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A postoperative TURP client is ordered continuous bladder irrigations. Later in the evening on the first postoperative day, he complains of increasing suprapubic pain. When assessing the client, the nurse notes diminished flow of bloody urine and several large blood clots in the drainage tubing. Which one of the following should be the initial nursing intervention?
A male client is started on IV anticoagulant therapy with heparin. Which of the following laboratory studies will be ordered to monitor the therapeutic effects of heparin?
A 32-year-old female client is being treated for Guillain- Barré syndrome. She complains of gradually increasing muscle weakness over the past several days. She has noticed an increased difficulty in ambulating and fell yesterday. When conducting a nursing assessment, which finding would indicate a need for immediate further evaluation?
The primary focus of nursing interventions for the child experiencing sickle cell crisis is aimed toward:
A 10-month-old infant’s mother says that he takes fresh whole milk eagerly, but that when she offered him baby foods at 6 months of age, he pushed them out of his mouth. Because he has gained weight appropriately, she has quit trying to get him to eat other foods. The nurse’s response is based on the knowledge that:
A client had abdominal surgery this morning. The nurse notices that there is a small amount of bloody drainage on his surgical dressing. The nurse would document this as what type of drainage?
The nurse needs to be aware that the most common early complication of a myocardial infarction is:
While changing the dressing on a client’s central line, the nurse notices redness and warmth at the needle insertion site. Which of the following actions would be appropriate to implement based on this finding?
Nursing care for the parents of a child with a congenital heart defect would include:
Which of the following lab data is representative of a client with aplastic anemia?
A client tells the nurse that he has been hearing voices that tell him to kill his girlfriend because she is a spy. He further states that he is having difficulty not obeying the voices because, if he does not, his house will be burned down. The highest priority nursing diagnosis for him at this time is:
A 4-year-old boy is brought to the emergency room with bruises on his head, face, arms, and legs. His mother states that he fell down some steps. The nurse suspects that he may have been physically abused. In accordance with the law, the nurse must:
The nurse is teaching a child’s parents how to protect the child from lead poisoning. The nurse knows that a common source of lead poisoning in children is:
A female client is started on warfarin (Coumadin) 5 mg po bid. To adequately evaluate the effectiveness of the warfarin therapy, the nurse must know that this medication:
During the admitting mental health assessment, a client demonstrates involuntary muscular activity. He has a marked facial tic around the mouth that is distracting to the nurse during the interview. The nurse recognizes the behavior and documents it as:
Which of the following nursing care goals has the highest priority for a child with epiglottitis?
The mother of a child taking phenytoin will need to plan appropriate mouth care and gingival stimulation. When tooth-brushing is contraindicated, the next most effective cleansing and gingival stimulation technique would be:
The following nursing diagnosis is written for a comatose client with cirrhosis of the liver and secondary splenomegaly—High risk for injury: Increased susceptibility to bleeding related to:
A client who has been diagnosed with anorexia nervosa reluctantly agrees to eat all prescribed meals. The most important intervention in monitoring her dietary compliance would be to:
A client is resting comfortably after delivering her first child. When assessing her pulse rate, the nurse would recognize the following finding to be typical:
Degenerative disorders are attributed to many factors. As a nurse assigned to a convalescent home, one must often educate families about how such conditions occur. Which of the following statements might the nurse need to explore when a daughter tries to explain to her mother what caused her degenerative disorder?
A client is medically cleared for ECT and is tentatively scheduled for six treatments over a 2-week period. Her husband asks, “Isn’t that a lot?” The nurse’s best response is:
While the nurse is taking a male client’s blood pressure, he makes flirtatious remarks to her. The nurse will handle this effectively if she:
A 26-year-old female client presents at 10 weeks’ gestation. She currently is a G3 1-0-1-1. Her mother and grandmother have heart disease. Her grandmother also has insulin-dependent diabetes. The client’s previous delivery was a term female infant weighing 9 lb 13 oz. The client is 5 ft 6 inches tall and her current weight is 130 lb. Based on her history, she is at risk for developing diabetes in pregnancy. Which of the following factors places her at risk for gestational diabetes?
A 2-year-old boy fell out of bed and has a subdural hematoma. When his mother leaves him for the first time, you will expect the child to:
The nurse and prenatal client discuss the effects of cigarette smoking on pregnancy. It would be correct for the nurse to explain that with cigarette smoking there is increased risk that the baby will have:
A 20-year-old female client delivers a stillborn infant. Following the delivery, an appropriate response by the labor nurse to the question, “Why did this happen to my baby?” is:
When preparing insulin for IV administration, the nurse identifies which kind of insulin to use?
A male client is experiencing auditory hallucinations. His nurse enters the room and he tells her that his mother is talking to him, and he will take his medicine after she leaves. The nurse looks around the room and sees that she and the client are the only ones in the room. The nurse’s most therapeutic response will be:
Which of the following nursing orders has the highest priority for a child with epiglottitis?
Which of the following medications requires close observation for bronchospasm in the client with chronic obstructive pulmonary disease or asthma?
When teaching a sex education class, the nurse identifies the most common STDs in the United States as:
The nurse practitioner determines that a client is approximately 9 weeks’ gestation. During the visit, the practitioner informs the client about symptoms of physical changes that she will experience during her first trimester, such as:
The day following his admission, the nurse sits down by a male client on the sofa in the dayroom. He was admitted for depression and thoughts of suicide. He looks at the nurse and says, “My life is so bad no one can do anything to help me.” The most helpful initial response by the nurse would be:
Hematotympanum and otorrhea are associated with which of the following head injuries?
A physician’s order reads: Administer furosemide oral solution 0.5 mL stat. The furosemide bottle dosage is 10 mg/mL. What dosage of furosemide should the nurse give to this infant?
A client undergoes a transurethral resection, prostate (TURP). He returns from surgery with a three-way continuous Foley irrigation of normal saline in progress. The purpose of this bladder irrigation is to prevent:
A 70-year-old client has pneumonia and has just had a respiratory arrest. He has just been intubated with an 8- mm endotracheal tube. During auscultation of his chest, breath sounds were found to be absent on the left side. The nurse identifies the most likely cause of this as:
A 30-year-old client has a history of several recent traumatic experiences. She presents at the physician’s office with a complaint of blindness. Physical exam and diagnostic testing reveal no organic cause. The nurse recognizes this as:
A post-lung surgery client is placed on a chest tube drainage system. When explaining to the family how the system works, the nurse states that the water-seal bottle of a three-bottle chest drainage system serves which of the following purposes?
A 29-year-old client delivered her fifth child by the Lamaze method and developed a postpartal hemorrhage in the recovery room. What are the initial symptoms of shock that she may experience?
A 52-year-old client is scheduled for a small-bowel resection in the morning. In conjunction with other preoperative preparation, the nurse is teaching her diaphragmatic breathing exercises. She will teach the client to:
A child becomes neutropenic and is placed on protective isolation. The purpose of protective isolation is to:
A 14-year-old boy fell off his bike while “popping a wheelie” on the dirt trails. He has sustained a head injury with laceration of his scalp over his temporal lobe. If he were to complain of headache during the first 24 hours of his hospitalization, the nurse would:
A client who has been diagnosed with anorexia nervosa refuses to eat lunch. The most therapeutic response by the nurse to her refusal is:
A 24-year-old graduate student recognizes that he has a phobia. He suffers severe anxiety when he is in darkness. It has altered his lifestyle because he is unable to go to a movie theater, concert, and other events that may require absence of light. The client is seeking assistance because he is no longer able to socialize with friends due to his phobia. The psychologist working with him is using desensitization. He has asked the nursing staff to assist the client in muscle relaxation techniques. What result would indicate client education has been successful?
A female client has a chest tube placed. It is accidentally pulled out of the intrapleural space when she is ambulating. The first action the nurse should take is to:
A newborn is admitted to the newborn nursery with tremors, apnea periods, and poor sucking reflex. The nurse should suspect:
On morning rounds, the nurse found a manic-depressive client who is taking lithium in a confused mental state, vomiting, twitching, and exhibiting a coarse hand tremor. Which one of the following nursing actions is essential at this time?
A female client is concerned that she is in a “high-risk” group for the development of acquired immunodeficiency syndrome (AIDS). She wants to know about the advisability of donating blood. Which of the following responses is correct?
A 22-year-old client is 16 weeks pregnant. She and her husband are expecting their first baby. The client tells the nurse that her last normal menstrual period was February 16, with 3 days of spotting on February 17, 18, and 19. The nurse calculates her expected date of delivery to be:
The nurse is collecting a nutritional history on a 28- year-old female client with iron-deficiency anemia and learns that the client likes to eat white chalk. When implementing a teaching plan, the nurse should explain that this practice:
A female client at 10 weeks’ gestation complains to her physician of slight vaginal bleeding and mild cramps. On examination, her physician determines that her cervix is closed. The client is exhibiting signs of:
A female client was employed as a client care technician in a hemodialysis unit. She recently began to experience extreme fatigue, being able to sleep for 16–20 hours at a time. She also noted that her urine was tea colored, which she rationalized was a result of the vitamins she began taking to alleviate fatigue. She was diagnosed with hepatitis B. After a brief hospital stay, she is discharged to her parent’s home. Her mother asks the nurse if any precautions are necessary to prevent transmission to the client’s family. The nurse explains necessary precautions, which include:
A 32-year-old male client is a marketing representative. His job requires him to have a tremendous amount of energy during the day. He frequently uses cocaine to sustain his energy level. Lately he has increased his use of cocaine and even experimented with crack cocaine. Realizing he can no longer continue this destructive behavior, he is seeking treatment for cocaine addiction. In planning nursing care for the client’s inpatient stay, which expected outcome is most appropriate?
A 48-hour-old male infant is ordered to have phototherapy. When his mother questions the nurse about its purpose, the nurse explains that phototherapy:
A female client at 37 weeks’ gestation has just undergone a nonstress test. The results were two fetal movements with a corresponding increase in fetal heart rate (FHR) of 15 bpm lasting 15 seconds within a 20-minute period. Her results would be classified as:
A 4-week-old infant is admitted to the emergency room in respiratory distress. Which of the following statements indicates the nurse’s knowledge of the anatomy of the respiratory system in pediatric clients?
A 30-year-old female client is receiving antineoplastic chemotherapy. Which of the following symptoms should especially concern the nurse when caring for her?
Which classification of drugs is contraindicated for the client with hypertrophic cardiomyopathy?
A 12-year-old girl has been diagnosed with insulindependent diabetes mellitus. Which of these principles would best guide her nutritional management?
An 8-year-old boy has been diagnosed with hemophilia. Which of the following diagnostic blood studies is characteristically abnormal in this disorder?
A 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these nursing measures should be included in the postoperative care?
A female client is exhibiting signs of respiratory distress. Which of the following signs indicate a possible pneumothorax?
A female client presents to the obstetric-gynecology clinic for a pregnancy test, the result which turns out to be positive. Her last menstrual period began December 10, 1993. Using Nägele’s rule, the nurse estimates her date of delivery to be:
A 24-year-old male client is admitted with a diagnosis of sickle cell anemia. The nurse discusses his disease with him and emphasizes the following information:
A 44-year-old female client is receiving external radiation to her scapula for metastasis of breast cancer.
Teaching related to skin care for the client would include which of the following?
A 50-year-old male client is to receive chemotherapy. The physician’s orders include antiemetics. When planning his care, the nurse should take into consideration that antiemetics are best administered in the following way:
A normal 3-year-old child is suspected of having meningitis. The doctor has ordered a lumbar puncture. In light of this procedure and developmental characteristics of this age group, which nursing measure is most appropriate?
A female client has been diagnosed with chronic renal failure. She is a candidate for either peritoneal dialysis or hemodialysis and must make a choice between the two. Which information should the nurse give her to help her decide?
A schizophrenic client who is experiencing thoughts of having special powers states that “I am a messenger from another planet and can rule the earth.” The nurse assesses this behavior as:
On admission, the client has signs and symptoms of pulmonary edema. The nurse places the client in the most appropriate position for a client in pulmonary edema, which is:
While the RN is assessing a mother’s perineum on her 2nd postpartum day after having a vaginal delivery, the RN notes a large ecchymotic area located to the left of the mother’s perineum. Which one of the following interventions should the RN initiate at this time?
In client teaching, the nurse should emphasize that fetal damage occurs more frequently with ingestion of drugs during:
Nursing care of the infant prior to surgical closure of a meningomyelocele would include:
A cardinal symptom of the schizophrenic client is hallucinations. A nurse identifies this as a problem in the category of:
A 79-year-old client with Alzheimer’s disease is exhibiting significant memory impairment, cognitive impairment, extremely impaired judgment in social situations, and agitation when placed in a new situation or around unfamiliar people. The nurse should include the following strategy in the client’s care:
A client is in active labor and has been admitted to the labor and delivery unit. The RN has just done a sterile vaginal exam and determines that the client is dilated 5 cm, effaced 85%, and the fetus’s head is at 0 station. She asks if she could have a lumbar epidural now. The epidural is started, and the anesthetic agent used is bupivacaine (Marcaine). After the client has received her lumbar epidural, it is important for the RN to monitor her for which of the following side effects:
A male client has been hospitalized with congestive heart failure. Medical management of heart failure focuses on improving myocardial contractility. This can be achieved by administering:
A 40-year-old client is admitted to the hospital for tests to diagnose cancer. Since his admission, he has become dependent and demanding to the nursing staff. The nurse identifies this behavior as which defense mechanism?
A client suspects that she is pregnant. She reports two missed menstrual periods. The first day of her last menstrual period was August 3. Her estimated date of confinement would be:
A 6-year-old child is attending a pediatric clinic for a routine examination. What should the nurse assess for while conducting a vision screening?
A newborn infant is exhibiting signs of respiratory distress. Which of the following would the nurse recognize as the earliest clinical sign of respiratory distress?
A client who is 7 months pregnant is diagnosed with pyelonephritis. The nurse anticipates the physician ordering:
After an infant is delivered by cesarean delivery and placed on the warmer, the RN dries and assesses the infant. At 1 and 5 minutes after birth, the RN does the Apgar scoring of the infant. The RN knows that because this infant was delivered by cesarean section, he is at increased risk for having which one of the following:
A client’s congestive heart failure has been treated, and he will soon be discharged. Discharge teaching should include instruction to call the physician if he notices a 2-lb weight gain in a 24-hour period. Increased weight gain may indicate:
The nurse should facilitate bonding during the postpartum period. What should the nurse expect to observe in the taking-hold phase?
Seven days ago, a 45-year-old female client had an ileostomy. She is self-sufficient and well otherwise. Which of the following long-term objectives would be unrealistic?
At 12 hours postvaginal delivery, a female client is without complications. Which of the following assessment findings would warrant further nursing interventions?
A 45-year-old male client experiences a sense of depression because he has not yet achieved his life’s goals. His career has not been satisfying. He is still looking for the right job. His wife spends too much money, and his children seem to ignore him while being very selfish. He is tired of all of their attitudes and is considering buying a red Corvette convertible. While obtaining these data concerning the client’s feelings about his life, the nurse is able to determine he is experiencing what psychological crisis according to Erikson’s stages?
A 3-year-old child has had symptoms of influenza including fever, productive cough, nausea, vomiting, and sore throat for the past several days. In caring for a young child with symptoms of influenza, the mother must be cautioned about:
A male client has been an insulin-dependent diabetic for approximately 30 years. He frequently indulges in highsugar foods and forgets to take his insulin. He has not experienced acute diabetic emergencies over the years but is now beginning to demonstrate symptoms of diabetic peripheral neuropathy. This distresses him because dancing is one of his favorite pastimes. He decides to question his wife’s home health nurse about diabetic peripheral neuropathy. The nurse points out his noncompliance to his diabetic diet and insulin regimen. The client answers the nurse, “It has been my experience that the diabetic diet is very difficult to follow. As far as the insulin, isn’t a fellow allowed to forget now and then?” The client’s actions and response best demonstrate:
An infant weighing 15 lb has just been treated for severe diarrhea in the hospital. Discharge instructions by the nurse will include maintenance fluid requirements for the pediatric client. Which of the following values best indicates the nurse’s understanding of normal fluid requirements for this infant?
A 14-year-old teenager is demonstrating behavior indicative of an obsessive-compulsive disorder. She is obsessed with her appearance. She will not leave her room until her hair, clothes, and makeup are perfect. She always dresses immaculately. Recently, she expressed disgust over her appearance after she gained 5 lb. After observing a marked weight loss over a 2-week period, her mother suspects that she is experiencing bulimia. She eats everything on her plate, then runs to the bathroom. In interviewing the teenager, she discusses in great detail all of the events leading to her bulimia, but not her feelings. What defense mechanism is she using?
A client has been in labor 10 hours and is becoming very tired. She has dilated to 7 cm and is at 0 station with the fetus in a right occipitoposterior position. She is complaining of severe backache with each contraction. One comfort measure the nurse can employ is to:
The nurse assesses a client’s monitor strip and finds the following: uterine contractions every 3–4 minutes, lasting 60–70 seconds; FHR baseline 134–146 bpm, with accelerations to 158 bpm with fetal movement. Which nursing intervention is appropriate?
A client is being admitted to the labor and delivery unit. She has had previous admissions for “false labor.” Which clinical manifestation would be most indicative of true labor?
A newborn girl’s father expresses concern that the newborn does not have good control of her hands and arms. It is important for the father to realize certain neurological patterns that characterize the newborn:
A husband asks if he can visit with his wife on her ECT treatment days and what to expect after the initial treatment. The nurse’s best response is:
A 45-year-old male client was admitted to a chemical dependency treatment center following legal problems related to alcohol abuse. He states, “I know that alcohol is a problem for some people, but I can stop whenever I want to. I’m never sick or miss work, and no one can complain about me.” During the initial assessment, the best response by the nurse would be:
A 66-year-old female client has smoked 2 packs of cigarettes per day for 20 years. Her arterial blood gases on room air are as follows: pH 7.35; PO2 70 mm Hg; PCO2 55 mm Hg; HCO3 32 mEq/L. These blood gases reflect:
A 70-year-old client is almost finished receiving her second unit of packed red blood cells. The client, who weighs 80 lb, has started complaining of being short of breath and now has crackles in the bases of her lungs. After slowing or stopping the transfusion, the most appropriate initial nursing action would be to:
A client with cirrhosis of the liver becomes comatose and is started on neomycin 300 mg q6h via nasogastric tube. The rationale for this therapy is to:
During the active phase of rheumatic fever, the nurse teaches parents of a child with acute rheumatic fever to assist in minimizing joint pain and promoting healing by:
A 6-month-old infant who was diagnosed at 4 weeks of age with a ventricular septal defect, was admitted today with a diagnosis of failure to thrive. His mother stated that he had not been eating well for the past month. A cardiac catheterization reveals congestive heart failure. All of the following nursing diagnoses are appropriate. Which nursing diagnosis should have priority?
A 35-year-old client is receiving psychopharmacological treatment of his major depression with tranylcypromine sulfate (Parnate), a monoamine oxidase (MAO) inhibitor. The nurse teaches the client that while he is taking this type of antidepressant, he needs to restrict his dietary intake of:
A 2-year-old toddler is hospitalized with epiglottitis. In assessing the toddler, the nurse would expect to find:
Loss of appetite for a child with leukemia is a major recurrent problem. The plan of care should be designed to:
During discharge planning, parents of a child with rheumatic fever should be able to identify which of the following as toxic symptoms of sodium salicylate?
The physician decides to prescribe both a short-acting insulin and an intermediate-acting insulin for a newly diagnosed 8-year-old diabetic client. An example of a short-acting insulin is:
The parents of a 9-year-old child with acute lymphocytic leukemia expressed concern about his alopecia from cranial irradiation. The nurse explains that:
The nurse writes the following nursing diagnosis for a client in acute renal failure—Impaired gas exchange related to:
An 18-year-old girl is admitted to the hospital with a depressed skull fracture as a result of a car accident. If the nurse were to observe a rising pulse rate and lowering blood pressure, the nurse would suspect that the client:
A 42-year-old male client has been treated at an alcoholic rehabilitation center for physiological alcohol dependence. The nurse will be able to determine that he is preparing for discharge and is effectively coping with his problem when he shares with her the following information:
A 2-year-old boy is in the hospital outpatient department for observation after falling out of his crib and hitting his head. The nurse calls the physician to report:
A 28-year-old multigravida has class II heart disease. At her prenatal visit at 34 weeks’ gestation, all of the following observations are made. Which would require intervention?
A client at 6 months’ gestation complains of tiredness and dizziness. Her hemoglobin level is 10 g/dL, and her hematocrit value is 32%. Her nutritional intake is assessed as sufficient. The most likely diagnosis is:
Early in her ninth month of pregnancy, a client has been diagnosed as having mild preeclampsia. In counseling her about her diet, the nurse must emphasize the importance of:
The nurse is caring for a 3-month-old girl with meningitis. She has a positive Kernig’s sign. The nurse expects her to react to discomfort if she:
After 7 hours in restraints and a total of 30-mg haloperidol in divided doses, a client complains of stiffness in his neck and his tongue “pulling to one side.” These extrapyramidal symptoms (EPS) will most likely be relieved by the administration of:
The nurse in the mental health center is instructing a depressed client about the dietary restrictions necessary in taking her medication, which is a monoamine oxidase (MAO) inhibitor. Which of the following is she restricting from the client’s diet?
A female client at 30 weeks’ gestation is brought into the emergency department after falling down a flight of stairs. On examination, the physician notes a rigid, boardlike abdomen; FHR in the 160s; and stable vital signs. Considering possible abdominal trauma, which obstetric emergency must be anticipated?
A client states to his nurse that “I was told by the doctor not to take one of my drugs because it seems to have caused decreasing blood cells.” Based on this information, which drug might the nurse expect to be discontinued?
Which stage of labor lasts from delivery of the baby to delivery of the placenta?
A client had a cardiac catheterization with angiography and thrombolytic therapy with streptokinase. The nurse should initiate which of the following interventions immediately after he returns to his room?
A 16-year-old diabetic girl has been selected as a cheerleader at her school. She asks the nurse whether she should increase her insulin when she is planning to attend cheerleading practice sessions lasting from 8 to 11 AM. The most appropriate answer would be:
The nurse is interviewing a client with a diagnosis of possible abdominal aortic aneurysm. Which of the following statements will be reflected in the client’s chief complaint?
A client is having episodes of hyperventilation related to her surgery that is scheduled tomorrow. Appropriate nursing actions to help control hyperventilating include:
A 20-year-old male client is being treated for protein deficiency. If he likes all of the following foods, which one would the nurse recommend to increase in the diet?
A couple is experiencing difficulties conceiving a baby. The nurse explains basal body temperature (BBT) by instructing the female client to take her temperature:
A child is admitted with severe headache, fever, vomiting, photophobia, drowsiness, and stiff neck associated with viral meningitis. She will be more comfortable if the nurse:
A client hospitalized with a medical diagnosis of adjustment disorder versus personality disorder states, “Nobody cares about the clients.” The nurse’s most effective response would be:
The pediatric nurse charts that the parents of a 4-yearold child are very anxious. Which observation would indicate to the nurse unhealthy coping by these parents:
The nurse is assessing breath sounds in a bronchovesicular client. She should expect that:
A child is to receive atropine 0.15 mg (1/400 g) as part of his preoperative medication. A vial containing atropine 0.4 mg (1/150 g)/mL is on hand. How much atropine should be given?
A 17-year-old pregnant client who is gravida 1, para 0, is at 36 weeks’ gestation. Based on the nurse’s knowledge of the maternal physiological changes in pregnancy, which of these findings would be of concern?
A client has returned to the unit following a left femoral popliteal bypass graft. Six hours later, his dorsalis pedis pulse cannot be palpated, and his foot is cool and dusky. The nurse should:
A client has returned to the unit from the recovery room after having a thyroidectomy. The nurse knows that a major complication after a thyroidectomy is:
Succinylcholine chloride (Anectine) is ordered prior to electroconvulsive therapy treatment for depressed clients. The nurse explains that the purpose of the drug is to:
Because a client is taking an MAO inhibitor, it is necessary to discuss the need for adherence to a low-tyramine diet. Which of the following are foods that she should avoid?
A 29-year-old client is diagnosed with borderline personality disorder. He has aroused the nurse’s anger by using a condescending tone of voice with other clients and staff persons. Which of the following statements from the nurse would be most appropriate in acknowledging feelings regarding the client’s behavior?
A female client has been treated since childhood for mitral valve prolapse. The antibiotic of choice for her during pregnancy would be:
Due to his prolonged history of alcohol abuse, an alcoholic client will most likely have deficiencies of which of the following nutrients?
On admission to the postpartal unit, the nurse’s assessment identifies the client’s fundus to be soft, 2 fingerbreadths above the umbilicus, and deviated to the right. This is most likely an indication of:
The nurse explains perineal hygiene self-care postpartum to the client. She should be instructed to:
A client is admitted to the labor room. She is dilated 4 cm. She is placed on electric fetal monitoring. Which of the following observations necessitates notifying the physician?
The doctor has ordered a restricted fluid intake for a 2- year-old child with a head injury. Normal fluid intake for a child of 2 years is:
Following TURP, which of the following instructions would be appropriate to prevent or alleviate anxiety concerning the client’s sexual functioning?
A client has had amniocentesis. One of the tests performed on the amniotic fluid is a lecithin/sphingomyelin (L/S) ratio. The results show a ratio of 1:1. This is indicative of:
Which nursing implication is appropriate for a client undergoing a paracentesis?
A complication for which the nurse should be alert following a liver biopsy is:
Following a gastric resection, which of the following actions would the nurse reinforce with the client in order to alleviate the distress from dumping syndrome?
The nurse provides a male client with diet teaching so that he can help prevent constipation in the future. Which food choices indicate that this teaching has been understood?
The nurse is teaching a mother care of her child’s spica cast. The mother states that he complains of itching under the edge of the cast. One nonpharmacological technique the nurse might suggest would be:
A gravida 2 para 1 client delivered a full-term newborn 12 hours ago. The nurse finds her uterus to be boggy, high, and deviated to the right. The most appropriate nursing action is to:
Assessment of severe depression in a client reveals feelings of hopelessness, worthlessness; inability to feel pleasure; sleep, psychomotor, and nutritional alterations; delusional thinking; negative view of self; and feelings of abandonment. These clinical features of the client’s depression alert the nurse to prioritize problems and care by addressing which of the following problems first:
In assessing the nature of the stool of a client who has cystic fibrosis, what would the nurse expect to see?
A client is being discharged on warfarin (Coumadin), an oral anticoagulant. The nurse instructs him about using this drug. Which following response by the client indicates the need for further teaching?
The nurse observes that a client has difficulty chewing and swallowing her food. A nursing response designed to reduce this problem would include:
A 74-year-old female client is 3 days postoperative. She has an indwelling catheter and has been progressing well. While the nurse is in the room, the client states, “Oh dear, I feel like I have to urinate again!” Which of the following is the most appropriate initial nursing response?
The nurse instructs a pregnant client (G2P1) to rest in a side-lying position and avoid lying flat on her back. The nurse explains that this is to avoid “vena caval syndrome,” a condition which:
The nurse is preparing a 6-year-old child for an IV insertion. Which one of the following statements by the nurse is appropriate when preparing a child for a potentially painful procedure?
A 16-year-old student has a long history of bronchial asthma and has experienced several severe asthmatic attacks during the school year. The school nurse is required to administer 0.2 mL of 1/1000 solution of epinephrine SC during an asthma attack. How does the school nurse evaluate the effectiveness of this intervention?
A 26-year-old client is in a treatment center for aprazolam (Xanax) abuse and continues to manifest moderate levels of anxiety 3 weeks into the rehabilitation program, often requesting medication for “his nerves.” Included in the client’s plan of care is to identify alternate methods of coping with stress and anxiety other than use of medication. After intervening with assistance in stress reduction techniques, identifying feelings and past coping, the nurse evaluates the outcome as being met if:
A mother brings her 3-year-old child who is unconscious but breathing to the ER with an apparent drug overdose. The mother found an empty bottle of aspirin next to her child in the bathroom. Which nursing action is the most appropriate?
A group of nursing students at a local preschool day care center are going to screen each child’s fine and gross motor, language, and social skills. The students will use which one of the most widely used screening tests?
A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving oxytocin.
The nurse’s first intervention should be to:
A 56-year-old client is admitted to the psychiatric unit in a state of total despair. She feels hopeless and worthless, has a flat affect and very sad appearance, and is unable to feel pleasure from anything. Her husband has been assisting her at home with the housework and cooking; however, she has not been eating much, lies around or sits in a chair most of the day, and is becoming confused and thinks her family does not want her around anymore. In assessing the client, the nurse determines that her behavior is consistent with:
Assessment of parturient reveals the following: cervical dilation 6 cm and station 22; no progress in the last 4 hours. Uterine contractions decreasing in frequency and intensity. Marked molding of the presenting fetal head is described. The physician orders, “Begin oxytocin induction at 1 mU/min.” The nurse should:
A couple is planning the conception of their first child.
The wife, whose normal menstrual cycle is 34 days in length, correctly identifies the time that she is most likely to ovulate if she states that ovulation should occur on day:
A client in active labor asks the nurse for coaching with her breathing during contractions. The client has attended Lamaze birth preparation classes. Which of the following is the best response by the nurse?
In cleansing the perineal area around the site of catheter insertion, the nurse would:
A client is pregnant with her second child. Her last menstrual period began on January 15. Her expected date of delivery would be:
A 4-year-old child is being discharged from the hospital after being treated for severe croup. Which one of the following instructions should the nurse give to the child’s mother for the home treatment of croup?
The nurse would assess the client’s correct understanding of the fertility awareness methods that enhance conception, if the client stated that:
Which of the following signs might indicate a complication during the labor process with vertex presentation?
A 6-month-old infant has developmental delays. His weight falls below the 5th percentile when plotted on a growth chart. A diagnosis of failure to thrive is made. What behaviors might indicate the possibility of maternal deprivation?
A client tells the nurse that she has had a history of urinary tract infections. The nurse would do further health teaching if she verbalizes she will:
MgSO4 blood levels are monitored and the nurse would be prepared to administer the following antidote for MgSO4 side effects or toxicity:
The nurse enters the playroom and finds an 8-year-old child having a grand mal seizure. Which one of the following actions should the nurse take?
A mother is unsure about the type of toys for her 17-month-old child. Based on knowledge of growth and development, what toy would the nurse suggest?
An 83-year-old client has been hospitalized following a fall in his home. He has developed a possible fecal impaction. Which of the following assessment findings would be most indicative of a fecal impaction?
A nurse should carefully monitor a client for the following side effect of MgSO4:
To prevent fungal infections of the mouth and throat, the nurse should teach clients on inhaled steroids to:
A 40-year-old client is admitted to the coronary care unit with chest pain and shortness of breath. The physician diagnosed an anterior wall myocardial infarction.
What tests should the nurse anticipate?
A 52-year-old client who underwent an exploratory laparotomy for a bowel obstruction begins to complain of hunger on the third postoperative day. His nasogastric (NG) tube was removed this morning, and he has an IV of D5W with 0.45% normal saline running at 125 mL/hr. He asks when he can get rid of his IV and start eating. The nurse recognizes that he will be able to begin taking oral fluids and nourishment when:
On the first postpartal day, a client tells the nurse that she has been changing her perineal pads every 1/2 hour because they are saturated with bright red vaginal drainage. When palpating the uterus, the nurse assesses that it is somewhat soft, 1 fingerbreadth above the umbilicus, and midline. The nursing action to be taken is to:
A physician tells the nurse that he wants to orally intubate a client with a No. 8 endotracheal tube. The finding of normal breath sounds on the right side of the chest and diminished, distant breath sounds on the left side of the chest of a newly intubated client is probably due to:
An 18-year-old client enters the emergency room complaining of coughing, chest tightness, dyspnea, and sputum production. On physical assessment, the nurse notes agitation, nasal flaring, tachypnea, and expiratory wheezing. These signs should alert the nurse to:
The nurse recognizes that a client with the diagnosis of cholecystitis and cholelithiasis would expect to have stools that are:
A client is being discharged from the hospital today. The discharge teaching for care of her colostomy included which of the following basic principles for protecting the skin around her stoma:
A 65-year-old client who has a new colostomy is preparing for discharge from the hospital. As part of the instructions on colostomy care, the nurse explains to the client that to regulate the bowel, colostomy irrigation should be performed at the same time each day. The best time is:
A 58-year-old client on a general surgery unit is scheduled for transurethral resection of the prostate (TURP) in 2 hours. The nurse explains to the client that this procedure means:
At her first prenatal visit, a 21-year-old woman who is gravida 2, para 0, ab 1, is currently at 32 weeks’ gestation and has a history of drug abuse, smoking, and occasional ethyl alcohol use. Fetal ultrasound tests indicate poor fetal growth. The most likely reason for the infant’s intrauterine growth retardation is:
A client diagnosed with severe anemia is to receive 2 U of packed red blood cells. Prior to starting the blood transfusion, the nurse must:
A 50-year-old depressed client has recently lost his job. He has been reluctant to leave his hospital room. Nursing care would include:
A client is being treated for congestive heart failure. His medical regimen consists of digoxin (Lanoxin) 0.25 mg po daily and furosemide 20 mg po bid. Which laboratory test should the nurse monitor?
A client is hyperactive and not sleeping. She will not remain at the table during mealtime. She is getting very limited calories and is using a lot of energy in her hyperactive state. The most therapeutic nursing action is to:
A client who is a breast-feeding mother develops mastitis. The clinical signs and symptoms of mastitis include:
A client returned to the unit following a pneumonectomy. As the nurse is assessing her incision, she notices fresh blood on the dressing. The nurse should first:
A client had a renal transplant 3 months ago. He has suddenly developed graft tenderness, an increased white blood cell count, and malaise. The client is experiencing which type of rejection?
A male client is scheduled to have angiography of his left leg. The nurse needs to include which of the following when preparing the client for this procedure?
Morphine sulfate 4 mg IV push q2h prn for chest pain was ordered for a client in the emergency room with severe chest pain. The nurse administering the morphine sulfate knows which of the following therapeutic actions is related to the morphine sulfate?
The family member of a child scheduled for heart surgery states, “I just don’t understand this open-heart or closed-heart business. I’m so confused! Can you help me understand it?” The nurse explains that patent ductus arteriosus repair is:
A 20-year-old client presents to the obstetrics-gynecology clinic for the first time. She tells the nurse that she is pregnant and wants to start prenatal care. After collecting some initial assessment data, the nurse measures her fundal height to be at the level of the umbilicus. The nurse estimates the fetal gestational age to be approximately:
In an interview for suspected child abuse, the child’s mother openly discusses her feelings. She feels her husband is too aggressive in disciplining their child. The child’s father states, “Being a school custodian, I see kids every day that are bad because they did not get enough discipline at home. That will not happen to our child.” Based on this remark, the nurse would make the following nursing diagnosis:
The nurse observes a client crying quietly. She has just experienced a spontaneous abortion at nine weeks’ gestation. An appropriate response by the nurse would be:
A female client is seeking counseling for personal problems. She admits to being very unhappy lately at both home and work. During the nursing assessment, she uses many defense mechanisms. Which statement or action made by the client is an example of adaptive suppression?
A client is pregnant for the fourth time and has had three normal vaginal deliveries. She is in active labor and fully dilated. Suddenly she calls, “Nurse, the baby is coming.” As the nurse responds to her call, which one of the following observations should the nurse make first?
A murmur has been discovered during the routine physical examination of a 1-year-old child. The parent is extremely concerned about this diagnosis. Which of the following explanations by the nurse indicates understanding of this dysfunction?
A female client has experienced varying degrees of depression throughout her life. Now that she is postmenopausal, her depression has increased. She is unable to motivate herself to clean her house or even to get out of bed and get dressed in the morning. The client was begun on fluoxetine (Prozac) therapy. When educating her about fluoxetine, what might the nurse caution her about?
As the nurse assesses a male adolescent with chlamydia, the nurse determines that a sign of chlamydia is:
When a client questions the nurse as to the purpose of exercise electrocardiography (ECG) in the diagnosis of cardiovascular disorders, the nurse’s response should be based on the fact that:
A client returns for her 6-month prenatal checkup and has gained 10 lb in 2 months. The results of her physical examination are normal. How does the nurse interpret the effectiveness of the instruction about diet and weight control?
A child sustains a supracondylar fracture of the femur. When assessing for vascular injury, the nurse should be alert for the signs of ischemia, which include:
The physician orders fluoxetine (Prozac) for a depressed client. Which of the following should the nurse remember about fluoxetine?
A client with a C-3–4 fracture has just arrived in the emergency room. The primary nursing intervention is:
A 27-year-old man was diagnosed with type I diabetes 3 months ago. Two weeks ago he complained of pain, redness, and tenderness in his right lower leg. He is admitted to the hospital with a slight elevation of temperature and vague complaints of “not feeling well.” At 4:30 PM on the day of his admission, his blood glucose level is 50 mg; dinner will be served at 5:00 PM. The best nursing action would be to:
Three weeks following discharge, a male client is readmitted to the psychiatric unit for depression. His wife stated that he had threatened to kill himself with a handgun. As the nurse admits him to the unit, he says, “I wish I were dead because I am worthless to everyone; I guess I am just no good.” Which response by the nurse is most appropriate at this time?
The following medications were noted on review of the client’s home medication profile. Which of the medications would most likely potentiate or elevate serum digoxin levels?
When assessing a child with diabetes insipidus, the nurse should be aware of the cardinal signs of:
A six-month-old infant has been admitted to the emergency room with febrile seizures. In the teaching of the parents, the nurse states that:
Which of the following would differentiate acute from chronic respiratory acidosis in the assessment of the trauma client?
In a client with chest trauma, the nurse needs to evaluate mediastinal position. This can best be done by:
Provide the 1-minute Apgar score for an infant born with the following findings: Heart rate: Above 100 Respiratory effort: Slow, irregular Muscle tone: Some flexion of extremities Reflex irritability: Vigorous cry Color: Body pink, blue extremities
A schizophrenic client has made sexual overtures toward her physician on numerous occasions. During lunch, the client tells the nurse, “My doctor is in love with me and wants to marry me.” This client is using which of the following defense mechanisms?
A client confides to the nurse that he tasted poison in his evening meal. This would be an example of what type of hallucination?
Which of the following ECG changes would be seen as a positive myocardial stress test response?
To appropriately monitor therapy and client progress, the nurse should be aware that increased myocardial work and O2 demand will occur with which of the following?
A long-term goal for the nurse in planning care for a depressed, suicidal client would be to:
Which of the following risk factors associated with breast cancer would a nurse consider most significant in a client’s history?
Pregnant women with diabetes often have problems related to the effectiveness of insulin in controlling their glucose levels during their second half of pregnancy. The nurse teaches the client that this is due to:
The cardiac client who exhibits the symptoms of disorientation, lethargy, and seizures may be exhibiting a toxic reaction to:
The physician recommends immediate hospital admission for a client with PIH. She says to the nurse, “It’s not so easy for me to just go right to the hospital like that.” After acknowledging her feelings, which of these approaches by the nurse would probably be best?
When the nurse is evaluating lab data for a client 18–24 hours after a major thermal burn, the expected physiological changes would include which of the following?
Nursing care for the substance abuse client experiencing alcohol withdrawal delirium includes:
During burn therapy, morphine is primarily administered IV for pain management because this route:
A pregnant client experiences a precipitous delivery. The nursing action during a precipitous delivery is to:
A 19-year-old client has sustained a C-7 fracture, which resulted in his spinal cord being partially transected. By 2 weeks’ postinjury, his neck has been surgically stabilized, and he has been transferred from the intensive care unit. A potential life-threatening complication the nurse monitors the client for is:
A 3-month-old infant has had a unilateral cleft lip repair. He has resumed feedings of oral formula. The nurse should feed the infant with:
A client is diagnosed with organic brain disorder. The nursing care should include:
A client had a vaginal delivery 3 days ago and is discharged from the hospital on the 2nd day postpartum. She told the RN, “I need to start exercising so that I can get back into shape. Could you suggest an exercise I could begin with?’’ The RN could suggest which one of the following?
A client was not using his seat belt when involved in a car accident. He fractured ribs 5, 6, and 7 on the left and developed a left pneumothorax. Assessment findings include:
A 16-year-old client with anorexia nervosa is on an inpatient psychiatric unit. She has a fear of gaining weight and is refusing to eat sufficient amounts to maintain body weight for her age, height, and stature. To assist with the problem of powerlessness and plan for the client to no longer need to withhold food to feel in control, the nurse uses the following strategy:
The nurse working with a client who is out of control should follow a model of intervention that includes which of the following?
TESTED 02 May 2026