialty-trained providers to care for clients in a disaster? Triage officer Public information officer Medical command physician Hospital incident command	Medical command physician
Which nursing practice is associated with a self-regulation skill? Reflecting on one’s experience Reflecting on one’s own behavior Supporting one’s findings and conclusions Clarifying any data that one is uncertain about	Reflecting on one’s own behavior
Which element of the decision-making process is the nurse exercising when he or she consults other team nurses to formulate a better teaching plan after learning the original discharge plan was inadequate? Authority Autonomy Responsibility	Autonomy
Which distinguishes research-based practice as different from evidence-based practice? It uses knowledge based only on research studies. It is a problem-solving approach to clinical practice. It involves the conscientious use of best practice	It uses knowledge based only on research studies.
Which statement made by the nurse indicates the need for further teaching when assessing clients with dark skin? "I will touch the skin to feel its consistency." "I will use a fluorescent light source to assess the skin color." "I will place my h	"I will use a fluorescent light source to assess the skin color."
Which record will the nurse use for recording client data from admission through discharge? Acuity record Source record Hand-off records Problem-oriented medical record (POMR)	Problem-oriented medical record (POMR)
A group member states "Administration won’t go for it" while making a decision for a critical issue. Which strategy would the nurse leader implement to deal effectively with this situation? Focus groups Brainstorming Delphi technique	Delphi technique
Soon after beginning to breast-feed, an infant chokes, has an excessive quantity of frothy secretions, and becomes cyanotic. Which action by the nurse is best? Tell the client to use the other breast and continue breast-feeding. Delay the feeding to	Halt the feeding and notify the health care provider to evaluate the infant for a tracheoesophageal fistula.
A client with preeclampsia has delivered and is receiving magnesium sulfate postpartum. Which nursing action is the priority during the immediate 4 hours after delivery? Monitoring blood pressure Monitoring urinary output Observing lochia	Monitoring urinary output
Postoperatively, a client complains about a variety of minor environmental factors, frequently changes positions, and avoids eye contact. The nurse responds to these observations by stating, "Let me get you some cold water and your pain pill, and you'll b	Premature interpretation of the findings
Which agencies have the power to implement Medicare and Medicaid reimbursement? Select all that apply. One, some, or all responses may be correct. Institute of Medicine (IOM) The Joint Commission (TJC) National Committee for Quality Assurance	The Joint Commission (TJC) Community Health Accreditation Program (CHAP) Accreditation Commission for Health Care (ACHC)
Which is the priority nursing action when admitting a child to the emergency department who was bitten by a stray dog and sustained a soft tissue injury on the inner aspect of the left forearm? Asking the mother whether her son is allergic to horse ser	Assessing the injury and the child’s vital signs and health history
Which health care team member is most suitable to provide oral medication to a client? Nurse manager Client care associate Licensed practical nurse (LPN) Unlicensed assistive personnel (UAP)	Licensed practical nurse (LPN)
The nurse adheres to which ethical principle when withholding a prescribed opioid medication from a client requesting to be treated for pain for fear the client will become addicted? Veracity Autonomy Paternalism Beneficence	Paternalism
In which situations can a minor give consent for himself or herself for medical treatment? SATA His or her siblings Any venereal disease If he or she is lawfully married For a drug or substance abuse	Any venereal disease If he or she is lawfully married For a drug or substance abuse
Which tort involves intentional touching without the client’s consent? Battery Invasion of privacy False imprisonment Defamation of character	Battery
Which right of delegation refers to the giving of clear, concise descriptions of a task to the delegatee? Right task Right person Right supervision Right communication	Right communication
Which describes the rationale for not discussing a client’s condition with another individual not directly involved in the client’s care? Libel Negligence Breach of confidentiality Defamation of character	Breach of confidentiality
Which action by the nurse is an example of a protective touch that may elicit negative feelings in a client? Providing a back massage to a client Obtaining a blood sample for laboratory tests Holding a client while assisting with ambulation Wi	Withdrawing from a client to escape the situation
A family member of a client who is prescribed a blood transfusion mentions that blood transfusions are not permitted in their faith. Which would the nurse do to handle the situation? Wait for the court’s order to give blood to the client. Proceed wi	Inform the primary health care provider and not give blood to the client.
The nurse suspects that a report on a client is incomplete. Which critical thinking attitude is being used when the nurse clarifies information by talking to the client directly? Fairness Humility Discipline Perseverance	Perseverance
Which approach to a staff nurse’s drug abuse problem would be taken as an initial intervention? Counseled by the staff psychiatrist Fired from the job immediately Referred to the employee assistance program Required to make a "stop drug use"	Referred to the employee assistance program
The nurse completes an assessment and a care plan for each assigned client. Which element of decision-making is the nurse demonstrating? Authority Autonomy Responsibility Accountability	Responsibility
The nurse needs to obtain consent for the medical treatment of a child whose parent is a minor. Which appropriate step would the nurse take to obtain consent? Ask the minor to give consent. Wait for the consent of the court. Ask any adult sibling	Ask the minor to give consent.
Which action indicates that the nurse is actively listening to the client? Stating personal opinions when the client is speaking Refraining from telling personal stories to the client Reading the client’s health record during the conversation	Interpreting what the client is saying and restating it for clarification
Which describes a living will? A legal document that allows registered nurses to offer special skills to the public An order that directs primary health care providers to refrain from reviving clients A written document that directs treatment acc	A written document that directs treatment according to the client’s wishes, in case of a terminal illness or condition
The nurse who promotes freedom of choice for clients in decision-making best supports which principle? Justice Autonomy Beneficence Paternalism	Autonomy
Which is appropriate for the nurse to include in the education of the ethical principal of nonmaleficence to a group of nursing students? Treat all clients equitably and fairly. Act in ways to prevent harm to clients. Tell the client the truth ab	Act in ways to prevent harm to clients.
Which client statement would cause the nurse to stop the health care provider from initiating epidural anesthesia? "I’m not exactly sure how an epidural works." "I understand that the epidural might or might not take my pain away." "I signed the	"I’m not exactly sure how an epidural works."
Before a treatment requiring informed consent can be performed, which information must the health care team give to the client? Select all that apply. One, some, or all responses may be correct. Cost of the treatment Alternative treatment options	Alternative treatment options Risks and benefits of the treatment Risks involved in refusing the treatment Nature of the problem requiring the treatment
Which would the nurse suspect when a toddler’s parent reports that the child wakes up screaming at night and then suddenly stops crying with no memory of what was wrong? Nightmares Sleep apnea Sleep terrors Nighttime fears	Sleep terrors
Which position would the nurse encourage for the client who had an above-the-knee amputation? Functional alignment Extended and abducted Flexed and externally rotated Hip raised when moving	Functional alignment
A peripheral nerve or dorsal column stimulator is implanted to relieve a client’s intractable pain. Which discharge instruction would the nurse provide? Disconnect the transmitter when bathing. Analgesics will no longer be necessary. The transmit	Disconnect the transmitter when bathing.
Which clinical sign is the most important indication of an accurate degree of dehydration? Dry skin Weight loss Sunken fontanel Decreased urine output	Weight loss
An infant is found to have developmental dysplasia of the hip 6 weeks after birth. The parents ask the nurse why their infant must be restrained in a harness at such an early age. How would the nurse respond? Infants are easier to manage in a harness t	Infants’ hip joints are cartilaginous, allowing molding of the acetabulum.
Which food would the nurse recommend to the parents of a child who is recovering from surgery that will ensure the maintenance of a positive nitrogen balance? Orange slices Bacon sandwich Hamburger on a bun Chicken soup with carrots	Hamburger on a bun
For which age group would the nurse recommend that parents teach their children to safely cross roads and walk in parking lots? Toddlers Adolescents Preschoolers School-age children	Preschoolers
The nurse is providing nutrition instructions for a client who has inflammatory bowel disease of the ascending colon. Which suggestion by the nurse is appropriate? Consume scrambled eggs and applesauce. Consume barbecued chicken and French fries.	Consume scrambled eggs and applesauce.
How would the nurse prepare a client for cranial surgery? Assist the client with securing a wig onto the head. Obtain the client’s consent to have the head shaved. Shampoo the client’s hair with a medicated shampoo. Tell the client that head s	Obtain the client’s consent to have the head shaved.
Which nursing interventions indicate client care that supports physical functioning? Select all that apply. One, some, or all responses may be correct. Facilitate client’s learning. Alter client’s undesirable behavior. Maintain client’s nutrition	Maintain client’s nutritional status. Maintain client’s regular bowel patterns.
Which equipment would the nurse recommend to foster independence at home for an ambulatory client who has Parkinson disease? A raised toilet seat Side rails for the bed Crutches for ambulation A trapeze above the bed	A raised toilet seat
Which dietary instruction would the nurse provide a client receiving continuous ambulatory peritoneal dialysis (CAPD) for chronic glomerulonephritis? Low-calorie foods High-quality protein Increased fluid intake Foods rich in potassium	High-quality protein
Which schedule would the nurse use for checking the placement of a nasogastric tube for an unconscious toddler who requires intermittent nasogastric feedings? Once a day Before each feeding At every shift change During the night shift	Before each feeding
Which recommendations would the nurse include in a client’s discharge instructions regarding a home skincare program for psoriasis? "Shower twice a day with mild soap and warm water." "Soak the affected areas in hot water on a daily basis." "Appl	"Apply an alcohol free, moisturizing lotion several times a day."
Which initial action would the nurse plan to take for a newly admitted client with bipolar I disorder, manic episode? Increase the client’s gym time. Isolate the client from peers. Encourage increased nutritional intake. Reinforce participatio	Encourage increased nutritional intake.
Which stage incorporating Meaningful Use is achieved by the nurse documenting basic care in the electronic health record using the system’s standardized format? Stage 1 Stage 2 Stage 3 Stage 4	Stage 1
Which finding in a newborn is a behavioral response to pain? Select all that apply. One, some, or all responses may be correct. Crying Tachypnea Diaphoresis Tachycardia Hypertension	Crying
Which information is most important to include when the nurse is teaching a client who has had an ST segment elevation myocardial infarction (STEMI) about the purpose of salt restriction? Low salt intake helps prevent ankle swelling. Salt intake inc	Salt intake increases the work of the heart.
Which nursing action would be included in the plan of care to promote the nutritional status of a client during the acute phase of treatment after extensive burns? Provide a diet high in sodium. Limit caloric intake to decrease the work of the body.	Administer the prescribed intravenous fluid with the added vitamin C.
The nurse provides teaching to a client who will begin to receive tube feedings after a total laryngectomy. The nurse concludes that the teaching was understood when the client makes which statement about tube feedings? "I will need tube feedings until	"I will need tube feedings until healing of the incision is complete."
Which finding would the nurse identify as normal inflammation versus an infection when assessing a client’s wound that was sutured 72 hours ago? Client report of increasing pain A temperature of 101.6°F (38.6°C) Small amounts of purulent drainage	A slight red border around the wound
Which activities might cause chest pain in a client with stable angina? Select all that apply. One, some, or all responses may be correct. Deep breathing during meditation Walking outside on a cold day Sexual activity Taking an afternoon nap	Walking outside on a cold day Sexual activity Smoking a cigarette Use of an oral decongestant
Why is it important for the nurse in the prenatal clinic to provide nutritional counseling to all newly pregnant women? Most weight gain is caused by fluid retention. Different cultural groups favor different essential nutrients. Dietary allowanc	Different cultural groups favor different essential nutrients.
Which food selection by a client with Meniere disease provides evidence that the nurse's teaching was effective? Pizza Macaroni Baked clams Grilled cheese sandwich	Macaroni
Which characteristic would be a concern for the nurse when caring for a client with schizophrenia in the early phase of treatment? Continual pacing Suspicious feelings Inability to socialize with others Disturbed relationship with the family	Continual pacing
Which client is displaying the use of cognitive distortion? A client with major depression says, "No matter what I do, everything turns out bad." A client with somatic disorder says, "Can you feel my forehead? I think I have a fever." A school-ag	A client with major depression says, "No matter what I do, everything turns out bad."
Which assessment would be priority for a client with schizophrenia who has paranoia? Continuous pacing Suspicious feelings Lack of love for parents Disregard for the feelings of others	Suspicious feelings
Which room assignment would the nurse make for a client exhibiting manic behavior? With a client who is very quiet Alone in a sparsely furnished room Alone in a room at the end of the hall With a client exhibiting similar behavior	Alone in a sparsely furnished room
Which behavior is most commonly used by an individual with a phobic disorder? Rumination Desensitization Avoidance Confrontation	Avoidance
A client who has concerns about getting married says, "I guess I'd better get married. All the plans are made and paid for, and the invitations have all been mailed." Which defense mechanism is the client using? Introjection Identification Compen	Rationalization
Which rationale best explains how an addiction to alcohol occurs? Person eventually requires alcohol for functioning Person lacks the motivation or will to stop drinking Person has developed very few coping mechanisms Person enjoys the socia	Person eventually requires alcohol for functioning
Which portion of the nervous system is primarily responsible for the clinical manifestations that occur during a crisis? Central nervous system Peripheral nervous system Sympathetic nervous system Parasympathetic nervous system	Sympathetic nervous system
When a client displays anger that subsides after several minutes, which short-term objective is the most important? Continue to express and vent angry feelings Your answer is incorrect Recognize the ways in which anger hurts others Talk about si	Talk about situations that cause angry outbursts
A client had a first-trimester abortion and has been unable to function for 3 months. Which type of grief is the client experiencing? Complex bereavement Anticipatory Disenfranchised Complicated	Disenfranchised
During the working phase of the nurse–client relationship, which question would the nurse ask the depressed client who has a history of suicide attempts when exploring alternative coping strategies? "How have you managed your problems in the past?"	"How will you manage the next time your problems start piling up?"
Which outcome statement indicates that the overly anxious client has successfully achieved the final goal of the counseling process? Client reports that anxiety is under control Client explores feelings about personal relationships Client demonst	Client demonstrates constructive coping skills
Which intervention is best for a client who has a borderline personality disorder? Establishing clear boundaries Exploring vocational possibilities Discussing feelings of being victimized Spending 1 to 2 hours per day with the client	Establishing clear boundaries
Which action would the nurse take for a client who has been actively hallucinating for several days? Ask the client who is speaking. Involve the client in simple activities on the unit. Allow the client to continue without interruption. Have t	Involve the client in simple activities on the unit.
Which characteristic about confusion would the nurse keep in mind when an older client with Alzheimer disease is admitted to a long-term care facility? Occurs with a transfer to new surroundings Will be unchanged despite reality orientation Is a	Occurs with a transfer to new surroundings
For a disturbed client who is brought to the emergency department by the police, which assessments are priority? Recollection of past events and events preceding police involvement Previous history of incarceration or hospitalization for psychiatric	Current behavior, appearance, cognitive function, affect, and orientation
Which response would the nurse make to a client who has been acting out for several weeks and says, "I’m really sorry about how I’ve acted. I’ll bet everyone thinks I’m an idiot"? "You’re wondering how others will react to you now." "Some clients ar	"You’re wondering how others will react to you now."
When a client displays anger that subsides after several minutes, which short-term objective is the most important? Continue to express and vent angry feelings Recognize the ways in which anger hurts others Talk about situations that cause angry	Continue to express and vent angry feelings
Which characteristic would be a concern for the nurse when caring for a client with schizophrenia in the early phase of treatment? Continual pacing Suspicious feelings Inability to socialize with others Disturbed relationship with the family	Suspicious feelings
Which intervention would the nurse use for a client taking quetiapine for acute psychosis who develops lead-pipe rigidity, trismus, and tachycardia? Select all that apply. One, some, or all responses may be correct. Perianal care Fall precautions	Perianal care Fall precautions Use of a cooling blanket Monitoring of intake and output Discontinuation of the medication Administration of bromocriptine as prescribed
In reviewing the client's history, the nurse is correct in concluding that she is at risk of developing a hypertensive disorder. Which other factors add to her risk of developing preeclampsia? (Select all that apply. One, some, or all options may be corre	Nulliparity. Familial history. Preexisting medical or genetic condition. Advanced maternal age.
To accurately assess this client's condition, what information from the prenatal record is most important for the nurse to obtain? Pattern and number of prenatal visits. Prenatal blood pressure readings. Prepregnancy weight. Client's Rh factor	Prenatal blood pressure readings.
What is the pathophysiology responsible for the client's complaint of a pounding headache and the elevated DTRs? Severe anxiety. Cerebral edema. Retinal arteriolar spasms. Increased perfusion to the brain.	Cerebral edema. As fluid leaks into the extravascular spaces, organ edema as well as peripheral edema occurs. This, in conjunction with cortical brain spasms, causes headache, increased deep tendon reflexes, and clonus.
The client's sister is very concerned about the swelling in her sister's face and hands because it seems to be worsening rapidly. She asks the nurse if the healthcare provider (HCP) will prescribe some water pills (diuretics) to help get rid of the excess	"I would be happy to explain to you about the effect of diuretics on pregnancy." The sister may have seen diuretics used for treating fluid retention before (for example, in cardiac disease), but may not be aware of how diuretics affect pregnancy. Diur
After the nurse establishes IV placement, she collects a bag of D5LR for the oxytocin, which is available as 20 units in 1000 mL D5LR. The prescription from the HCP is oxytocin 2 mU/min to augment labor. What is the drip rate for the oxytocin? (Enter the	6ml/hr
While the nurse is awaiting the lab results to determine if the client has elevations in liver function, diminished kidney function, or altered coagulopathies, which questions should the nurse ask her? (Select all that apply. One, some, or all options may	“Do you have any dizziness?” "Do you have blurry vision?” “Do you have abdominal pain?” “Do you have shortness of breath or chest discomfort?”
Which technique should the nurse use when evaluating the client's blood pressure while she is on bed rest? Have the client lie supine and take the blood pressure on the left arm. Have the client lie in a lateral position and take the blood pressure	Have the client lie in a lateral position and take the blood pressure on the dependent arm. The lateral position supports placental perfusion. The lower (dependent) arm should be positioned so the client is not lying on it, and the blood pressure shoul
The nurse performs a nonstress test to evaluate fetal well-being. The client is getting nervous and anxious with the situation. She asks the nurse why she is doing a nonstress test. What is the nurse's best response? It measures the oxygen levels of th	It evaluates the heart rate of the fetus in response to its own movements. The basis for the nonstress test is that the normal fetus with an intact central nervous system (CNS) will respond to fetal movements with an increased heart rate (episodic acce
If the client had HELLP syndrome, which laboratory results would the nurse expect to see? Elevated hemoglobin and hematocrit without burr cells, elevated liver enzymes, and decreased platelets. Decreased hemoglobin and hematocrit with burr cells, el	Decreased hemoglobin and hematocrit with burr cells, elevated liver enzymes, and decreased platelets. All of these indicate HELLP syndrome. HELLP stands for: hemolysis (H), evidenced by burr cells or an elevated bilirubin level; elevated liver enzymes (E
Using the Maternal Fetal Triage Index, triage the following clients in order from 1 to 5, with 1 being the highest priority and 5 being the lowest. (Rank in priority from 1 to 5 with 1 being the highest priority and 5 being the lowest priority.) Click fo	A primigravida has been laboring without complications, but calls the desk to say her "water broke and something is hanging out down there." 2. A G4P3 client arrives in Labor & Delivery saying her HCP diagnosed her with placenta previa and she has been
The day shift charge nurse is preparing to make client care assignments. Which client should be assigned to the most experienced nurse? A 15-year-old gravida 1, para 0, with mild preeclampsia. A 35-year-old gravida 3, para 2, with HELLP syndrome.	A 35-year-old gravida 3, para 2, with HELLP syndrome. This client is the most critical among this group of clients and is at the highest risk for morbidity and mortality. HELLP syndrome occurs in only 2% to 12% of clients with severe preeclampsia.
Prior to initiating the HCP's prescription, the nurse must first obtain consent for vaginal and cesarean birth, analgesia and anesthesia, and blood transfusion. The HCP prescribes this plan of care for the client: Obtain permits for vaginal birth, ces	"It is a central nervous system depressant given to prevent seizures." Magnesium sulfate depresses the CNS by interfering with the neuromuscular junction. It is given to prevent or control eclamptic seizures.
What information should be included in the client and family teaching about magnesium sulfate? This medication will be given intramuscular every four hours for 24 hours. Magnesium sulfate may cause hyperactivity, leg cramps, and difficulty sleeping.	Magnesium is excreted in the urine, so the nurse will closely monitor the urine output. If renal function declines, not all of magnesium sulfate will be excreted, resulting in magnesium toxicity.
If the nurse observes that a client on magnesium sulfate has 40 mL in the urimeter in 2 hours, her respiratory rate is 10 breaths/minute and her deep tendon reflexes are 4, which medication should the nurse prepare to administer? Vitamin K. Corticos	Calcium gluconate. If magnesium toxicity is suspected, the magnesium should be discontinued immediately and the nurse should prepare to administer calcium gluconate. The symptoms of magnesium toxicity include: blood pressure: systolic ≥160 mm Hg or diast
A 4-gram bolus of magnesium sulfate is prescribed to run over 20 minutes. It arrives from the pharmacy diluted in 250 mL of normal saline. What rate does the nurse set the IV pump to run the bolus? (Enter a whole number, round as needed. ) mL/hour	750
The HCP prescribes an IV infusion of magnesium sulfate of 1 gram/hour after the bolus has been completed. The pharmacy sends an IV bag with 40 grams/1000 mL. What rate should the nurse set the IV pump? (Enter a whole number, if needed, round to a whole nu	25ml/hr
The nurse asks the client if the HCP has discussed the labor and delivery processes, potential complications, and the management of those complications with her and if she understands them. The client replies, "I think so," and then asks for a pen. Whi	Ask the client to explain what she understands about the procedures she is undergoing.
what does scotoma mean?	A scotoma is a blind spot or area of vision loss within the visual field.
The 0900 assessment reveals the following: Client reports that her headache has decreased slightly, but the epigastric pain has increased. Complaints of scotoma began about 5 minutes ago. Reflexes are 4+ biceps and patellar and 3+ triceps with 3 beats of	The HCP increased the dosage to achieve the level that prevents seizures. The magnesium level is not up to therapeutic range (4 to 7 mEq/L) because it is being excreted from the body.
When evaluating the fetal monitor strip, the nurse notes a decrease in the fetal heart rate with minimal variability. What is the best explanation for this change? Cord compression is occurring due to oxytocin making the contractions stronger. The f	The fetus has the same magnesium level as the mother's, causing the fetus to be sedated. Because magnesium sulfate crosses the placenta, the baby will have a magnesium level equal to the mother. Although sources differ on the effect that magnesium leve
The nurse is aware that continued magnesium sulfate puts the client at risk for postpartum hemorrhage even though oxytocin is infusing. The nurse recognizes that which medication is safest for the cient if a second drug is needed to treat postpartum hemor	Carboprost tromethamine. This medication, a derivative of prostaglandin F2 alpha, may be administered intramuscularly, intramyometrially at cesarean birth, or intraabdominally after vaginal birth. When given intramuscularly in the postpartum period, th
Which clinical indicators are consistent with the diagnosis of hyperthyroidism? Select all that apply. One, some, or all responses may be correct. Emotional lability Dyspnea on exertion Abdominal distention Decreased bowel sounds Hyperactiv	Emotional lability Dyspnea on exertion Hyperactive deep tendon reflexes
What is Exophthalmos?	Exophthalmos (also known as proptosis) is a medical term that describes bulging or protrusion of one or both eyes from the eye socket (orbit). It is often a sign of an underlying medical condition.
The nurse is providing discharge instructions for a client with a diagnosis of gastroesophageal reflux disease (GERD). Which recommendations would the nurse give to the client to limit symptoms of GERD? Select all that apply. One, some, or all responses m	Avoid heavy lifting. Avoid drinking alcohol. Eat small, frequent meals.
Which condition would the nurse suspect in the client who survived an explosion, is in severe pain, and whose skin is hypersensitive to touch or air and has moist blebs and blisters with cherry red color? First-degree burn Second-degree burn Thir	Second-degree burn
Which fungal infection is commonly referred to as athlete’s foot? Tinea pedis Tinea cruris Tinea corporis Tinea unguium	Tinea pedis
Which toxic effect would the nurse find in a client who has overdosed on isocarboxazid? Mydriasis Bradycardia Hypothermia Circulatory collapse	Circulatory collapse
Which factor would cause a rise in temperature to 102°F (38.9°C) after a seizure in a client with eclampsia? Excessive muscular activity Development of a systemic infection Dehydration caused by rapid fluid loss Irregularity in the cerebral th	Irregularity in the cerebral thermal center Increased electrical charges in the brain during a seizure may disturb the cerebral thermoregulation center in the hypothalamus. Excessive muscular activity usually causes perspiration, leading to a drop in b
An older adult client with postherpetic neuralgia reports deep tissue pain. Which skin infection does the nurse expect to observe in the client’s electronic medical record? Cellulitis Candidiasis Herpes zoster Herpes simplex	Herpes zoster
Which action would be included in the plan of care for a client with a history of parkinsonism who has recently developed rigidity, tremors, and signs of pneumonia? Gait training in the physical therapy department daily Isometric exercises every 2	Passive range-of-motion exercises at least every 8 hours Passive range-of-motion exercises at least every 8 hours maintain the range of joint movement with a minimum of energy expenditure by the client. Ambulation may fatigue the client and does not pr
Initially after a stroke, a client's pupils are equal and reactive to light. Later, the nurse assesses that the right pupil is reacting more slowly than the left and that the systolic blood pressure is rising. Which complication would the nurse plan to ad	Increased intracranial pressure
The nurse teaches a postoperative client how to use an incentive spirometer. Which client behavior indicates to the nurse that the spirometer is being used correctly? Inhales deeply through the mouthpiece, relaxes, and then exhales Inhales deeply,	Inhales deeply through the mouthpiece, relaxes, and then exhales
Which finding will the nurse identify in most children with symptomaticcardiac malformations? Mental retardation Inherited genetic disorders Delayed physical growth Clubbing of the fingertips	Delayed physical growth
Which intervention would the nurse implement when caring for a client 24 hours after thyroidectomy? Check the sides of the operative site dressing and the back of neck. Support the head during mild range-of-motion (ROM) exercises. Encourage the c	Check the sides of the operative site dressing and the back of neck.
Which is the most therapeutic instruction for the nurse to provide to a client with preeclampsia regarding methods for improving her health? "Eat a sodium-restricted diet." "Walk at least 1 mile (2.2 km) every day." "Rest often in the side-lying	"Rest often in the side-lying position."
Which hormonal deficiency would increase the client’s risk for fractures? Growth hormone Follicle-stimulating hormone Thyroid-stimulating hormone Adrenocorticotropic hormone	Growth hormone
A client who had a history of chicken pox arrived at the hospital complaining of itching and deep pain on the skin. Which assessment finding made by the nurse helps confirm the diagnosis? Red, moist, irritated skin Red-colored raised rash with pustu	Multiple lesions in a segmental distribution on the skin
Which action would the nurse take for a client whose right radial pulse is weak and thready? Select all that apply. One, some, or all responses may be correct. Assessing all peripheral pulses Assessing and comparing both radial pulses Asking a se	Assessing all peripheral pulses Assessing and comparing both radial pulses Assessing for edema or other issues that may be restricting peripheral blood flow Observing for pallor/skin temperature differences distal to the weak pulse If the clie
At 32 weeks’ gestation a client undergoes an ultrasound examination, which reveals a low-lying placenta. Which assessment finding would the nurse anticipate as the client’s pregnancy approaches term? Sharp abdominal pain Painless vaginal bleeding	Painless vaginal bleeding
Which clinical findings would cause the nurse to suspect that an adolescent child with type 1 diabetes is hypoglycemic? Increased thirst, sleepiness, and nausea Confusion, dry mouth, and diminished reflexes Difficulty concentrating, hunger, and d	Difficulty concentrating, hunger, and diaphoresis
The nurse is assessing a client who reports excessive daytime sleepiness, sudden muscle weakness during intense emotions, and an inability to walk just after waking or before going to sleep. Which disorder would the nurse suspect that the client is experi	Narcolepsy
While assessing the client’s skin, the nurse notices a skin condition. The nurse realizes the pathophysiology involves increased visibility of oxyhemoglobin caused by an increased blood flow due to capillary dilation. Which skin condition is associated wi	Erythema
Which nursing intervention would be the priority for a 4-week-old infant with hypertrophic pyloric stenosis who has been admitted to the pediatric unit for corrective surgery? Stabilizing vital signs Strict intake and output documentation Correct	Correcting fluid and electrolyte imbalances
After assessing the muscle functionality of a client, the nurse assigns a grade of F (fair) on the Lovett scale in the client. Which describes the muscle functionality of the client? Full range of motion with gravity Full range of motion with gravit	Full range of motion with gravity
Which type of shock would the nurse monitor for in a client with a ruptured abdominal aortic aneurysm? Obstructive Neurogenic Cardiogenic Hypovolemic	Hypovolemic
The nurse is performing a breast assessment. Which statement made by the client indicates a risk of breast cancer? Select all that apply. One, some, or all responses may be correct. "I had a late onset of menarche." "My first child was born when I w	"My first child was born when I was 32." "I noticed a slight discharge from a nipple." "I consume two to four glasses of alcohol a day."
Which peripheral vascular assessment cannot be performed while a corrective boot cast for talipes equinovarus (clubfoot) is in place? Color Pulse Warmth Blanching	Blanching
Two hours after a 1-year-old child with acute laryngitis is admitted to the hospital, the nurse observes increases in the child’s respiratory and cardiac rates, increased restlessness, and substernal and intercostal retractions. Which action would the nur	Calling the health care provider to report the child’s respiratory status
How would the nurse screen the newborn of a diabetic mother for hypoglycemia? Testing for glucose tolerance Drawing arterial blood for glucose evaluation Arranging for a fasting blood glucose determination Testing heel blood with the use of a	Testing heel blood with the use of a glucose-oxidase strip
An adolescent with Duchenne muscular dystrophy has received care at the pediatric clinic since early childhood. On which body system would the nurse perform a focused assessment to identify life-threatening complications as the child ages? Neurologic	Cardiopulmonary
Which prescribed medication would the nurse anticipate administering to a client who tested positive for human epidermal growth factor (HER) and has a diagnosis of advanced breast cancer? Erlotinib Lapatinib Rituximab Tositumomab	Lapatinib
Which action would the nurse include in the postprocedure plan of care for a client with peripheral arterial disease who is scheduled for a femoral angiogram? Elevate the foot of the bed. Place in the high-Fowler position. Perform urinary cathete	Check pedal pulses every 15 minutes postprocedure.
For a postsurgical client, which data suggest acute alcohol withdrawal? Select all that apply. One, some, or all responses may be correct. Tremors in both hands make it difficult for the client to hold a cup. Systolic blood pressure has dropped 6 po	Tremors in both hands make it difficult for the client to hold a cup. The client’s bed linens and pajamas had to be changed during the night because of diaphoresis. The client who has been cooperative becomes verbally abusive and irritable.
A client weighs 150 lb and is 5 feet 7 inches tall. What is this client’s body mass index (BMI)? Record your answer using two decimal places.	23.49
When auscultating a client's chest, the nurse hears swishing sounds of normal breathing. How would the nurse document this finding? Adventitious sounds Fine crackling sounds Vesicular breath sounds Diminished breath sounds	Vesicular breath sounds
Which client would the nurse see first among this group of clients? A 2-year-old client with diarrhea A 35-year-old client who is nauseated A 40-year-old client who has vomiting because of food poisoning An 83-year-old client whose last bowel	A 40-year-old client who has vomiting because of food poisoning
The nurse is reviewing the laboratory report of an infant with tetralogy of Fallot that shows an increased red blood cell (RBC) count. Which would the nurse identify as the cause of the polycythemia? Low blood pressure Diminished iron level Tissu	Tissue oxygen needs
When a client who is taking a diuretic has been instructed to eat foods high in potassium, which fruit would the nurse suggest? Apples Grapes Cantaloupe Cranberries	Cantaloupe
The nurse teaches a parent of a toddler how to perform a cellophane-tape test for pinworms. At which time would the nurse teach the parent to perform the test? Immediately after meals After a bowel movement At bedtime, before the child’s bath	Early morning, before the child gets up
A 42-year-old client at 39 weeks' gestation has a reactive nonstress test (NST). Which interpretation pertains to this result? Immediate birth is indicated. This is the desired response at this stage of gestation. Further testing is unnecessary w	This is the desired response at this stage of gestation.
A client has delivered her infant by cesarean birth. The nurse monitors the newborn’s respiration closely, because infants born via the cesarean method are prone to atelectasis. Why does this occur? The ribcage is not compressed and released during bir	The ribcage is not compressed and released during birth.
Which clinical indicator would the nurse review before scheduling a client for an endoscopic retrograde cholangiopancreatography (ERCP)? Urine output Bilirubin level Blood pressure Serum glucose	Bilirubin level
How will the nurse calculate pulse pressure for a hospitalized client? Calculate the difference between the radial and apical pulse rates. Subtract the diastolic blood pressure from the systolic blood pressure. Add the systolic pressure plus 2 ti	Subtract the diastolic blood pressure from the systolic blood pressure.
A client has left hemiplegia because of a cerebrovascular accident (CVA, "brain attack"). What can the nurse do to contribute to the client’s rehabilitation? Begin active exercises. Make a referral to the physical therapist. Position the client t	Position the client to prevent contractures.
When teaching a client with diabetes about monitoring for episodes of hypoglycemia, which symptom would the nurse include in the teaching plan? Thirst Nausea Anorexia Sweating	Sweating
A client comes to the emergency room reporting severe abdominal cramping and heavy bleeding at 10 weeks’ gestation. Cervical examination reveals heavy bleeding; the cervical os is open and tissue is present. Which type of abortion is the client experienci	Inevitable
The student nurse provides follow-up care instructions to a client who recently underwent a biopsy procedure. Which statement made by the student nurse requires correction? "Report any redness or excessive drainage." "Avoid using tap water to remove	"Avoid using tap water to remove dried blood."
Which stage of shock results in two or more organ system failures? Compensatory Initial Refractory Progressive	Refractory The refractory stage of shock is the fourth stage, in which treatment is ineffective and organs fail (multiple organ dysfunction syndrome), resulting in death.
During the progressive stage of shock, cellular death occurs due to which processes? Select all that apply. One, some, or all responses may be correct. Apoptosis Anaerobic metabolism switch Sodium-potassium pump failure Cytokines Adrenocort	Apoptosis Sodium-potassium pump failure Apoptosis Apoptosis is programmed cellular suicide, which typically occurs in shock to regain homeostasis due to damage or overproduction. Sodium-potassium pump failure Located within the mitochondria (
what is apoptosis?	Apoptosis Apoptosis is programmed cellular suicide, which typically occurs in shock to regain homeostasis due to damage or overproduction. Sodium-potassium pump failure Located within the mitochondria (energy portion of the cell) is the sodium-po
Which global indicator of systemic perfusion is useful in evaluating the severity of shock? Creatinine levels Hypotension Arterial blood gas Hypothermia	Arterial blood gas Arterial blood gas is a useful test to predict the severity of shock. It can indicate both acidosis and alkalosis from a respiratory and metabolic standpoint.
Which type of intravenous fluid would be used to correct intravascular volume depletion related to shock? Crystalloids Parental nutrition Sodium bicarbonate Enteral nutrition	Crystalloids Crystalloids are balanced electrolyte solutions such as 0.9% normal saline and lactated Ringer. They are used to correct volume depletion.
Which nursing interventions would provide quality care for a patient with shock? Select all that apply. One, some, or all responses may be correct. Utilizing a standard plan of care Ensuring visitors are allowed during routine hours Facilitating	Facilitating team problem solving and decision making Shock is a complex, multisystem problem. A team approach allows for proactive and timely interventions. Allowing family presence during invasive procedures Allowing family presence during inva
Which team strategy is used to support oxygen transport during shock treatment? Identify lactic acidosis cause(s). Provide nutritional support. Ensure adequate organ perfusion. Initiate mechanical ventilation.	Initiate mechanical ventilation.
A baby is born very prematurely and requires intensive, specialized treatment. Which type of inpatient setting is most likely to have the needed neonatal intensive care unit? Cancer center Community hospital Long-term care facility Academic	Academic medical center
An RN case manager evaluates a patient to assess the progress being made toward identified outcomes. Which can the case manager use for this evaluation? Team work Critical path One-on-one care Direct bedside care	Critical path
Which are the duties of the registered nurse in team nursing? Select all that apply. Team leader Primary care of patients Matching skills to licensure Taking responsibility for the team Designing pleasant surroundings	Team leader Matching skills to licensure Taking responsibility for the team
Which factors inform the ANA’s approach to staffing? Select all that apply. Staff skill mix Patient acuity Staff experience Support services Cost containment	Staff skill mix Patient acuity Staff experience Support services
What is reality shock? A feeling that new nurses get because of their long shifts. An inability to carry out the duties and demands of the job because caseloads are too high. A feeling of powerlessness that leads to an inability to cope with th	A feeling of powerlessness that leads to an inability to cope with the demands of the profession.
Why is self-care an important factor for coping with reality shock? Select all that apply. Getting plenty of rest gives nurses the energy to care for patients. Being mentally and physically strong helps nurses face the demands of the nursing pr	Getting plenty of rest gives nurses the energy to care for patients. Being mentally and physically strong helps nurses face the demands of the nursing profession. Having a healthy social life with friends and family gives nurses an outlet to unwind
In what way is the Health care industry as a whole impacted by reality shock? Too many overnight shifts are unfilled by nurses. Modern technology is taking over the direct care that nurses provide. Nurses’ salaries are decreased because of how	Resources such as time and money are spent on hiring and training nurses to replace those who leave.
Which scenario represents the beginning stages of incivility along the continuum? A nurse is insulted because of her religious beliefs. A nurse is teased about her outfit by her colleagues. A nurse uses her cell phone for texting while at the n	A nurse uses her cell phone for texting while at the nurses’ station.
Which scenario demonstrates horizontal violence? A new nurse is being bullied by her coworkers because of the nurse’s religious beliefs. A patient with mental illness becomes violent toward the nurse when administering medication. A patient’s f	A new nurse is being bullied by her coworkers because of the nurse’s religious beliefs.
Place the scenarios in order from lowest risk to highest risk of the incivility continuum. Place the scenarios in order from lowest risk to highest risk of the incivility continuum. A nurse makes sarcastic jokes about a peer’s clothes. A nurse ca	2 A nurse makes sarcastic jokes about a peer’s clothes. 3 A nurse calls the new nurse a “goody two shoes.” 5 A nurse jumps on top of her colleague in the heat of an argument and chokes her. 4 A nurse insults a colleague’s religion. 1 A
Which nurses are at risk for substance abuse? Bernice takes one day off after every two days of working. Patrick has worked for two weeks straight without a day off. Gabriela works in the trauma center, which she does	Patrick has worked for two weeks straight without a day off. Gabriela works in the trauma center, which she does not like. Kari has a terribly sore back and is caring for a patient who is prescribed pain killers.
A nurse believes that a patient with hypoxia does not have adequate pulmonary gas exchange. Which intervention would be the nurse’s priority? Monitor the patient’s saturation using a pulse oximetry. Ensure the patient is speaking in full sentences.	Ensure the patient is speaking in full sentences.
A patient is being admitted for bacterial infection and a concern for shock is present. Which laboratory test would best indicate the severity of shock? D-dimer Hemoglobin Lactate levels Prothrombin time	Lactate levels
A patient with shock due to a severe antibody-antigen reaction is being evaluated. Which administration would best treat preload-related intravascular volume depletion? Dobutamine Normal saline Norepinephrine Packed red blood cells	Normal saline
Which set of vital signs would best reflect a patient in class II hypovolemic shock?	Temperature 97.8°F (36.5°C), heart rate 108, respiration 24, and blood pressure 106/58
Which care plans would best support the preventative strategies for nursing management of hypovolemic shock? Select all that apply. One, some, or all responses may be correct.	Risk for fluid volume deficit related to compromised regulatory mechanisms Risk for impaired nutrition related to inability to digest food
A nurse is assessing a patient admitted with acute kidney injury and notes blood leaking from old venipuncture sites, hypotension, and dyspnea. Which condition would the nurse most likely suspect?	Disseminated intravascular coagulation
A patient is being admitted to the emergency department after a motorcycle crash with an estimated blood loss of 1800 mL. Which immediate interventions would the nurse anticipate?	Urinary catheter insertion Frequent vital signs and pulse oximetry Application of supplemental oxygen
A patient is being treated for hypovolemic shock and develops supraventricular tachycardia (SVT) at 180 bpm and a blood pressure of 102/60. Which medication would the nurse most likely administer? Labetalol Hydralazine Adenosine Milrinone	Adenosine
Which patient’s condition would most likely indicate an initial stage of shock? Pale, cool, clammy skin and increased confusion Urine output of 350 mL in 24 hours and hypertension Mean arterial pressure of 58 mm Hg and restlessness	Mean arterial pressure of 58 mm Hg and restlessness
A patient readmitted for asthma exacerbation states that they always develop hives on the chest after a couple of days in the hospital. Which anaphylactic trigger would the nurse most likely suspect?	Monitoring electrodes
A nurse is assessing a patient with no known drug allergies reporting pruritus after a second intravenous dose of vancomycin 8 hours later. Which additional criteria is needed to confirm the probable diagnosis of anaphylactic shock?	Syncope
A patient taking sotalol and ibuprofen is admitted for anaphylactic shock. The patient is still hypotensive and experiencing bronchospasms after several doses of epinephrine. Which additional intravenous medication would provide the best treatment for thi	Glucagon
A patient treated 2 days ago for a severe anaphylactic reaction after receiving a second dose of cefepime intravenously is now experiencing a reemergence of symptoms. Which immunological response most likely caused this condition?	Biphasic reaction
What is Biphasic reaction	A biphasic reaction generally refers to a reaction that occurs in two distinct phases or stages, often with different characteristics in each phase. This term can be applied in various contexts, such as chemistry, pharmacology, or biology.
A nurse is assessing a patient 5 days after a myocardial infarction whose oxygen requirement continues to increase. Which nursing interventions would the nurse utilize to confirm cardiogenic shock? Select all that apply. One, some, or all responses may be
A patient is admitted with constrictive pericarditis with a history of atherosclerosis and gout. Which additional condition would the nurse anticipate due to the risk of cardiogenic shock for this patient? Atrial fibrillation	Atrial fibrillation
Which patient is at the highest risk for sepsis and septic shock?	A 68-year-old male patient with a history of lupus admitted with hepatitis and has a triple-lumen subclavian line
Which patient symptoms meet the quick SOFA (Sequential Organ Failure Assessment) criteria for organ dysfunction?	New confusion to current place and a respiratory rate of 24
A nurse is assessing a patient admitted with cellulitis that has an elevated white blood count. Which additional laboratory values would the nurse expect to be elevated, indicating sepsis?	Procalcitonin Serum glucose
Which intervention would the nurse include in the plan of care for a patient with severe multiple organ dysfunction syndrome (MODS)? Encourage oral fluid intake. Prepare for mechanical ventilation. Implement fluid restrictions. Administer vaso	Prepare for mechanical ventilation.
When caring for a patient with MODS, the nurse would most closely monitor which organ for manifestations of reperfusion injury? Kidney Liver Gallbladder Pancreas	kidneys
What is the medication Flumazenil?	Flumazenil reverses the effects of benzodiazepines and naloxone for narcotics.
What is Empyema?	Empyema is the accumulation of pus in the pleural space, typically as a result of infection, most commonly from bacterial pneumonia. It can also develop after thoracic surgery, lung abscess rupture, or chest trauma.
What is silicosis?	Silicosis is a chronic, progressive lung disease caused by inhaling crystalline silica dust, typically over a long period. It’s a form of pneumoconiosis (occupational lung disease) and is irreversible but preventable.
Which action would the nurse take when preparing to apply a nonrebreathing mask to a patient in respiratory distress? Adjust the Fio2 dial to 70%. Administer 3 L/min flow. Ensure the reservoir bag inflates. Monitor closely for nasal polyps.	Ensure the reservoir bag inflates.
Which patient would benefit from a nasopharyngeal airway? Unconscious patient admitted for stroke Conscious patient with significant nasal polyps Conscious patient admitted for respiratory depression	Conscious patient admitted for respiratory depression
Which action would the nurse include in the plan of care for a patient with an orotracheal tube who is experiencing frequent tube obstruction? Humidify the inspired gases. Secure the tube to the upper lip. Insert a nasopharyngeal airway.	Humidify the inspired gases.
Which action would the nurse take when caring for a patient with a tracheostomy tube and assesses the presence of subcutaneous emphysema within the tissues around the stoma? Remove packing and sutures. Humidify inspired gases.	Remove packing and sutures.
Which device would the nurse use to deliver oxygen to a patient with an Sao2 level of 35 mm Hg? Nasal cannula Nasal catheter Simple mask Air-entrainment mask	Air-entrainment mask
Which action would the nurse take first if a patient accidentally removes the endotracheal tube? Apply bilateral wrist restraints. Notify the health care provider. Provide bag-valve mask ventilations. Administer a sedative.	Provide bag-valve mask ventilations.
Which action would the nurse include in the plan of care for a patient with an orotracheal tube? Adjust cuff pressure to 40 cm H2O. Deflate the cuff once a shift. Maintain the head of the bed (HOB) at 60 degrees.	Maintain the head of the bed (HOB) at 60 degrees.
Which mechanical ventilation mode would be used for a patient with acute respiratory distress syndrome and decreased lung compliance? Pressure-controlled continuous mandatory ventilation (CMV) Continuous positive airway pressure (CPAP)	Pressure-controlled continuous mandatory ventilation (CMV)
Which assessment finding would indicate a complication related to mechanical ventilation? SATA Hyperactive bowel sounds Decreased preload Increased blood pressure Decreased urinary output Increased intracranial pressure	Decreased preload Decreased urinary output Increased intracranial pressure
Which patient would be at the highest risk for ventilator-associated pneumonia (VAP)? An overly sedated patient with an orotracheal tube A patient with an intraaortic balloon pump (IABP) and nasotracheal tube	A patient with an intraaortic balloon pump (IABP) and nasotracheal tube

Created by: natalia44

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