Funds
The nurse is teaching an older adult client with right leg weakness how to use a crane. Which behavior by the client indicates that the teaching was effective?
A. The client holds the cane with the right hand, moves the cane forward followed by the right leg, then moves the left leg.
B. The client holds the cane with the right hand, moves the cane forward followed by the left leg, and then moves the right leg.
C. The client holds the cane with the left hand, moves the cane forward followed by the right leg, and then moves the left leg.
D. The client holds the cane with the left hand, moves the cane forward followed by the left leg, and then moves the right leg.
C (442) The cane acts as a support and aids in weight-bearing for the weaker right leg
The nurse is preparing the client for peritoneal dialysis. Which action should the nurse take first?
A. Assess the access point for a bruit and a thrill.
B. Warm the dialysate solution
C. Apply a warm heating pad to the client's abdomen
D. Position the client for comfort using pillows
D (441)
DAILY DOUBLE
The nurse is teaching a client how to breastfeed her newborn. The nurse knows that teaching has been successful if the client makes which statement?
A. "My baby's weight should equal the birth weight in 5 to 7 days."
B. "My baby should have at least 6 to 8 wet diapers per day."
C. "My baby will sleep at least 6 hours between feedings."
D. "My baby will feed for about 10 minutes per feeding"
B (454)
A clinic nurse is assessing a client immediately post cataract surgery with implantation. Which point should the nurse include in the discharge teaching?
A. Importance of reporting a scratchy feeling in the eye.
B. Lie on the side of the affected eye the night after surgery.
C. Wipe eye with a single gesture from the outer canthus inward.
D. Avoid lifting objects that weight more than 15 lb (6.8kg)
D. (462 - avoid increasing pressure)
A client diagnosed with anorexia nervosa is admitted to the hospital. Which statement by the client requires immediate follow-up by the nurse?
A. "My gums bled this morning"
B. "I'm getting fatter every day."
C. "Nobody likes me, I'm so ugly."
D. "I feel dizzy and weak today."
D (452)
A client is admitted who reports severe pain the right lower quadrant of the abdomen. Which action should the nurse take to assist the client with pain relief?
A. Encourage rhythmic, shallow breathing.
B. Massage the right lower quadrant of the abdomen
C. Apply a warm heating pad to the clients abdomen.
D. Position client for comfort using pillows
The nurse is calculating the IV flow rate of a postoperative client. The client is to receive 3000 mL of lactated Ringer's solution IV infused over 24 hours. The IV Administration set has a drop factor of 10gtt/mL. The nurse should regulate the client's IV administration set to deliver how many gtt per min?
21gtt/min
The nurse is caring for clients on the pediatric unit. A client with second- and third-degree burns on the right thigh is being admitted. The nurse should assign the new client to which roommate?
A. A client with chickenpox
B. A client with asthma
C. A client who developed acute diarrhea with antibiotics
D. A client with Methicillin-resistant staphlococcus aureas on Vancomycin
B
After 2 weeks of receiving lithium therapy, a client in the psychiatric unit becomes depressed. Which evaluation of the client's behavior by the nurse would be most accurate?
A. The treatment plan is not effective; the client requires a larger dose of lithium.
B. This is an abnormal response to lithium therapy; the client should stop the lithium immediately.
C. This is a normal response to lithium therapy; the client should be monitored for suicidal behavior.
D. The treamtment plan is not effective; the client requires an antidepressant
C
DAILY DOUBLE
After receiving hand-off report, the nurse should see which client first?
A. A client in sickle cell crisis experiencing an IV infiltration of fluids
B. A client with leukemia receiving a red blood cell transfusion.
C. A client scheduled for an elective bronchoscopy.
D. A client reporting a leaking colostomy appliance.
A (445) Patient is in crisis, fluids required for treatment to prevent clotting and reduce pain
The nursing team consists of 1 RN, 2 LPN/LVNs, and 3 unlicensed assistive personnel (UAPs). The RN should care for which client?
A. The client with a chest tube who is ambulating in the hallway
B. A client with a colostomy who requires colostomy irrigation assistance
C. A client with a right-sided stroke who requires assistance with bathing.
D. A client who is refusing medication to treat cancer of the colon
D (435)
The nurse is preparing discharge teaching for a client with a new colostomy. The nurse knows teaching was successful when the client chooses which menu option?
A. Sausage, sauerkraut, baked potato, and fresh fruit.
B. Cheese omelet with bran muffin and fresh pineapple
C. Pork chop, mashed potatoes, turnips, and salad.
D. Baked chicken, boiled potato, cooked carrots, and yogurt
D (all others with high residue, gas producing, high fiber)
The nurse is caring for a client at 37 weeks' gestation who has a history of type 1 diabetes mellitus. The client states, "I am so thrilled that I will be breastfeeding my baby." Which response by the nurse is best?
A. "You will probably require less insulin while you breastfeed."
B. "You will initially require more insulin after the baby is born."
C. "You will be able to take an oral antidiabetic agent instead of insulin."
D. "You will likely require the same dose of insulin that you require now."
A (437)
A commuter train derailment has resulted in multiple casualties arriving at the emergency department. As the triage nurse, you must prioritize patients using disaster triage principles.
Which category would you assign each of the following (Red-immediately, yellow-delayed, Green-minor, black-deceased)
A 45-year-old with an open femur fracture, capillary refill of 3 seconds, and controlled bleeding
A 30-year-old who is unconscious, not breathing, and does not respond after airway repositioning
A 22-year-old with severe respiratory distress, respirations 34/min, and cyanosis
A 60-year-old with minor lacerations, walking, and asking for water
Yellow
Black
Red
Green
A client reports worsening cough, headache and new onset shortness of breath since the last clinic visit. The client started antibiotic therapy at home but reports "not feeling well" the last 2 days and inability to take anything by mouth, including antibiotics. Client is alert and oriented X3, lungs sounds clear on left, course crackles noted on the right base. S1/S2 present, no murmurs. Skin warm to the touch and appears flushed. Cap refill >3 seconds.
Which complications is the client at greatest risk for? SELECT ALL THAT APPLY
A. Septic shock
B. Urinary tract infection
C. Pneumonia
D. Airway obstruction
E. Anaphylaxis
A,C (449)
The nurse is teaching a client about elastic stocking use. WHich statement by the client indicates to the nurse that teaching was successful?
A. "I will wear the stockings until I'm told to remove them."
B. "I should wear the stockings even when I am asleep."
C. "Every 4 hours I shold remove the stockings for a half-hour."
D. "I'll put on stockings before I get out of bed in the morning."
D (450)
A client with emphysema becomes restless and confused. Which step should the nurse take next?
A. Encourage pursed lipped breathing.
B. Measure the client's temperature
C. Assess the client's potassium level
D. Increase oxygen flow rate to 6L/min
A (445)
The nurse knows that pre-eclampsia increases the client's risk for developing (1) due to the (2) and associated (3)
(1) Placenta accreta - placenta previa - placental abruption
(2) Maternal hypertension - IV oxytocin induction - preterm gestation
(3) Head compression - placental compromise - umbilical cord compression
Placental abruption
Maternal hypertension
Placental compromise
(381)
The nurse is caring for a client diagnosed with bipolar disorder. The client paces endlessly in the halls and makes hostile comments to other clients. The client resists the nurse's attempts to move the client to a room in the unit. Which action by the nurse is most important?
A. Offer the client fluids every hour.
B. Inform the client about unit rules
C. Administer Haldol prn
D. Encourage the client to rest
C (476) need to decrease hyperactive behavior for client to take food/fluids and maintain physiological safety
A. Chlordiazepoxide
B. Disulfiram
C. Methadone
D. Naloxone
A (442) Chlordiazepoxide is Librium, long acting Benzo
The nurse is working at a skilled nursing facility. The nurse witnesses a client getting up from a sitting position on the floor and asks the client what happened. The client responds "I fell". What is the most appropriate documentation for this event?
A. Client fell on the floor and there was no injury noted.
B. Client fell on the floor landing in a sitting position.
C. Client found on floor and was able to get up without assistance. Appears that client slipped or tripped.
D. Client found on floor and reported "I fell", Assessment revealed no injury. Provider notified
D (499)
A client admitted 3 days ago for scheduled CABG x3 vessels. No complications intraoperatively now recovering in the ICU. Chest tube removed this morning. Currently AAOx3, lungs clear, S1/S2 present, +BS all 4 quads, voiding without issue, MAE through FROM. HR 146, BP 118/76, RR 16, O2 95% on RA, T 98.8. Upon change of shift assessment client is complaining of "racing" heartbeat and feeling faint. Irregular hear rhythm is auscultated.
The nurse knows the client is most likely experiencing: Myocardial infarction, pneumonia, Atrial fibrillation, ventricular tachycardia
The nurse will take which TWO actions: Measure airflow via incentive spirometry, 12 lead EKG, Prepare diltiazem continuous infusion, Prepare for exercise stress test, prepare the client for cardioversion
The nurse will monitor which TWO parameters: Neuro status, serum troponin, Chest Xray, Cap refill, heart rate
Afib
12 lead EKG, diltiazem
Neuro status, heart rate (467)
The nurse is teaching a woman who comes to the clinic at 32 weeks' gestation with a diagnosis of pregnancy induced hypertension (PIH). Which statement by the client indicates to the nurse that further teaching is required?
A. "Lying in bed on my left side is likely to increase my urine output"
B. "If the bed rest works, I may lose a pound or two in the next few days."
C. "I should be sure to maintain a diet that has a good amount of protein"
D. "I will have to keep my room darkened and not watch much television"
D (472) Distraction during rest/bed rest
After completing an assessment, the nurse determines that a client is exhibiting early symptoms of a dystonic reaction related to the use of an antipsychotic medication. Which action by the nurse would be most appropriate?
A. Reality test with the client and assure the client that physical symptoms are not real
B. Teach the client about common side effects of antipsychotic medications
C. Explain to the client that there is no treatment that will relieve these symptoms
D. Notify the health care provider to obtain a prescription for IM Diphenhydramine
D (474) dystonic reaction- face and neck muscle tightness, difficulty swallowing, protect airway
The nurse is evaluating the care provided to a client hospitalized for treatment of adrenal crisis. Which change would indicate to the nurse that the client is responding favorably to medical and nursing treatment?
A. Urinary output has increased
B. Blood pressure has increased
C. The client has experienced weight loss
D. Peripheral edema has decreased
B (473) hypotension is experienced with adrenal insufficiency