NCLEX-rn Exam Free Review By NCLEX Masters

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  • 1. 
    The nurse would anticipate that an eight month-old would be able to  do one or more of the following:
    • A. 

      Say two words

    • B. 

      Pull up to stand

    • C. 

      Sit without support

    • D. 

      Use a spoon


  • 2. 
    The nurse would anticipate that an eight month-old would be able to  do one or more of the following:
    • A. 

      Say two words

    • B. 

      Pull up to stand

    • C. 

      Sit without support

    • D. 

      Use a spoon


  • 3. 
    A client states, "People think I'm no good,you know what I mean? " Which nursing response would be most therapeutic for this client?
    • A. 

      " People often take their own feelings of inadequacy out on others. "

    • B. 

      " Let 's identify a few people who like you."

    • C. 

      "I' m not sure what you mean. Tell me a bit more about that. "

    • D. 

      Lets' explore what you may have done to create this impression on people


  • 4. 
    A client states, " People think I 'm no good, you know what I mean?" Which nursing response would be most therapeutic for this client?
    • A. 

      "People often take their own feelings of inadequacy out on others."

    • B. 

      "Let' s identify a few people who like you. "

    • C. 

      " I 'm not sure what you mean. Tell me a bit more about that."

    • D. 

      Lets' explore what you may have done to create this impression on people


  • 5. 
    A client calls the evening health clinic to state "I know I have a severely low sugar since the Lantus insulin was given three hours ago and it peaks in two hours." What should be the nurse 's initial response to the client?
    • A. 

      What else do you know about this type of insulin?.

    • B. 

      What are you feeling at this moment?

    • C. 

      Have you eaten anything today?

    • D. 

      Are you taking any other insulin or medication?


  • 6. 
    A client calls the evening health clinic to state "I know I have a severely low sugar since the Lantus insulin was given three hours ago and it peaks in two hours." What should be the nurse' s initial response to the client?
    • A. 

      What else do you know about this type of insulin?.

    • B. 

      What are you feeling at this moment?

    • C. 

      Have you eaten anything today?

    • D. 

      Are you taking any other insulin or medication?


  • 7. 
    A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove her dentures prior to leaving the unit for the operating room. The most appropriate intervention by the nurse is:
    • A. 

      Explain to the client that the dentures must come out as they may get lost or broken in the operating room

    • B. 

      Ask the client if there are second thoughts about the procedure

    • C. 

      Ask the client if it would be preferred to remove the dentures in the waiting room and give them to a familiy member

    • D. 

      Ask the client if it would be preferred to remove the dentures in the operating room receiving area


  • 8. 
    A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove her dentures prior to leaving the unit for the operating room. The most appropriate intervention by the nurse is:
    • A. 

      Explain to the client that the dentures must come out as they may get lost or broken in the operating room

    • B. 

      Ask the client if there are second thoughts about the procedure

    • C. 

      Ask the client if it would be preferred to remove the dentures in the waiting room and give them to a familiy member

    • D. 

      Ask the client if it would be preferred to remove the dentures in the operating room receiving area


  • 9. 
    The mother of a two year-old hospitalized child asks the nurse 's advice about the child' s screaming every time the mother gets ready to leave the hospital room. The best response of the nurse would be to:    
    • A. 

      Request for the mother to remain with the child at all times

    • B. 

      Request for the mother to remain with the child at all times

    • C. 

      Help the mother understand that this is a normal response to hospitalization

    • D. 

      Suggest that the mother "sneak out" of the child 's room when the child is asleep


  • 10. 
    Which of these actions best describes the application of time management strategies for the role of the PN charge nurse?
    • A. 

      Schedule staff efficiently to cover client needs

    • B. 

      Take a fair share of the assigned clients as a role model

    • C. 

      Set daily goals to prioritize the workload of self and others

    • D. 

      Delegate tasks to reduce workload within the team


  • 11. 
    Which of these actions best describes the application of time management strategies for the role of the PN charge nurse?
    • A. 

      Schedule staff efficiently to cover client needs

    • B. 

      Take a fair share of the assigned clients as a role model

    • C. 

      Set daily goals to prioritize the workload of self and others

    • D. 

      Delegate tasks to reduce workload within the team


  • 12. 
    A client with paranoid delusions stares at the nurse over a period of several days. The client suddenly walks up to the nurse and shouts "You think you' re so perfect and pure and good. " The appropriate response for the nurse is:  
    • A. 

      " That explains why you 've been starring at me."

    • B. 

      "You seem to be in a bad mood."

    • C. 

      "Perfect? I don' t quite understand. "

    • D. 

      " You are angry right now. "


  • 13. 
    A client with paranoid delusions stares at the nurse over a period of several days. The client suddenly walks up to the nurse and shouts " You think you 're so perfect and pure and good." The appropriate response for the nurse is:  
    • A. 

      "That explains why you' ve been starring at me. "

    • B. 

      " You seem to be in a bad mood. "

    • C. 

      " Perfect? I don't quite understand."

    • D. 

      "You are angry right now."


  • 14. 
    The health care provider order reads "aspirate nasogastric feeding (NG) tube every four hours and check pH of aspirate". The pH of the aspirate is 10. Which action should the nurse take?
    • A. 

      Hold the tube feeding and notify the provider

    • B. 

      Administer the tube feeding as scheduled

    • C. 

      Irrigate the tube with cola diet soda.

    • D. 

      Apply intermittent suction to the feeding tube


  • 15. 
    The health care provider order reads "aspirate nasogastric feeding (NG) tube every four hours and check pH of aspirate". The pH of the aspirate is 10. Which action should the nurse take?
    • A. 

      Hold the tube feeding and notify the provider

    • B. 

      Administer the tube feeding as scheduled

    • C. 

      Irrigate the tube with cola diet soda.

    • D. 

      Apply intermittent suction to the feeding tube


  • 16. 
    The nurse is reviewing a handout on infant feeding to be distributed to families visiting the clinic. Which information should be included in the teaching materials?  
    • A. 

      Solid foods are introduced one at a time beginning with cereal

    • B. 

      Finely ground meat should be started early to provide iron

    • C. 

      Egg white is added early to increase protein intake

    • D. 

      Solid foods should be mixed with formula in a bottle


  • 17. 
    The nurse is reviewing a handout on infant feeding to be distributed to families visiting the clinic. Which information should be included in the teaching materials?  
    • A. 

      Solid foods are introduced one at a time beginning with cereal

    • B. 

      Finely ground meat should be started early to provide iron

    • C. 

      Egg white is added early to increase protein intake

    • D. 

      Solid foods should be mixed with formula in a bottle


  • 18. 
    A female client is admitted for a breast biopsy. She says, tearfully to the nurse, "If this turns out to be cancer and I have to have my breast removed, my companion will never come near me." The nurse's best response would be "Are you:
    • A. 

      Questioning the depth of your relationship?"

    • B. 

      Concerned that you will be rejected? "

    • C. 

      wondering about the effect on your sexual relations?"

    • D. 

      Worried that the surgery will change you? "


  • 19. 
    A female client is admitted for a breast biopsy. She says, tearfully to the nurse, " If this turns out to be cancer and I have to have my breast removed,my companion will never come near me. " The nurse's best response would be " Are you:
    • A. 

      Questioning the depth of your relationship? "

    • B. 

      Concerned that you will be rejected?"

    • C. 

      wondering about the effect on your sexual relations? "

    • D. 

      Worried that the surgery will change you?"


  • 20. 
    A client was just taken off the ventilator following surgery and has a nasogastric tube draining bile colored liquids. Which nursing measure will provide the most comfort to the client?
    • A. 

      Allow the client to melt ice chips in the mouth

    • B. 

      Provide mints to freshen the breath

    • C. 

      Perform frequent oral care with a toothsponge

    • D. 

      Swab the mouth with glycerin swabs


  • 21. 
    A client was just taken off the ventilator following surgery and has a nasogastric tube draining bile colored liquids. Which nursing measure will provide the most comfort to the client?
    • A. 

      Allow the client to melt ice chips in the mouth

    • B. 

      Provide mints to freshen the breath

    • C. 

      Perform frequent oral care with a toothsponge

    • D. 

      Swab the mouth with glycerin swabs


  • 22. 
    The parents of a four year-old hospitalized child tell the nurse they will leave for a time and return at 6 PM. When the child asks when the parents will come again,the nurse can best respond by saying:
    • A. 

      "They will be back right after supper."

    • B. 

      "In about two hours, you will see them."

    • C. 

      "After you play awhile, they will be here."

    • D. 

      D) "When the clock hands are on six and twelve."


  • 23. 
    The parents of a four year-old hospitalized child tell the nurse they will leave for a time and return at 6 PM. When the child asks when the parents will come again, the nurse can best respond by saying:
    • A. 

      "They will be back right after supper."

    • B. 

      "In about two hours, you will see them."

    • C. 

      "After you play awhile, they will be here."

    • D. 

      D) "When the clock hands are on six and twelve."


  • 24. 
    The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir (Zovirax) for a Herpes Simplex Virus type 2 infection. The nurse should be sure to include which information?
    • A. 

      Complete the entire course of the medication for an effective cure

    • B. 

      Begin treatment with acyclovir at the onset of findings of recurrence

    • C. 

      Stop treatment if she thinks she may be pregnant to prevent birth defects

    • D. 

      Continue to take prophylactic doses for at least five years after the diagnosis


  • 25. 
    The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir (Zovirax) for a Herpes Simplex Virus type 2 infection. The nurse should be sure to include which information?
    • A. 

      Complete the entire course of the medication for an effective cure

    • B. 

      Begin treatment with acyclovir at the onset of findings of recurrence

    • C. 

      Stop treatment if she thinks she may be pregnant to prevent birth defects

    • D. 

      Continue to take prophylactic doses for at least five years after the diagnosis


  • 26. 
    A client is admitted to the emergency room following an acute asthma attack. Which of the following findings would be most important to report?
    • A. 

      Diffuse, inspiratory wheezing

    • B. 

      Loose, productive cough

    • C. 

      Lengthened expiratory phase

    • D. 

      Expiratory wheezing


  • 27. 
    A client is admitted to the emergency room following an acute asthma attack. Which of the following findings would be most important to report?
    • A. 

      Diffuse, inspiratory wheezing

    • B. 

      Loose, productive cough

    • C. 

      Lengthened expiratory phase

    • D. 

      Expiratory wheezing


  • 28. 
    In the last 48 hours of life, a hospice client may complain of dry mouth from a poor fluid intake. The nurse should only offer to moisten the mouth because:
    • A. 

      The client can aspirate on thin liquids

    • B. 

      Increased hydration can prolong discomfort

    • C. 

      renal function cannot handle the extra fluids

    • D. 

      The venous system cannot accommodate fluids.


  • 29. 
    In the last 48 hours of life, a hospice client may complain of dry mouth from a poor fluid intake. The nurse should only offer to moisten the mouth because:
    • A. 

      The client can aspirate on thin liquids

    • B. 

      Increased hydration can prolong discomfort

    • C. 

      renal function cannot handle the extra fluids

    • D. 

      The venous system cannot accommodate fluids.


  • 30. 
    A child, injured on the school playground, appears to have a fractured leg. The first action the school nurse should take is
    • A. 

      Call for emergency transport to the hospital

    • B. 

      Immobilize the limb and joints above and below the injury

    • C. 

      Assess the child and the extent of the injury

    • D. 

      Apply cold compresses to the injured area


  • 31. 
    A child, injured on the school playground, appears to have a fractured leg. The first action the school nurse should take is
    • A. 

      Call for emergency transport to the hospital

    • B. 

      Immobilize the limb and joints above and below the injury

    • C. 

      Assess the child and the extent of the injury

    • D. 

      Apply cold compresses to the injured area


  • 32. 
    An important goal in the development of a therapeutic inpatient milieu is providing a A) businesslike atmosphere where clients can work on individual goals forum in which clients deB) group cide on unit rules, regulations, and policies
    • A. 

      businesslike atmosphere where clients can work on individual goals

    • B. 

      Group forum in which clients decide on unit rules, regulations, and policies

    • C. 

      Testing ground for new patterns of behavior for which the client takes responsibility

    • D. 

      Discouragment for expressions of anger because they can be disruptive to other clients


  • 33. 
    An important goal in the development of a therapeutic inpatient milieu is providing a A) businesslike atmosphere where clients can work on individual goals forum in which clients deB) group cide on unit rules, regulations, and policies
    • A. 

      businesslike atmosphere where clients can work on individual goals

    • B. 

      Group forum in which clients decide on unit rules, regulations, and policies

    • C. 

      Testing ground for new patterns of behavior for which the client takes responsibility

    • D. 

      Discouragment for expressions of anger because they can be disruptive to other clients


  • 34. 
    The nurse is collecting data on a client with a stage 2 skin ulcer. Which treatment is considered most effective to promote healing?
    • A. 

      Covering the wound with a dry dressing

    • B. 

      Using hydrogen peroxide soaks

    • C. 

      Leaving the area open to dry

    • D. 

      Applying a transparent film cover


  • 35. 
    The nurse is collecting data on a client with a stage 2 skin ulcer. Which treatment is considered most effective to promote healing?
    • A. 

      Covering the wound with a dry dressing

    • B. 

      Using hydrogen peroxide soaks

    • C. 

      Leaving the area open to dry

    • D. 

      Applying a transparent film cover


  • 36. 
    The nurse is caring for a four year-old two hours after tonsillectomy and adenoidectomy. Which observation must be reported immediately?
    • A. 

      Vomiting of dark brown emesis

    • B. 

      Complaints of throat pain

    • C. 

      Apical heart rate of 110

    • D. 

      Increased restlessness


  • 37. 
    The nurse is caring for a four year-old two hours after tonsillectomy and adenoidectomy. Which observation must be reported immediately?
    • A. 

      Vomiting of dark brown emesis

    • B. 

      Complaints of throat pain

    • C. 

      Apical heart rate of 110

    • D. 

      Increased restlessness


  • 38. 
    The nurse is assisting with a pre-kindergarten physical on a five year-old. The last MMR vaccine will be administered. Allergy to which item might be a contraindication to giving the vaccine?
    • A. 

      Chocolate

    • B. 

      Peanut butter

    • C. 

      Eggs

    • D. 

      Strawberries


  • 39. 
    The nurse is assisting with a pre-kindergarten physical on a five year-old. The last MMR vaccine will be administered. Allergy to which item might be a contraindication to giving the vaccine?
    • A. 

      Chocolate

    • B. 

      Peanut butter

    • C. 

      Eggs

    • D. 

      Strawberries


  • 40. 
    A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit the nurse observes the client smacking the lips alternately with grinding of the teeth. The nurse assesses this as
    • A. 

      Dystonia

    • B. 

      Akathesia

    • C. 

      Brady dysknesia

    • D. 

      Tardive dyskinesia


  • 41. 
    A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit the nurse observes the client smacking the lips alternately with grinding of the teeth. The nurse assesses this as
    • A. 

      Dystonia

    • B. 

      Akathesia

    • C. 

      Brady dysknesia

    • D. 

      Tardive dyskinesia


  • 42. 
    A 14 month-old child ingested half a bottle of aspirin tablets. Which finding would the nurse expect to see in the child?
    • A. 

      Hypothermia

    • B. 

      Dysopnea

    • C. 

      Dizziness

    • D. 

      Epistaxis


  • 43. 
    A 14 month-old child ingested half a bottle of aspirin tablets. Which finding would the nurse expect to see in the child?
    • A. 

      Hypothermia

    • B. 

      Dysopnea

    • C. 

      Dizziness

    • D. 

      Epistaxis


  • 44. 
    The nurse is reinforcing instructions for a client with asthma. Which item should be stressed for the client to monitor on a daily basis?
    • A. 

      Respiratory rate

    • B. 

      Peak air flow volumes

    • C. 

      Pulse oximetry

    • D. 

      Skin color


  • 45. 
    The nurse is reinforcing instructions for a client with asthma. Which item should be stressed for the client to monitor on a daily basis?
    • A. 

      Respiratory rate

    • B. 

      Peak air flow volumes

    • C. 

      Pulse oximetry

    • D. 

      Skin color


  • 46. 
    A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to
    • A. 

      Have the client identify coping methods

    • B. 

      Get the description of the location and intensity of the pain

    • C. 

      Accept the client's report of pain

    • D. 

      Determine the client's status of pain


  • 47. 
    A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to
    • A. 

      Have the client identify coping methods

    • B. 

      Get the description of the location and intensity of the pain

    • C. 

      Accept the client's report of pain

    • D. 

      Determine the client's status of pain


  • 48. 
    The nurse is observing a client with an obsessive-compulsive disorder in an inpatient setting. Which behavior is consistent with this diagnosis?
    • A. 

      Repeatedly checking that the door is locked

    • B. 

      Verbalized suspicions about thefts

    • C. 

      Preference for consistent care givers

    • D. 

      Repetitive, involuntary movements


  • 49. 
    The nurse is observing a client with an obsessive-compulsive disorder in an inpatient setting. Which behavior is consistent with this diagnosis?
    • A. 

      Repeatedly checking that the door is locked

    • B. 

      Verbalized suspicions about thefts

    • C. 

      Preference for consistent care givers

    • D. 

      Repetitive, involuntary movements


  • 50. 
    Which one of these tasks could be assigned to the certified nursing assistant (cna)? 
    • A. 

      Feeding a client who has difficulty swallowing after a stroke

    • B. 

      Giving enemas until clear to a middle-aged man scheduled for a colonoscopy

    • C. 

      Performing a post-op dressing change

    • D. 

      Assisting a client with colostomy care 24 hours after surgery


  • 51. 
    Which one of these tasks could be assigned to the certified nursing assistant (cna)? 
    • A. 

      Feeding a client who has difficulty swallowing after a stroke

    • B. 

      Giving enemas until clear to a middle-aged man scheduled for a colonoscopy

    • C. 

      Performing a post-op dressing change

    • D. 

      Assisting a client with colostomy care 24 hours after surgery


  • 52. 
    A client refuses to take the medication prescribed because the client prefers to take an herbal preparation. What is the first action the nurse should take?
    • A. 

      Report the behavior to the charge nurse

    • B. 

      Talk with the client to find out about the preferred herbal preparation

    • C. 

      Contact the client's health care provider about the refusal

    • D. 

      Explain the importance of the medication to the client


  • 53. 
    A client refuses to take the medication prescribed because the client prefers to take an herbal preparation. What is the first action the nurse should take?
    • A. 

      Report the behavior to the charge nurse

    • B. 

      Talk with the client to find out about the preferred herbal preparation

    • C. 

      Contact the client's health care provider about the refusal

    • D. 

      Explain the importance of the medication to the client


  • 54. 
    Which statement by the nurse is appropriate when asking an unlicensed assistive personnel (UAP) to assist a 69 year-old surgical client to ambulate for the first time?
    • A. 

      "Have the client sit on the side of the bed before starting to walk in the room."

    • B. 

      "If the client is dizzy on standing, ask the client to take some deep breaths."

    • C. 

      "Assist the client to the bathroom at least twice."

    • D. 

      "After you assist the client to the chair, let me know if any complaints of abnormal feelings by the client."


  • 55. 
    Which statement by the nurse is appropriate when asking an unlicensed assistive personnel (UAP) to assist a 69 year-old surgical client to ambulate for the first time?
    • A. 

      "Have the client sit on the side of the bed before starting to walk in the room."

    • B. 

      "If the client is dizzy on standing, ask the client to take some deep breaths."

    • C. 

      "Assist the client to the bathroom at least twice."

    • D. 

      "After you assist the client to the chair, let me know if any complaints of abnormal feelings by the client."


  • 56. 
    If a nurse is uncertain about whether he or she is licensed to perform certain tasks, they should first check information in which of these resources?
    • A. 

      The nurse practice act of the state in which they practice

    • B. 

      With a nursing colleague from the local nursing program

    • C. 

      The guidelines of the unit that they work in

    • D. 

      The health care agency's policies


  • 57. 
    If a nurse is uncertain about whether he or she is licensed to perform certain tasks, they should first check information in which of these resources?
    • A. 

      The nurse practice act of the state in which they practice

    • B. 

      With a nursing colleague from the local nursing program

    • C. 

      The guidelines of the unit that they work in

    • D. 

      The health care agency's policies


  • 58. 
    A nurse who works at an extended care facility has just reviewed a new medication order which is not legible. Which statement best reflects assertive communication to the health care provider who wrote the order?
    • A. 

      "I cannot give this medication as you have written it."

    • B. 

      "Would you please clarify what you have written so I am sure I am reading it correctly?"

    • C. 

      "I am having difficulty reading your handwriting. It would save me time if you would be more careful."

    • D. 

      "Please print in the future so I do not have to spend extra time trying to read your writing."


  • 59. 
    A nurse who works at an extended care facility has just reviewed a new medication order which is not legible. Which statement best reflects assertive communication to the health care provider who wrote the order?
    • A. 

      "I cannot give this medication as you have written it."

    • B. 

      "Would you please clarify what you have written so I am sure I am reading it correctly?"

    • C. 

      "I am having difficulty reading your handwriting. It would save me time if you would be more careful."

    • D. 

      "Please print in the future so I do not have to spend extra time trying to read your writing."


  • 60. 
    A client with a diagnosis of bipolar disorder has been referred to a local boarding home to be considered for placement. The social worker telephoned the hospital unit for information about the client's mental status and adjustment. The nurse should know that the most acceptable is : 
    • A. 

      Referral information can only be provided by health care providers

    • B. 

      The nurse can never give information about a client to anyone by telephone

    • C. 

      Since this is a referral, the nurse can give the social worker the needed information

    • D. 

      The nurse will need to check for or get the client's written consent before the release of any information


  • 61. 
    A client with a diagnosis of bipolar disorder has been referred to a local boarding home to be considered for placement. The social worker telephoned the hospital unit for information about the client's mental status and adjustment. The nurse should know that the most acceptable is : 
    • A. 

      Referral information can only be provided by health care providers

    • B. 

      The nurse can never give information about a client to anyone by telephone

    • C. 

      Since this is a referral, the nurse can give the social worker the needed information

    • D. 

      The nurse will need to check for or get the client's written consent before the release of any information


  • 62. 
    A client who has just joined a health maintenance organization (HMO) asks for information about the payment obligations with this plan. The most accurate description of health care costs is that the client will be charged
    • A. 

      Just for services provided by specialists

    • B. 

      A flat rate for each service rendered

    • C. 

      A pre-determined fee for all services

    • D. 

      A usual and customary fee for services


  • 63. 
    A client who has just joined a health maintenance organization (HMO) asks for information about the payment obligations with this plan. The most accurate description of health care costs is that the client will be charged
    • A. 

      Just for services provided by specialists

    • B. 

      A flat rate for each service rendered

    • C. 

      A pre-determined fee for all services

    • D. 

      A usual and customary fee for services


  • 64. 
    A nurse arranges for an interpreter to assist with communication between the health care team and a non-English speaking client. To promote therapeutic communication when working with an interpreter, the utmost thing for the nurse to remember is to :
    • A. 

      Focus on the client's verbal and nonverbal exchange

    • B. 

      Speak only a few sentences at a time to the interpreter

    • C. 

      Plan for the session to take more time

    • D. 

      Ask the interpreter to speak slowly


  • 65. 
    A nurse arranges for an interpreter to assist with communication between the health care team and a non-English speaking client. To promote therapeutic communication when working with an interpreter, the utmost thing for the nurse to remember is to :
    • A. 

      Focus on the client's verbal and nonverbal exchange

    • B. 

      Speak only a few sentences at a time to the interpreter

    • C. 

      Plan for the session to take more time

    • D. 

      Ask the interpreter to speak slowly


  • 66. 
    Which of the followwing entries in the progress notes of a client is the most complete?
    • A. 

      Demerol 75mg administered for severe abdominal pain

    • B. 

      Client seems anxious about low salt diet preparation at home

    • C. 

      Dark green drainage of 100 ml from nasogastric tube in the last four hours

    • D. 

      Client's urinary output adequate for the age group


  • 67. 
    Which of the followwing entries in the progress notes of a client is the most complete?
    • A. 

      Demerol 75mg administered for severe abdominal pain

    • B. 

      Client seems anxious about low salt diet preparation at home

    • C. 

      Dark green drainage of 100 ml from nasogastric tube in the last four hours

    • D. 

      Client's urinary output adequate for the age group


  • 68. 
    Privacy and confidentiality of client information is legally protected. In which of these situations would the nurse make an exception to this practice?
    • A. 

      A family member offers information about their loved one

    • B. 

      The client threatens self-harm and/or harm to others

    • C. 

      The nurse decides that the family has a right to know the client's diagnosis

    • D. 

      A visitor insists that the client has given permission to write the client's story


  • 69. 
    Privacy and confidentiality of client information is legally protected. In which of these situations would the nurse make an exception to this practice?
    • A. 

      A family member offers information about their loved one

    • B. 

      The client threatens self-harm and/or harm to others

    • C. 

      The nurse decides that the family has a right to know the client's diagnosis

    • D. 

      A visitor insists that the client has given permission to write the client's story


  • 70. 
    The nurse should be informed about cultural issues related to the client's background because one of the following:
    • A. 

      Normal patterns of behavior may be labeled as deviant, immoral, or insane

    • B. 

      The meaning of the client's behavior can be derived from conventional wisdom

    • C. 

      The nurse should rely on personal values and other staff member observations

    • D. 

      The nurse should rely on knowledge of developmental mental stages


  • 71. 
    The nurse should be informed about cultural issues related to the client's background because one of the following:
    • A. 

      Normal patterns of behavior may be labeled as deviant, immoral, or insane

    • B. 

      The meaning of the client's behavior can be derived from conventional wisdom

    • C. 

      The nurse should rely on personal values and other staff member observations

    • D. 

      The nurse should rely on knowledge of developmental mental stages


  • 72. 
    A client frequently compliments the nurse and invites the nurse to go to a movie and dinner. The nurse should take which approach?
    • A. 

      Minimize further interaction with the client

    • B. 

      Tell the client that this behavior is inappropriate

    • C. 

      Inform the client that hospital policy prohibits dating clients

    • D. 

      Talk about the boundaries of the relationship with the client


  • 73. 
    A client frequently compliments the nurse and invites the nurse to go to a movie and dinner. The nurse should take which approach?
    • A. 

      Minimize further interaction with the client

    • B. 

      Tell the client that this behavior is inappropriate

    • C. 

      Inform the client that hospital policy prohibits dating clients

    • D. 

      Talk about the boundaries of the relationship with the client


  • 74. 
    After working with a very demanding client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that client. I just can't do anything that pleases him. I'm not going in there again." The nurse's appropriate response should be
    • A. 

      "He has a lot of problems. You need to be patient with him."

    • B. 

      "I will talk with him and try to figure out what to do."

    • C. 

      "He is scared and taking it out on you. Let's try to figure out what to do."

    • D. 

      "Ignore him and get the rest of your work done. Someone else can care for him."


  • 75. 
    After working with a very demanding client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that client. I just can't do anything that pleases him. I'm not going in there again." The nurse's appropriate response should be
    • A. 

      "He has a lot of problems. You need to be patient with him."

    • B. 

      "I will talk with him and try to figure out what to do."

    • C. 

      "He is scared and taking it out on you. Let's try to figure out what to do."

    • D. 

      "Ignore him and get the rest of your work done. Someone else can care for him."


  • 76. 
    A nurse has been named in a lawsuit. The best evidence a nurse can use for self- protection in a court of law is which of these items?
    • A. 

      Clinical certification in a nursing specialty

    • B. 

      Documentation of nursing own actions on the client's record

    • C. 

      Proficiency reports about the nurse prepared by the nurse manager

    • D. 

      Verification of orders for the plan of care on a daily basis


  • 77. 
    A nurse has been named in a lawsuit. The best evidence a nurse can use for self- protection in a court of law is which of these items?
    • A. 

      Clinical certification in a nursing specialty

    • B. 

      Documentation of nursing own actions on the client's record

    • C. 

      Proficiency reports about the nurse prepared by the nurse manager

    • D. 

      Verification of orders for the plan of care on a daily basis


  • 78. 
    Which one of these tasks for a 69 year-old client with a diagnosis of hyperglycemia could the nurse assign to the unlicensed assistive personnel (UAP)?
    • A. 

      Test blood sugar every 2 hours

    • B. 

      Reinforce findings of hyperglycemia

    • C. 

      Observe for mental status changes

    • D. 

      Check sensation in the extremities


  • 79. 
    Which one of these tasks for a 69 year-old client with a diagnosis of hyperglycemia could the nurse assign to the unlicensed assistive personnel (UAP)?
    • A. 

      Test blood sugar every 2 hours

    • B. 

      Reinforce findings of hyperglycemia

    • C. 

      Observe for mental status changes

    • D. 

      Check sensation in the extremities


  • 80. 
    A client is admitted with a diagnosis of schizophrenia. The client states "I don't need medication. It makes me sleepy." The client insists that the nurse explain the use and side effects of the medication. The nurse should understand that the best intervention is:
    • A. 

      The nurse should refer the client to the psychiatrist for answers about medication

    • B. 

      The client has a right to know about any prescribed or over-the-counter medications

    • C. 

      It is the nurse's decision to reinforce or not reinforce information about medications

    • D. 

      It is dangerous for clients with schizophrenia to know about medications


  • 81. 
    A client is admitted with a diagnosis of schizophrenia. The client states "I don't need medication. It makes me sleepy." The client insists that the nurse explain the use and side effects of the medication. The nurse should understand that the best intervention is:
    • A. 

      The nurse should refer the client to the psychiatrist for answers about medication

    • B. 

      The client has a right to know about any prescribed or over-the-counter medications

    • C. 

      It is the nurse's decision to reinforce or not reinforce information about medications

    • D. 

      It is dangerous for clients with schizophrenia to know about medications


  • 82. 
    A client tells the nurse, "I have something very important to tell you if you promise not to tell anyone." The appropriate response by the nurse would be
    • A. 

      "I must report everything to the treatment team."

    • B. 

      "That depends on what you tell me."

    • C. 

      "I can't make such a promise."

    • D. 

      "All right, I promise."


  • 83. 
    A client tells the nurse, "I have something very important to tell you if you promise not to tell anyone." The appropriate response by the nurse would be
    • A. 

      "I must report everything to the treatment team."

    • B. 

      "That depends on what you tell me."

    • C. 

      "I can't make such a promise."

    • D. 

      "All right, I promise."


  • 84. 
    Which newly admitted client would be most appropriate to assign to the unlicensed assistive personnel (UAP)?
    • A. 

      A heroin addict in the process of withdrawal

    • B. 

      An adolescent with dehydration and anorexia

    • C. 

      A client with chronic peripheral vascular disease

    • D. 

      A 76 year-old client with severe depression


  • 85. 
    The nurse should begin considering discharge concerns for a hospitalized client considering one fo of the following:
    • A. 

      With the client or family demonstrating readiness to learn self care modalities

    • B. 

      With the health care provider designating a discharge date

    • C. 

      During the admission process in the emergency room or on the assigned unit

    • D. 

      When the client's condition is stabilized for at least 24 hours


  • 86. 
    Which newly admitted client would be most appropriate to assign to the unlicensed assistive personnel (UAP)?
    • A. 

      A heroin addict in the process of withdrawal

    • B. 

      An adolescent with dehydration and anorexia

    • C. 

      A client with chronic peripheral vascular disease

    • D. 

      A 76 year-old client with severe depression


  • 87. 
    When a client is diagnosed with tuberculosis, the public health department is to be notified for what reason?
    • A. 

      Disease statistics need to be maintained by healthcare authorities

    • B. 

      Contacts need to be traced and screened for follow ups

    • C. 

      The incidence of tuberculosis is on the rise in USA

    • D. 

      Follow-up with additional tests are required by healthcare law


  • 88. 
    The nurse should begin considering discharge concerns for a hospitalized client considering one fo of the following:
    • A. 

      With the client or family demonstrating readiness to learn self care modalities

    • B. 

      With the health care provider designating a discharge date

    • C. 

      During the admission process in the emergency room or on the assigned unit

    • D. 

      When the client's condition is stabilized for at least 24 hours


  • 89. 
    A 5 years old child has been admitted to the pediatric unit after swallowing a household cleaner. Which of these findings is more commonly associated with the fact that the poison was a corrosive?
    • A. 

      Burning mouth and throat pain

    • B. 

      Bradycardia and orthopnea

    • C. 

      Oliguria and cyanosis

    • D. 

      Diarrhea and vomiting


  • 90. 
    When a client is diagnosed with tuberculosis, the public health department is to be notified for what reason?
    • A. 

      Disease statistics need to be maintained by healthcare authorities

    • B. 

      Contacts need to be traced and screened for follow ups

    • C. 

      The incidence of tuberculosis is on the rise in USA

    • D. 

      Follow-up with additional tests are required by healthcare law


  • 91. 
    Which of these actions is the first priority in the prevention of infections, whether in the hospital or home setting?
    • A. 

      Handwashing

    • B. 

      Use of antibacterial soaps

    • C. 

      Sneeze into the elbow with a bent arm

    • D. 

      Wash the hands before eating


  • 92. 
    A 14 years child goes into seizures. Which nursing action is a priority for a client during a seizure
    • A. 

      Protect the client from injury

    • B. 

      Observe the movements

    • C. 

      Loosen restrictive clothing

    • D. 

      Suction the mouth


  • 93. 
    X-RN A client with a diagnosis of methicillin resistant staphylococcus aureus (MRSA) has died. Which type of transmission-based precautions is the appropriate type to use when performing postmortem care?
    • A. 

      Airborne precautions

    • B. 

      Droplet precautions

    • C. 

      Contact precautions

    • D. 

      Compromised host precautions


  • 94. 
    Several clients are admitted to an adult medical unit. The nurse would expect airborne precautions for a client with which of the following medical conditions?
    • A. 

      A diagnosis of AIDS with cytomegalovirus

    • B. 

      A positive purified protein derivative (PPD) test with an abnormal chest x-ray

    • C. 

      A tentative diagnosis of viral pneumonia

    • D. 

      Advanced carcinoma of the lung


  • 95. 
    A 5 years old child has been admitted to the pediatric unit after swallowing a household cleaner. Which of these findings is more commonly associated with the fact that the poison was a corrosive?
    • A. 

      Burning mouth and throat pain

    • B. 

      Bradycardia and orthopnea

    • C. 

      Oliguria and cyanosis

    • D. 

      Diarrhea and vomiting


  • 96. 
    A three year-old child is treated in the emergency room after ingestion of an ounce from a liquid narcotic bottle. What action should the nurse take first?
    • A. 

      Provide humidified oxygen via mask

    • B. 

      Suction mouth and nose if needed

    • C. 

      Check the airway and breathing effort

    • D. 

      Obtain a radial and apical pulse


  • 97. 
    Which of these actions is the first priority in the prevention of infections, whether in the hospital or home setting?
    • A. 

      Handwashing

    • B. 

      Use of antibacterial soaps

    • C. 

      Sneeze into the elbow with a bent arm

    • D. 

      Wash the hands before eating


  • 98. 
    A school nurse plans to reinforce information about the most effective methods to prevent the spread of head lice in school age children at a teacher's conference . The most appropriate information to give would be that
    • A. 

      The classroom should be sprayed with an insecticide at the end of each day

    • B. 

      Handwashing should be done before and after each break by each child

    • C. 

      The children are not to share hats and scarves

    • D. 

      The heads of children are to be checked weekly for lice


  • 99. 
    A 14 years child goes into seizures. Which nursing action is a priority for a client during a seizure
    • A. 

      Protect the client from injury

    • B. 

      Observe the movements

    • C. 

      Loosen restrictive clothing

    • D. 

      Suction the mouth


  • 100. 
    Which of these protocols would be essential for the nurse to implement during the care of a client with active tuberculosis?
    • A. 

      With the client in a room with another client with tuberculosis use personal protective equipment

    • B. 

      With the client in a negative pressure room use masks, gloves and gowns

    • C. 

      With the client in a private room wear masks, gloves and gowns

    • D. 

      With the client in a negative pressure room use customized respirators


  • 101. 
    X-RN A client with a diagnosis of methicillin resistant staphylococcus aureus (MRSA) has died. Which type of transmission-based precautions is the appropriate type to use when performing postmortem care?
    • A. 

      Airborne precautions

    • B. 

      Droplet precautions

    • C. 

      Contact precautions

    • D. 

      Compromised host precautions


  • 102. 
    The mother of an infant who is being treated for pesticide poisoning asks why activated charcoal is the treatment. What is the nurse's best response?
    • A. 

      "Activated charcoal stimulates bowel evacuation. By doing so it decreases the systemic absorption of the poison."

    • B. 

      "The charcoal absorbs the poison and forms a compound that doesn't hurt a child."

    • C. 

      "The charcoal absorbs the poison and forms a compound that doesn't hurt a child."

    • D. 

      "When it is absorbed into the blood stream, activated charcoal neutralizes the poison."


  • 103. 
    Several clients are admitted to an adult medical unit. The nurse would expect airborne precautions for a client with which of the following medical conditions?
    • A. 

      A diagnosis of AIDS with cytomegalovirus

    • B. 

      A positive purified protein derivative (PPD) test with an abnormal chest x-ray

    • C. 

      A tentative diagnosis of viral pneumonia

    • D. 

      Advanced carcinoma of the lung


  • 104. 
    Which nursing diagnosis would indicate that an 86 year-old client is at greatest risk for falls?
    • A. 

      Sensory perceptual alterations related to decreased vision

    • B. 

      Alteration in mobility related to fatigue

    • C. 

      Impaired gas exchange related to retained secretions

    • D. 

      Altered patterns of urinary elimination related to nocturia


  • 105. 
    A three year-old child is treated in the emergency room after ingestion of an ounce from a liquid narcotic bottle. What action should the nurse take first?
    • A. 

      Provide humidified oxygen via mask

    • B. 

      Suction mouth and nose if needed

    • C. 

      Check the airway and breathing effort

    • D. 

      Obtain a radial and apical pulse


  • 106. 
    In addition to handwashing, an appropriate infection control intervention during the care of a newly admitted adult client with a diagnosis of Hepatitis A would be which action?
    • A. 

      Use of a HEPA filter personal protection device

    • B. 

      Keep the door of the room closed

    • C. 

      Wear a gown and gloves to change any linens

    • D. 

      Use gloves when handling the client's bedpan or urinal


  • 107. 
    A school nurse plans to reinforce information about the most effective methods to prevent the spread of head lice in school age children at a teacher's conference . The most appropriate information to give would be that
    • A. 

      The classroom should be sprayed with an insecticide at the end of each day

    • B. 

      Handwashing should be done before and after each break by each child

    • C. 

      The children are not to share hats and scarves

    • D. 

      The heads of children are to be checked weekly for lice


  • 108. 
    The nurse is assigned to a client with HIV infection. The client also has a secondary herpes simplex 1 (HSV 1) infection. The nurse knows that the most likely cause of the HSV 1 infection is which of these items?
    • A. 

      Immunosuppression caused by the HIV infection

    • B. 

      Emotional stress caused by the chronic diseases

    • C. 

      Reaction to the the prescribed medications

    • D. 

      Poor oral hygiene often associated with these infections


  • 109. 
    A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which of these nursing actions should the nurse expect to do first?
    • A. 

      Institute seizure precautions

    • B. 

      Identify baseline neurologic status

    • C. 

      Place on airborne precautions

    • D. 

      Check vital signs


  • 110. 
    A nurse is reinforcing teaching with a client about compromised host precautions. The client is receiving filgrastim (Neupogen) for neutropenia. The selection of which lunch suggests the client has learned about necessary dietary changes?
    • A. 

      Grilled chicken sandwich and skim milk

    • B. 

      Roast beef, mashed potatoes, and green beans

    • C. 

      Peanut butter sandwich, banana, and iced tea

    • D. 

      Barbeque beef, baked beans, and cole slaw


  • 111. 
    The nurse is responsible for assisting in the decisions about client room assignments. Which of these possible roommates would be most appropriate for a three year-old child with minimal change nephrotic syndrome?
    • A. 

      Two year-old with respiratory infection

    • B. 

      Three year-old fracture whose sibling has chickenpox

    • C. 

      Four year-old with bilateral inguinal hernia repair

    • D. 

      Six year-old with a sickle cell anemia crisis


  • 112. 
    A ten year-old child has a history of tonic-clonic seizures. The school nurse should instruct the classroom teacher that if the child experiences a seizure in the classroom, the most important action during the seizure activity would be to
    • A. 

      Avoid the insertion of anything in the mouth

    • B. 

      Maintain the child in a supine position

    • C. 

      Provide privacy to prevent embarrassment

    • D. 

      Protect the child from self injury


  • 113. 
    Which of these protocols would be essential for the nurse to implement during the care of a client with active tuberculosis?
    • A. 

      With the client in a room with another client with tuberculosis use personal protective equipment

    • B. 

      With the client in a negative pressure room use masks, gloves and gowns

    • C. 

      With the client in a private room wear masks, gloves and gowns

    • D. 

      With the client in a negative pressure room use customized respirators


  • 114. 
    An outpatient client is scheduled to receive an oral solution of radioactive iodine. In order to reduce hazards, the nurse should reinforce to the client that
    • A. 

      Urine and saliva will be radioactive for 24 hours

    • B. 

      No special precautions will be necessary

    • C. 

      No special precautions will be necessary

    • D. 

      Guests to the client's home are restricted for 48 hours


  • 115. 
    The mother of an infant who is being treated for pesticide poisoning asks why activated charcoal is the treatment. What is the nurse's best response?
    • A. 

      "Activated charcoal stimulates bowel evacuation. By doing so it decreases the systemic absorption of the poison."

    • B. 

      "The charcoal absorbs the poison and forms a compound that doesn't hurt a child."

    • C. 

      "The charcoal absorbs the poison and forms a compound that doesn't hurt a child."

    • D. 

      "When it is absorbed into the blood stream, activated charcoal neutralizes the poison."


  • 116. 
    What is the primary nursing intervention to limit transmission of organisms for a client with a salmonella infection?
    • A. 

      Wash hands thoroughly before and after any client contact

    • B. 

      Wear gloves when in contact with body secretions

    • C. 

      Double glove when in contact with feces or vomitus

    • D. 

      Wear gloves when disposing of contaminated linens


  • 117. 
    Which nursing diagnosis would indicate that an 86 year-old client is at greatest risk for falls?
    • A. 

      Sensory perceptual alterations related to decreased vision

    • B. 

      Alteration in mobility related to fatigue

    • C. 

      Impaired gas exchange related to retained secretions

    • D. 

      Altered patterns of urinary elimination related to nocturia


  • 118. 
    A two month-old infant has both a cleft lip and palate which will be repaired in stages. In the immediate postoperative period for a cleft lip repair, which of these nursing actions should be the priority?
    • A. 

      Utilize bilateral elbow restraints at all times

    • B. 

      Initiate formula/breast feedings for infant when alert

    • C. 

      Reinforce about steps to cleanse the suture line with a peroxide solution

    • D. 

      Position the infant after feedings in a supine position, propped up on a pillow


  • 119. 
    In addition to handwashing, an appropriate infection control intervention during the care of a newly admitted adult client with a diagnosis of Hepatitis A would be which action?
    • A. 

      Use of a HEPA filter personal protection device

    • B. 

      Keep the door of the room closed

    • C. 

      Wear a gown and gloves to change any linens

    • D. 

      Use gloves when handling the client's bedpan or urinal


  • 120. 

    Scoliosis a C S curvature of the spine; it cna a temporary or permanent condidtion. At what time would the nurse expect early findings of scoliosis to appear?                                                                                      
    • A. 

      In utero

    • B. 

      Infant

    • C. 

      Toddler

    • D. 

      Preadolescent


  • 121. 
    The nurse is assigned to a client with HIV infection. The client also has a secondary herpes simplex 1 (HSV 1) infection. The nurse knows that the most likely cause of the HSV 1 infection is which of these items?
    • A. 

      Immunosuppression caused by the HIV infection

    • B. 

      Emotional stress caused by the chronic diseases

    • C. 

      Reaction to the the prescribed medications

    • D. 

      Poor oral hygiene often associated with these infections


  • 122. 
    The nurse is gathering data from a client who states her last menstrual period was March 16, and she has missed one period. She reports episodes of nausea and vomiting. After confirming pregnancy, the nurse calculates the estimated date of delivery (EDD) to be about:
    • A. 

      April 8

    • B. 

      January 15

    • C. 

      February 11

    • D. 

      December 23


  • 123. 
    A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which of these nursing actions should the nurse expect to do first?
    • A. 

      Institute seizure precautions

    • B. 

      Identify baseline neurologic status

    • C. 

      Place on airborne precautions

    • D. 

      Check vital signs


  • 124. 
    In taking the history of a pregnant woman, which factor would the nurse recognize as the primary contraindication for breast feeding?
    • A. 

      Age 40 years-old

    • B. 

      Lactose intolerance

    • C. 

      Family history of breast cancer

    • D. 

      Uses cocaine on weekends


  • 125. 
    A nurse is reinforcing teaching with a client about compromised host precautions. The client is receiving filgrastim (Neupogen) for neutropenia. The selection of which lunch suggests the client has learned about necessary dietary changes?
    • A. 

      Grilled chicken sandwich and skim milk

    • B. 

      Roast beef, mashed potatoes, and green beans

    • C. 

      Peanut butter sandwich, banana, and iced tea

    • D. 

      Barbeque beef, baked beans, and cole slaw


  • 126. 
    While caring for a client, the nurse notes a pulsating mass in the client's periumbilical area. Which of the following actions is appropriate for the nurse to perform?
    • A. 

      Measure the length of the mass

    • B. 

      Auscultate the mass

    • C. 

      Percuss the mass

    • D. 

      Palpate the mass


  • 127. 
    The nurse is responsible for assisting in the decisions about client room assignments. Which of these possible roommates would be most appropriate for a three year-old child with minimal change nephrotic syndrome?
    • A. 

      Two year-old with respiratory infection

    • B. 

      Three year-old fracture whose sibling has chickenpox

    • C. 

      Four year-old with bilateral inguinal hernia repair

    • D. 

      Six year-old with a sickle cell anemia crisis


  • 128. 
    A ten year-old child has a history of tonic-clonic seizures. The school nurse should instruct the classroom teacher that if the child experiences a seizure in the classroom, the most important action during the seizure activity would be to
    • A. 

      Avoid the insertion of anything in the mouth

    • B. 

      Maintain the child in a supine position

    • C. 

      Provide privacy to prevent embarrassment

    • D. 

      Protect the child from self injury


  • 129. 
    The nurse will administer liquid medicine to a nine month-old child. Which method is appropriate?
    • A. 

      Allow the infant to drink the liquid from a medicine cup

    • B. 

      Administer the medication with a syringe next to the tongue

    • C. 

      Mix the medication with the infant's formula in the bottle

    • D. 

      Hold the child upright and administer the medicine by spoon


  • 130. 
    An outpatient client is scheduled to receive an oral solution of radioactive iodine. In order to reduce hazards, the nurse should reinforce to the client that
    • A. 

      Urine and saliva will be radioactive for 24 hours

    • B. 

      No special precautions will be necessary

    • C. 

      No special precautions will be necessary

    • D. 

      Guests to the client's home are restricted for 48 hours


  • 131. 
    A 52 year-old post menopausal woman asks the nurse how frequently she should have a mammogram. The nurse's best response is:
    • A. 

      "Your health care provider will advise you about your risks."

    • B. 

      "Unless you had previous problems, every 2 years is best."

    • C. 

      "Once a woman reaches 50, she should have a mammogram yearly."

    • D. 

      "Yearly mammograms are advised for all women over 35."


  • 132. 
    What is the primary nursing intervention to limit transmission of organisms for a client with a salmonella infection?
    • A. 

      Wash hands thoroughly before and after any client contact

    • B. 

      Wear gloves when in contact with body secretions

    • C. 

      Double glove when in contact with feces or vomitus

    • D. 

      Wear gloves when disposing of contaminated linens


  • 133. 
    The hospice nurse is visiting a 75 year-old client with end-stage cancer. For chronic malignant pain management in this client the nurse understands that:
    • A. 

      The pain threshold is higher in older adults

    • B. 

      Maximum doses of analgesics are needed

    • C. 

      Heart rate, respirations and B/P will be elevated

    • D. 

      Relief of temporary pain is immediate


  • 134. 
    A two month-old infant has both a cleft lip and palate which will be repaired in stages. In the immediate postoperative period for a cleft lip repair, which of these nursing actions should be the priority?
    • A. 

      Utilize bilateral elbow restraints at all times

    • B. 

      Initiate formula/breast feedings for infant when alert

    • C. 

      Reinforce about steps to cleanse the suture line with a peroxide solution

    • D. 

      Position the infant after feedings in a supine position, propped up on a pillow


  • 135. 
    The nurse is assisting with teaching a group of college students about breast self-examination. A woman asks when to perform the monthly exam. The appropriate reply by the nurse would be which of these?
    • A. 

      "The first of every month, because it will be easiest to remember."

    • B. 

      "Right after the period, when your breasts are less tender."

    • C. 

      "Do the exam at the same time every month."

    • D. 

      "Ovulation, or mid-cycle is the best time to detect changes."


  • 136. 

    Scoliosis a C S curvature of the spine; it cna a temporary or permanent condidtion. At what time would the nurse expect early findings of scoliosis to appear?                                                                                      
    • A. 

      In utero

    • B. 

      Infant

    • C. 

      Toddler

    • D. 

      Preadolescent


  • 137. 
    The nurse observes a newborn whose Apgar score was 8 and 9. This score would be most closely associated with which of these areas?
    • A. 

      Heart rate

    • B. 

      Muscle tone

    • C. 

      Cry

    • D. 

      Color


  • 138. 
    The nurse is gathering data from a client who states her last menstrual period was March 16, and she has missed one period. She reports episodes of nausea and vomiting. After confirming pregnancy, the nurse calculates the estimated date of delivery (EDD) to be about:
    • A. 

      April 8

    • B. 

      January 15

    • C. 

      February 11

    • D. 

      December 23


  • 139. 
    Which action would be the best strategy for the nurse to use when reinforcing insulin injection techniques to a newly diagnosed adult client with diabetes mellitus?
    • A. 

      Listen to client verbalize understanding

    • B. 

      Ask the client questions during practice

    • C. 

      Allow another client who does insulin injections to assist

    • D. 

      Observe a return demonstration


  • 140. 
    In taking the history of a pregnant woman, which factor would the nurse recognize as the primary contraindication for breast feeding?
    • A. 

      Age 40 years-old

    • B. 

      Lactose intolerance

    • C. 

      Family history of breast cancer

    • D. 

      Uses cocaine on weekends


  • 141. 
    The nurse is caring for a client who is four days post-op for a transverse colostomy. The client is ready for discharge and asks the nurse to empty the colostomy pouch. The nurse's best response to the client is:
    • A. 

      "You should be emptying the pouch yourself."

    • B. 

      "Let me demonstrate to you how to empty the pouch."

    • C. 

      "Tell me what have you learned about emptying your pouch."

    • D. 

      "Show me what you have learned about emptying your pouch."


  • 142. 
    While caring for a client, the nurse notes a pulsating mass in the client's periumbilical area. Which of the following actions is appropriate for the nurse to perform?
    • A. 

      Measure the length of the mass

    • B. 

      Auscultate the mass

    • C. 

      Percuss the mass

    • D. 

      Palpate the mass


  • 143. 
    While giving nursing care to a hospitalized adolescent, the nurse should be aware that the major threat felt by the hospitalized adolescent is :
    • A. 

      Unrelieved pain

    • B. 

      Restricted physical activity

    • C. 

      Altered body image

    • D. 

      Separation from family


  • 144. 
    The nurse will administer liquid medicine to a nine month-old child. Which method is appropriate?
    • A. 

      Allow the infant to drink the liquid from a medicine cup

    • B. 

      Administer the medication with a syringe next to the tongue

    • C. 

      Mix the medication with the infant's formula in the bottle

    • D. 

      Hold the child upright and administer the medicine by spoon


  • 145. 
    A 52 year-old post menopausal woman asks the nurse how frequently she should have a mammogram. The nurse's best response is:
    • A. 

      "Your health care provider will advise you about your risks."

    • B. 

      "Unless you had previous problems, every 2 years is best."

    • C. 

      "Once a woman reaches 50, she should have a mammogram yearly."

    • D. 

      "Yearly mammograms are advised for all women over 35."


  • 146. 
    The hospice nurse is visiting a 75 year-old client with end-stage cancer. For chronic malignant pain management in this client the nurse understands that:
    • A. 

      The pain threshold is higher in older adults

    • B. 

      Maximum doses of analgesics are needed

    • C. 

      Heart rate, respirations and B/P will be elevated

    • D. 

      Relief of temporary pain is immediate


  • 147. 
    The nurse is assisting with teaching a group of college students about breast self-examination. A woman asks when to perform the monthly exam. The appropriate reply by the nurse would be which of these?
    • A. 

      "The first of every month, because it will be easiest to remember."

    • B. 

      "Right after the period, when your breasts are less tender."

    • C. 

      "Do the exam at the same time every month."

    • D. 

      "Ovulation, or mid-cycle is the best time to detect changes."


  • 148. 
    The nurse observes a newborn whose Apgar score was 8 and 9. This score would be most closely associated with which of these areas?
    • A. 

      Heart rate

    • B. 

      Muscle tone

    • C. 

      Cry

    • D. 

      Color


  • 149. 
    Which action would be the best strategy for the nurse to use when reinforcing insulin injection techniques to a newly diagnosed adult client with diabetes mellitus?
    • A. 

      Listen to client verbalize understanding

    • B. 

      Ask the client questions during practice

    • C. 

      Allow another client who does insulin injections to assist

    • D. 

      Observe a return demonstration


  • 150. 
    The nurse is caring for a client who is four days post-op for a transverse colostomy. The client is ready for discharge and asks the nurse to empty the colostomy pouch. The nurse's best response to the client is:
    • A. 

      "You should be emptying the pouch yourself."

    • B. 

      "Let me demonstrate to you how to empty the pouch."

    • C. 

      "Tell me what have you learned about emptying your pouch."

    • D. 

      "Show me what you have learned about emptying your pouch."


  • 151. 
    While giving nursing care to a hospitalized adolescent, the nurse should be aware that the major threat felt by the hospitalized adolescent is :
    • A. 

      Unrelieved pain

    • B. 

      Restricted physical activity

    • C. 

      Altered body image

    • D. 

      Separation from family


  • 152. 
    A 74 year-old male is admitted due to inability to void. He has a history of an enlarged prostate and has not voided in 14 hours. When assessing for bladder distention, the best method for the nurse to use is to check for
    • A. 

      Rebound tenderness

    • B. 

      Left lower quadrant dullness

    • C. 

      Rounded swelling above the pubis

    • D. 

      Urinary discharge


  • 153. 
    A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and beccomes lost when she leaves home. Which statement would provide the best reality orientation for this client?
    • A. 

      "Good morning. Do you remember where you are?"

    • B. 

      "Hello. My name is Elaine Jones and I am your nurse for today."

    • C. 

      "How are you today? Remember, you're in the hospital."

    • D. 

      "Good morning. You're in the hospital. I am your nurse Elaine Jones."


  • 154. 
    A client says, "It's raining outside and it's raining in my heart. Did you know that St. Patrick drove the snakes out of Ireland? I've never been to Ireland." The nurse reviews this data and determines that this client is experiencing a speech pattern commonly seen in manic episodes called
    • A. 

      Perseveration

    • B. 

      Circumstantiality

    • C. 

      Neologisms

    • D. 

      Flight of ideas


  • 155. 
    The parents of a child who has suddenly been hospitalized for an acute illness state that they should have taken the child to the pediatrician earlier. Which approach by the nurse is appropriate?
    • A. 

      Focus on the child's needs and recovery

    • B. 

      Explain the cause of the child's illness

    • C. 

      Acknowledge that earlier care might have different outcomes

    • D. 

      Accept their feelings without judgment


  • 156. 
    Mr. Reynolds, 69 years of age, is found unconscious by his wife at 7:00 a.m. An ambulance is summoned by the physician, and Mr. Reynolds is admitted to the medical unit, where you work as a practical nurse, with a diagnosis of cerebral vascular accident (CVA). As you assist the team leader with the admission process, you note a previous history of hypertension. His wife has also revealed that Mr. Reynolds complained of a headache before retiring the night before. In addition to the headache and hypertension, which of the following symptoms would you expect Mr. Reynolds to exhibit?
    • A. 

      Labored respiration.

    • B. 

      Dysphagia and hemiplegia.

    • C. 

      Aphasia.

    • D. 

      All of the above.


  • 157. 
    Mr. Reynolds, 69 years of age, is found unconscious by his wife at 7:00 a.m. An ambulance is summoned by the physician, and Mr. Reynolds is admitted to the medical unit, where you work as a practical nurse, with a diagnosis of cerebral vascular accident (CVA). As you assist the team leader with the admission process, you note a previous history of hypertension. His wife has also revealed that Mr. Reynolds complained of a headache before retiring the night before. The team leader instructs you to remove Mr. Reynolds's dentures. You do so because
    • A. 

      The team leader will report you if you do not follow directions.

    • B. 

      The dentures need to be cleaned.

    • C. 

      The dentures might obstruct the respiratory passages.

    • D. 

      Mr. Reynolds usually removes them for sleep anyway.


  • 158. 
    Mr. Reynolds, 69 years of age, is found unconscious by his wife at 7:00 a.m. An ambulance is summoned by the physician, and Mr. Reynolds is admitted to the medical unit, where you work as a practical nurse, with a diagnosis of cerebral vascular accident (CVA). As you assist the team leader with the admission process, you note a previous history of hypertension. His wife has also revealed that Mr. Reynolds complained of a headache before retiring the night before. Unresponsive patients like Mr. Reynolds may develop a drying of the cornea, which is usually caused by
    • A. 

      Bulging of the eyeballs.

    • B. 

      Absence of the blinking reflex and reduction in tear formation.

    • C. 

      Lack of humidity in the room.

    • D. 

      Bulging of the eyeballs


  • 159. 
    Marty Cole, 7 years old, is admitted to the pediatric service with a diagnosis of juvenile diabetes mellitus. He has not been under treatment previously. As a practical nurse, you would expect Marty to exhibit all of the following symptoms EXCEPT
    • A. 

      increased thirst.

    • B. 

      Fatigue.

    • C. 

      Increased appetite with weight gain.

    • D. 

      Increased urination with enuresis.


  • 160. 
    Marty Cole, 7 years old, is admitted to the pediatric service with a diagnosis of juvenile diabetes mellitus. He has not been under treatment previously. Because Marty is so young and because his mother works, it is decided to start him on
    • A. 

      Regular insulin.

    • B. 

      Regular + semilente insulin.

    • C. 

      Semilente insulin.

    • D. 

      Protamine zinc insulin (PZI).


  • 161. 
    Marty Cole, 7 years old, is admitted to the pediatric service with a diagnosis of juvenile diabetes mellitus. He has not been under treatment previously. When counseling Marty about his diabetes and its treatment, you would advise against eating
    • A. 

      French fries.

    • B. 

      Ice cream

    • C. 

      A tuna fish sandwich.

    • D. 

      A peanut butter sandwich.


  • 162. 
    Which one of the following statements best describes the effects of immobility in children?
    • A. 

      Immobility prevents the normal progression of language and fine motor development

    • B. 

      Immobility in children has physical effects similar to those found in adults

    • C. 

      Children are more susceptible to the effects of immobility than are adults

    • D. 

      Children are likely to have prolonged immobility with subsequent complications


  • 163. 
    A client with heart failure has been instructed by the RN about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction?
    • A. 

      Cheese sandwich with a glass of 2% milk

    • B. 

      Sliced turkey sandwich and canned pineapple

    • C. 

      Cheeseburger and baked potato

    • D. 

      Mushroom pizza and ice cream


  • 164. 
    After a client has an intestinal feeding tube inserted, the most accurate method for verification of placement is
    • A. 

      Abdominal x-ray

    • B. 

      Auscultation with air insertion

    • C. 

      Chest x-ray

    • D. 

      Aspiration for green gastric contents


  • 165. 
    Which of the following agents should be avoided by clients on methotrexate therapy?
    • A. 

      Folic acid

    • B. 

      Vitamin D

    • C. 

      Vitamin C

    • D. 

      Iron


  • 166. 
    The visiting nurse makes a postpartum home visit to a married female client. Upon arrival, the nurse observes that the client has a black eye and numerous bruises on her arms and legs. The next nursing intervention would be to
    • A. 

      Call the police to report indications of domestic violence

    • B. 

      Talk with the couple about the findings

    • C. 

      Leave the home because of the unsafe environment

    • D. 

      Interview the client without the partner to determine the origin of the injuries


  • 167. 
    A client is admitted with severe injuries from an auto accident. The client's vital signs are BP 120/50, pulse rate 110, and respiratory rate of 28. The initial nursing intervention would be to
    • A. 

      Begin the ordered pain control therapy

    • B. 

      Initiate continuous blood pressure monitoring

    • C. 

      Administer oxygen therapy

    • D. 

      Institute cardiac monitoring


  • 168. 
    The client is receiving an intravenous piggyback infusion of penicillin. Which client statement would require the nurse's immediate attention?
    • A. 

      "I have a burning sensation when I urinate."

    • B. 

      "I have soreness and aching in my muscles

    • C. 

      "I am itching all over."

    • D. 

      "I have cramping in my stomach."


  • 169. 
    The nurse is caring for a client who is receiving TPA (altipase) For a cerebral vascular accident (CVA). Which of these nursing interventions should receive priority?
    • A. 

      Maintain bedrest

    • B. 

      Check the mental status

    • C. 

      Monitor vital signs

    • D. 

      Protect invasive lines or tubes


  • 170. 
    Before administering digoxin (Lanoxin) to a client, which nursing action is a priority?
    • A. 

      Observe respiratory effort

    • B. 

      Check for bowel sounds

    • C. 

      Take the heart rate

    • D. 

      Measure the blood pressure


  • 171. 
    When reinforcing teaching to a depressed client about a new prescription for nortriptyline (Pamelor), the nurse must emphasize
    • A. 

      Symptom relief occurs in a few days

    • B. 

      Alcohol use is to be avoided

    • C. 

      Medication must be stored in the refrigerator

    • D. 

      Episodes of diarrhea can be expected


  • 172. 
    The nurse checks a client with chronic obstructive pulmonary disease. The client has oxygen per mask for low PaO2 levels. A nursing priority would be to:
    • A. 

      Evaluate SaO2 levels frequently

    • B. 

      Observe skin color changes

    • C. 

      Check for clubbing fingers

    • D. 

      Monitor activity tolerance


  • 173. 
    The nurse is assisting in the assessment of a client's home in preparation for discharge. Which focus should be given priority consideration?
    • A. 

      Family's understanding of the client's needs

    • B. 

      Financial status of the client and family to buy prescribed drugs

    • C. 

      Location of bathrooms and accessibility by client

    • D. 

      Proximity to emergency services and telephone number


  • 174. 
    The nurse is caring for a two month-old infant with a congenital heart defect. Which of the following is a priority nursing action?
    • A. 

      Provide small feedings every three hours

    • B. 

      Maintain intravenous fluids

    • C. 

      Add strained cereal to the diet

    • D. 

      Change formula to reduced calorie


  • 175. 
    The best action to establish correct placement of a gastric tube is for the nurse to
    • A. 

      Aspirate for the color and pH test

    • B. 

      Inject air while listening for the gastric gurgle

    • C. 

      Check the results of the x-ray results of tube placement

    • D. 

      Measure the residual volume then reinsert the aspirate


  • 176. 
    The nurse is working in a high risk antepartal clinic. A 40 year-old woman in the first trimester gives a thorough health history. Which of the following collected data should receive priority attention by the nurse?
    • A. 

      Her father and brother are insulin dependent diabetics

    • B. 

      She has taken 800 mcg of folic acid daily for the past year

    • C. 

      Her husband was treated for tuberculosis as a child

    • D. 

      She reports recent use of over-the counter sinus remedies


  • 177. 
    The nurse is checking a woman in early labor. While positioning for a vaginal exam, she complains of dizziness and nausea and appears pale. Her blood pressure has dropped slightly. What is the appropriate initial nursing action?
    • A. 

      Call the health care provider

    • B. 

      Encourage deep breathing

    • C. 

      Elevate the foot of the bed

    • D. 

      Turn her to her left side


  • 178. 
    The nurse is caring for a client several days following a cerebral vascular accident (CVA). Coumadin (warfarin) has been prescribed. Today's prothrombin level is abnormally elevated. Which item is a priority to check?
    • A. 

      Neurological signs

    • B. 

      Lung sounds

    • C. 

      Homan's sign

    • D. 

      Gum bleeding


  • 179. 
    The nurse is caring for a client who is receiving procainamide (Pronestyl) intravenously. What is a priority for the nurse to do for her client?
    • A. 

      Hourly urinary output

    • B. 

      Blood pressure

    • C. 

      Continuous ECG readings

    • D. 

      Neurological signs


  • 180. 
    A client is receiving a nitroglycerin (NTG) infusion for unstable angina. What would be a priority for monitoring the effects of this medication?
    • A. 

      Blood pressure

    • B. 

      Cardiac labs

    • C. 

      Rhythm strips

    • D. 

      Respiratory rate


  • 181. 
    The partner of a client with Alzheimer's disease expresses concern about the burden of caregiving. Which action by the nurse should be a priority?
    • A. 

      Link the caregiver with a support group

    • B. 

      Suggest that friends need to visit regularly

    • C. 

      Schedule a home visit each week

    • D. 

      Develop a telephone support system


  • 182. 
    A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first?
    • A. 

      Ask client to cough sputum into container

    • B. 

      Have the client take several deep breaths

    • C. 

      Provide an appropriate specimen container

    • D. 

      Assist with oral hygiene


  • 183. 
    Following change-of-shift report on an orthopedic unit, which client should the nurse see first?
    • A. 

      16 year-old who had an open reduction of a fractured wrist ten hours ago

    • B. 

      20 year-old in skeletal traction for two weeks since a motor cycle accident

    • C. 

      72 year-old recovering from surgery after a hip replacement two hours ago

    • D. 

      75 year-old who is in skin traction prior to planned hip pinning surgery.


  • 184. 
    The nurse is caring for a post-operative client who develops an abdominal wound evisceration. The first nursing intervention should be to
    • A. 

      Medicate the client for pain

    • B. 

      Alert the family of the need to leave the room

    • C. 

      Cover the wound with sterile saline dressing

    • D. 

      Place the bed in a Mid-Fowler's position


  • 185. 
    Postoperative nursing care for an infant who has had a pyloromyotomy would include which of these items?
    • A. 

      Bland diet appropriate for age

    • B. 

      Intravenous fluids for three to four days

    • C. 

      NPO then glucose and electrolyte solutions

    • D. 

      Formula or breast milk as tolerated


  • 186. 
    A client receives high doses of potassium over 30 minutes. Which is a priority to check prior to giving this medication?
    • A. 

      Oral fluid intake

    • B. 

      Bowel sounds

    • C. 

      Grip strength

    • D. 

      Urine output


  • 187. 
    A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethizine hydrochloride (Phenergan) 50 mg IM to a pre-operative client. Which action should the nurse take first?
    • A. 

      Raise the side rails on the bed

    • B. 

      Place the call bell within reach

    • C. 

      Instruct the client to remain in bed

    • D. 

      Have the client empty bladder


  • 188. 
    A client calls the PN because of an onset of chest pain. Which of these statements would require the most immediate action?
    • A. 

      "When I take in a deep breath, it stabs like a knife."

    • B. 

      "The pain came on after dinner. That soup seemed very spicy."

    • C. 

      "When I turn in bed to reach the remote for the TV, my chest hurts."

    • D. 

      "I feel like a balloon is blowing up in my chest."


  • 189. 
    Ms. O'Brien is bedridden. The nurse is evaluating whether the family members understand how to position the client correctly. Which of the following should the nurse observe?
    • A. 

      The extremities should always be extended to prevent contractures.

    • B. 

      Lower arm and leg are always supported in the lateral positions.

    • C. 

      The spine should have maximal lordosis in almost all positions.

    • D. 

      The family should change the position at least every two hours.


  • 190. 
    A victim of a motor vehicle accident is brought to the emergency room via ambulance in hypovolemic shock. When placing the client in a modified Trendelenburg position, the nurse should place the client
    • A. 

      With the legs only elevated above the heart.

    • B. 

      Prone, with the head of the bed elevated.

    • C. 

      Supine, with the head of the bed lowered.

    • D. 

      Supine, tilting the bed so the head is above the heart.


  • 191. 
    Ms. Jordan is bedridden and positioned on her right side. There is a pillow beneath her head. Her right arm is extended near her hip. Her left leg is extended and parallel with the right leg. Which of the following is correct?
    • A. 

      She should be semiprone with the weight on her upper chest.

    • B. 

      Ms. Jordan's right arm should be flexed at the shoulder and elbow.

    • C. 

      There should not be a pillow under her head.

    • D. 

      The client's right leg should be flexed at the hip and knee.

    • E. 

      The correct answer is B. The lower arm should be flexed, so the body does not rest on it.


  • 192. 
    The nurse uses a wide stance when moving a heavy box of supplies. Which of the following is the best reason the nurse would do this? Because it
    • A. 

      Avoids back strain.

    • B. 

      Lowers the center of gravity.

    • C. 

      Increases stability.

    • D. 

      Contracts the muscles.


  • 193. 
    Mr. Lowell is brought in after a motor vehicle accident. He has suffered a head injury and possible spinal injury. When moving him from the stretcher to the bed, the nurse should do the following
    • A. 

      Sit up and transfer patient to the bed

    • B. 

      Have the client move segmentally

    • C. 

      Move the patient with a draw sheet.

    • D. 

      Log roll the client.


  • 194. 
    Mr. T. is a C4 quadriplegic in a nursing home. Which of the following techniques would the nurse use to transfer him from bed to wheelchair?
    • A. 

      One nurse dangling the client, then using a transfer belt.

    • B. 

      Two nurses, one on either side, lifting Mr. T. with a sheet.

    • C. 

      Two nurses using a mechanical lifting device (Hoya).

    • D. 

      Two people, one at Mr. T.'s knees, the other under his arms.


  • 195. 
    The nurse is dangling Ms. S. prior to transferring her from the bed to a wheelchair. Which of the following assessments is essential for the nurse to make before moving the client?
    • A. 

      Taking the client's pulse and respiration

    • B. 

      Assessing the client's height and range of motion.

    • C. 

      Ensuring that the bed is in the highest position.

    • D. 

      Enlisting the help of another nurse or a CNA.


  • 196. 
    Mr. C. has just been admitted for acute asthma exacerbation and placed in a high Fowler's position. The nurse knows this position is best because it
    • A. 

      Is required for the aerosol treatments to work

    • B. 

      Is the position for the chest X-ray.

    • C. 

      Facilitates maximal ventilation.

    • D. 

      Allows for chest physiotherapy.


  • 197. 
    Ms. L. is to go home with her family. The nurse is evaluating that the family members can correctly move Ms. L. from the bed to a chair. Which of the following should be seen?
    • A. 

      The client has one foot slightly in front of the other.

    • B. 

      There is no pause while the client is standing.

    • C. 

      The transfer belt is placed loosely around the waist.

    • D. 

      The family member leans forward from the waist.


  • 198. 
    Ms. F. suffered a stroke and has right-sided hemiparesis. The nurse is going to transfer her from bed to wheelchair. Which of the following is the best method?
    • A. 

      Have the client put her arms around the nurse's neck.

    • B. 

      Put the wheelchair at a 45° angle to the bed.

    • C. 

      Place the wheelchair about a foot away from the bed

    • D. 

      Position the wheelchair closer to the weaker foot.


  • 199. 
    The nurse knows which of the following is the proper technique for medical asepsis selecting:
    • A. 

      Using your hands to turn off the faucet after handwashing.

    • B. 

      Changing hospital linen weekly.

    • C. 

      Gloving for all client contact.

    • D. 

      Gowning to care for a one-year-old child with infectious diarrhea.


  • 200. 
    The nurse is conducting a class on aseptic technique and universal precautions. Which of the following statements is correct and should be included in the discussion?
    • A. 

      The term universal precautions is synonymous with disease or category-specific isolation precautions.

    • B. 

      Universal precautions are designed to reduce the number of potentially infectious agents.

    • C. 

      Medical asepsis is designed to decrease exposure to bloodborne pathogens.

    • D. 

      Medical asepsis is designed to confine microorganisms to a specific area, limiting the number, growth, and transmission of microorganisms.


  • 201. 
    The nurse is to open a sterile package from central supply. Which is the correct direction to open the first flap?
    • A. 

      Away from the nurse

    • B. 

      Toward the nurse

    • C. 

      To the nurse's left or right.

    • D. 

      It does not matter as long as the nurse only touches the outside edge


  • 202. 
    For which procedure would the nurse use aseptic technique and which would require the nurse to use sterile technique?
    • A. 

      Aseptic technique for urinary catheterization in the hospital and sterile technique for cleaning surgical wounds

    • B. 

      Aseptic technique for food preparation and sterile technique for starting an IV line

    • C. 

      Aseptic technique for changing the client's linen and sterile technique for placing a central line.

    • D. 

      Aseptic technique for a spinal tap and sterile technique for surgery


  • 203. 
    Ms. W. has a draining pressure ulcer on her sacrum and is to be discharged to her daughter's care. The nurse has taught Ms. W.'s daughter to perform dressing changes. Which observation by the nurse indicates the daughter's technique is done correctly? The daughter
    • A. 

      Places the forceps used to remove the old dressing on the sterile field

    • B. 

      Irrigates the wound from the bottom up.

    • C. 

      Uses only sterile gloves to remove the old dressing.

    • D. 

      Washes her hands before each gloving and after the procedure is done.


  • 204. 
    Ms. P. is transferred to a skilled nursing facility from the hospital because she is unable to ambulate due to a left femoral fracture. The nurse knows Ms. P.'s greatest risk factor for developing a pressure ulcer is that she
    • A. 

      Has slightly limited mobility and needs assistance to move from bed to chair

    • B. 

      Is 5 ft 4 in tall, 130 lb, and eats more than half of most meals.

    • C. 

      Is apathetic but oriented to person, place, and time.

    • D. 

      Has good skin turgor, no edema, and her capillary refill is less than three seconds.


  • 205. 
    An elderly male client is transferred to a skilled nursing facility from the hospital because he is unable to ambulate due to a left femoral fracture. When doing a skin assessment, the nurse notices a 3-cm, round area partial thickness skin loss that looks like a blister on the client's sacrum. The nurse knows this is a
    • A. 

      Stage IV pressure ulcer.

    • B. 

      Stage II pressure ulcer.

    • C. 

      Stage III pressure ulcer.

    • D. 

      Stage I pressure ulcer.


  • 206. 
    When planning for the care of a client with a pressure ulcer on the sacrum, the nurse would include which of the following?
    • A. 

      Having a pressure-relieving device such as an egg crate mattress or gel flotation pad.

    • B. 

      Positioning the client with a donut around the area to relieve pressure on the ulcer.

    • C. 

      Massaging the sacrum, concentrating on the bony prominences and reddened areas.

    • D. 

      Using a heat lamp twice a day to dry the wound.


  • 207. 
    The nurse is to apply a dressing to a stage II pressure ulcer. Which of the following dressings is best?
    • A. 

      Wet gauze dressing.

    • B. 

      Moisture-vapor permeable dressing.

    • C. 

      Wet to dry dressing.

    • D. 

      Dry gauze dressing.


  • 208. 
    When evaluating a client with a pressure ulcer, the nurse understands that the best response to treatment of the sacral pressure ulcer on a client with a hip fracture would be indicated by
    • A. 

      Absence of clinical signs of infection including redness, warmth, swelling, pain, odor, and exudate.

    • B. 

      Increased mobility including the ability to reposition self in bed or wheelchair and walking with assistance.

    • C. 

      The client's nutritional status including adequate protein; carbohydrates; fats; vitamins A, B, C, and K; and minerals including copper, iron, and zinc.

    • D. 

      The client's skin status including length, width, depth, condition of the wound margins, and stage of the ulcer as well as the integrity of the surrounding skin.


  • 209. 
    Mr. D. has a disorder of the hypothalamus and is on a hypothermia blanket. The nurse should make which of the following assessments?
    • A. 

      Document the client's ability to sweat.

    • B. 

      Ensure the client's skin is warm and dry.

    • C. 

      Confirm that the client is alert and oriented.

    • D. 

      Record baseline vital signs, neurologic status, and skin integrity.


  • 210. 
    When Mr. C. is placed on a hypothermia blanket, which of the following should be included in the nursing care plan?
    • A. 

      Placing the client directly on the blanket.

    • B. 

      Taking frequent vital signs, and doing skin assessments.

    • C. 

      Monitoring Mr. C.'s temperature through the hypothermia machine's rectal probe.

    • D. 

      Ensuring the hypothermia blanket continues to cool until the client's temperature reaches 98.6° F.


  • 211. 
    The physician's orders for Mr. C. include warm compresses to the left leg three times a day for treatment of an open wound. The nurse should
    • A. 

      Place both a dry covering and waterproof material over the compress

    • B. 

      Use medical aseptic techniques throughout the procedure.

    • C. 

      Wet the compress and apply it directly to the area

    • D. 

      Remove the compress after about five minutes.


  • 212. 
    While giving an adult a tepid sponge bath to reduce his temperature, the nurse notes that the client is shivering. The nurse correctly interprets this to mean  
    • A. 

      Sponge bath is being given too slowly.

    • B. 

      Temperature of the water is below 90° F (32° C).

    • C. 

      Body is trying to warm itself

    • D. 

      Client has a decreased metabolic demand.


  • 213. 
    Mr. S. is to have a tepid sponge bath to lower his fever. What temperature should the nurse make the water?
    • A. 

      105° F (40.5° C).

    • B. 

      90° F (32° C).

    • C. 

      110° F (43° C).

    • D. 

      65° F (18° C).


  • 214. 
    Mr. A. has sprained his ankle. The physician would order cold applied to the injured area to
    • A. 

      Reduce the body's temperature.

    • B. 

      Relieve pain and control bleeding.

    • C. 

      Aid in reabsorbing the edema.

    • D. 

      Increase circulation to the area.


  • 215. 
     The nurse is talking with a mother to assess her child. A positive response to which question would indicate the child is in the anal stage of psychosexual development as described by Freud?
    • A. 

      "Does he put everything in his mouth?"

    • B. 

      "Does he say 'No!' to everything you say?"

    • C. 

      "Does he like to dress up and pretend to be his father?"

    • D. 

      "Does he seem jealous when you show affection to his father?"


  • 216. 
    The nurse is beginning to establish a nurse­client relationship with Ms. E. who was referred for help in managing her children. Ms. E. arrives late for appointments and focuses on her busy schedule, the difficulty in parking, and other reasons for being late. The nurse best interprets this behavior as
    • A. 

      Transference.

    • B. 

      Counter-transference.

    • C. 

      Identification.

    • D. 

      Resistance


  • 217. 
    Which cognitive skill would the nurse expect a six-year-old child to be in the process of developing?
    • A. 

      Understanding of basic rules.

    • B. 

      Ability to understand abstract concepts.

    • C. 

      Recognition of object permanence.

    • D. 

      Recognition of object permanence.


  • 218. 
    A nurse is part of a community task force on teenage suicide. The task force is considering all of the following steps in an effort to reduce teen suicide. Which action represents primary prevention?
    • A. 

      Encourage emergency room staff to request psychiatric consultation for adolescents who overdose.

    • B. 

      Educate teachers, counselors, and school nurses in recognition and early intervention with suicidal teens.

    • C. 

      Provide community programs, such as Scouts, which increase self-esteem for children and adolescents.

    • D. 

      Increase the number of inpatient adolescent psychiatric beds available in the community


  • 219. 
    Mrs. F. has remained close to the nurse all day. When the nurse talked with other clients during dinner, Mrs. F. tried to regain the nurse's attention and then began to shout "You're just like my mother. You pay attention to everyone but me!" The best interpretation of this behavior is that
    • A. 

      Mrs. Frank. is exhibiting resistance.

    • B. 

      Mrs. Frank has been simply spoiled by her family.

    • C. 

      The nurse has failed to meet the patient's needs.

    • D. 

      Mrs. Frank is demonstrating transference


  • 220. 
    During the focused assessment of a client with major depression, the nurse may ask which of the following questions?
    • A. 

      "You seem to have a lot of energy; when did you last have six or more hours of sleep?"

    • B. 

      "You seem to be angry with your family now; when was it that you last got along?"

    • C. 

      "Have you had any thoughts of harming yourself?"

    • D. 

      "You seem to be listening to something. Could you tell me about it?"


  • 221. 
    Which of the following nursing diagnoses would be most appropriate for a client who is diagnosed as bipolar I disorder, single manic episode and is intrusive, argumentative, and severely critical of peers?
    • A. 

      Impaired social interaction related to narcissistic behavior as evidenced by inability to sustain relationships.

    • B. 

      Risk for injury related to extreme hyperactivity as evidenced by increased agitation and lack of control over behavior.

    • C. 

      Social isolation related to feelings of inadequacy in social interaction as evidence by problematic interaction with others

    • D. 

      Defensive coping related to social learning patterns as evidenced by difficulty interacting with others.


  • 222. 
    An adult is in an acute manic phase of bipolar disorder. He talks and paces incessantly, frequently shouting and threatening other clients. The nurse expects the client's care plan to include which of the following?
    • A. 

      Monitor blood lithium levels.

    • B. 

      Monitor client during phototherapy.

    • C. 

      Monitor client after electroconvulsive therapy.

    • D. 

      Teach client to avoid foods with tyramine


  • 223. 
    The nurse is preparing to administer lithium (Eskalith) to a client with bipolar disorder. The client complains of nausea and muscle weakness, and his speech is slurred. His lithium level is 1.6 mEq/L. The best action for the nurse to take is to
    • A. 

      Chart the client's symptoms after giving the lithium.

    • B. 

      Administer a prn antiparkinsonism drug.

    • C. 

      Explain that these are common side-effects and withhold the client's lithium.

    • D. 

      Administer an anti-lithium immediately


  • 224. 
    Mr. Warren, a client with paranoid schizophrenia, has a delusion of persecution. He tells the nurse, "They are out to get me. They're spying on me." The nurse's best initial response is :
    • A. 

      "Mr. Warren., I don't want to hurt you."

    • B. 

      "Mr. Warren, how would they spy on you here?"

    • C. 

      "Mr. Warren, tell me how they're trying to get you."

    • D. 

      "Mr. Warren, I know they wouldn't want to hurt you."


  • 225. 
    The nurse recognizes that the client with posttraumatic stress disorder (PTSD), is improving when he
    • A. 

      States he feels "numb" most of the time.

    • B. 

      Drinks alcohol to cope with his feelings.

    • C. 

      Talks about a benefit of the traumatic experience.

    • D. 

      Attends weekly group therapy.


  • 226. 
    Miss Peters is found wandering on campus after a fraternity party. She is disheveled and does not know who she is. She has no recollection of the evening. She is diagnosed with dissociative amnesia subsequent to a rape. The most appropriate nursing diagnosis for the nurse to formulate is :
    • A. 

      Ineffective individual coping

    • B. 

      Personal identity disturbance

    • C. 

      Anxiety related to alteration in memory

    • D. 

      High risk for violence, self-directed


  • 227. 
    The nurse finds, during the initial assessment of the star player on the basketball team, that he is not concerned about the sudden paralysis of his "shooting arm." This behavior is known as :
    • A. 

      Secondary gain.

    • B. 

      La belle indifference

    • C. 

      Malingering.

    • D. 

      .hypochondriasis


  • 228. 
       Mr. Manor's family brought him into the hospital because of his many somatic complaints. He has been seen by many medical specialists in     the past without discovery of organic pathology  .The nurse assesses that Mr. Manor is experiencing which of the following problems?            
    • A. 

      Conversion disorder

    • B. 

      Body dysmorphic disorder.

    • C. 

      Malingering

    • D. 

      Hypochondriasis


  • 229. 
    Mrs. Wyatt is hospitalized for treatment of a conversion disorder. She complained of paralysis of her right side after her husband threatened to leave her and their children. She seems unconcerned about her paralysis. An appropriate long-term goal for the nurse to formulate is that Mrs. Waytt. will
    • A. 

      Cope effectively with stress without recurring to conversion.

    • B. 

      Identify stressors within herself behavior

    • C. 

      Express feelings about the conflict in her relationship

    • D. 

      Develop an increased sense of relatedness to others


  • 230. 
    PharmacologyAn antibiotic (intramuscular) IM injection for a two year-old child is ordered. The total volume of the injection equals 2.0 ml The correct action is to
    • A. 

      Administer the medication in 2 separate injections

    • B. 

      Give the medication in the dorsal gluteal site

    • C. 

      Call to get a smaller volume ordered

    • D. 

      Check with pharmacy for a liquid form of the medication


  • 231. 
    A client has been taking Procardia for Raynaud's disease and hypertension. Which finding would indicate that the client may be having a side effect of the medication?
    • A. 

      Decreased urinary output

    • B. 

      Facial flushing

    • C. 

      Cyanosis of the lips

    • D. 

      Increased pain in fingers


  • 232. 
    The nurse monitors a client after the treatment of bradycardia with intravenous atropine sulfate. Which of these findings should be reported to the health care provider immediately?
    • A. 

      Frequent palpitations

    • B. 

      Increased salivation

    • C. 

      Bronchial spasms

    • D. 

      Frequent urination


  • 233. 
    The health care provider has written "Morphine sulfate 2 mgs IV every three-to-four hours prn for pain" on the chart of an elderly client in an extended care facility. The PN has no other licensed persons working that shift. The initial action by the PN should be to
    • A. 

      Check with the pharmacist

    • B. 

      Hold the medication and contact the health care provider

    • C. 

      Administer the prescribed dose as ordered

    • D. 

      Give half of the dose at a time


  • 234. 
    The nurse would reinforce the need to take alendronate (Fosamax) as prescribed by the physician,
    • A. 

      On an empty stomach and water only

    • B. 

      After meals to increase absorption levels

    • C. 

      With added calcium and milk

    • D. 

      With milk two hours after meals


  • 235. 
    The nurse is reinforcing teaching about the use of nonsteroidal anti-inflammatory (NSAIDs) drugs to a group of arthritic clients. To minimize the side effects, the nurse should emphasize
    • A. 

      Lying down for 30 minutes after taking the medication

    • B. 

      Using alcohol in moderation unless driving

    • C. 

      Taking the drug with food, milk, or antacids

    • D. 

      Taking the medication one hour before or two hours after meals


  • 236. 
    A client with chronic obstructive pulmonary disease (COPD) and a history of coronary artery disease is receiving Aminophylline, 25mg/hour. Which finding by the nurse would require immediate intervention?
    • A. 

      Decreased blood pressure and respirations

    • B. 

      Flushing and headache

    • C. 

      Restlessness and palpitations

    • D. 

      Increased heart rate and blood pressure


  • 237. 
    A client with a panic disorder has a new prescription for Xanax (alpazolam). When reinforcing teaching to the client about the drug's actions and side effects, which item should the nurse emphasize?
    • A. 

      Short-term relief can be expected

    • B. 

      The medication acts as a stimulant

    • C. 

      Dosage will be increased as tolerated

    • D. 

      Initial side effects often continue


  • 238. 
    A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication
    • A. 

      Sometimes alters consciousness

    • B. 

      May lead to oliguria

    • C. 

      Can predispose to dysrhythmias

    • D. 

      May cause irritability and anxiety


  • 239. 
    Dorreen an adolescent female is newly diagnosed with bulimia. The nurse is reinforcing instructions to the client and her parents about the theraputic benefits of Tofranil. Which statement demonstrates an understanding by the client?
    • A. 

      "I will begin to feel better after a few days."

    • B. 

      "I only need to take this medication until I can control my binging."

    • C. 

      "I will need to take the medication for at least two weeks before I can see any benefit."

    • D. 

      "I can double the medication if I miss a dose."


  • 240. 
    A client is admitted for Lithium (Lithane) toxicity. Which finding should the nurse report immediately to the health care provider?
    • A. 

      Peripheral edema

    • B. 

      Vomiting with diarrhea

    • C. 

      Dizziness with unsteady gait

    • D. 

      Onset of manic mood


  • 241. 
    A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic?
    • A. 

      Bruising at the operative site

    • B. 

      Elevated heart rate

    • C. 

      Decreased platelet count

    • D. 

      No bowel movement for 3 days


  • 242. 
    A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make?
    • A. 

      "Why don't we now have the client turn back to the left side."

    • B. 

      "That was done correctly. Did you have any problems with the insertion?"

    • C. 

      "Let's check to see if the suppository is in far enough."

    • D. 

      "Did you feel any stool in the intestinal tract?"


  • 243. 
    Which of these points should be reinforced during the discharge instructions to a client who is prescribed warfarin sodium (Coumadin) for the next six months?
    • A. 

      Eliminate all dark green lettuce from your diet

    • B. 

      Report any changes in the color of your stools and urine

    • C. 

      Take limited aspirin or nonsteriodal antiinflammatories for minor pains

    • D. 

      Use a soft tooth brush with an expectation that a little bleeding of your gums might occur after brushing your teeth


  • 244. 
    Pediatric Nursing The nurse is testing reflexes in a four-month­old infant as part of the neurologic asse,ssment. Which of the following findings would indicate an abnormal reflex pattern and an area of concern in a four-month-old -infant?
    • A. 

      Closes hand tightly when palm is touched

    • B. 

      Begins strong sucking movements when mouth area is stimulated

    • C. 

      Hyperextends toes in response to stroking sole of foot upward

    • D. 

      Does not extend and abduct extremities in response to loud noise


  • 245. 
    The mother of a three-month-old infant asks the nurse when she can start feeding her baby solid food. Which of the following should the nurse include in teaching this mother about the nutritional needs of infants?
    • A. 

      Infant cereal can be introduced by spoon when the extrusion reflex fades

    • B. 

      Solid foods should be given as soon as the infant's first tooth erupts

    • C. 

      Pureed food can be offered when the infant has tripled his birth weight

    • D. 

      Infant formula or breast milk provides adequate nutrients for the first year


  • 246. 
    The nurse is assessing a six-month-old infant during a well child visit. The nurse makes all of the following observations. Which of the following assessments made by the nurse is an area of concern indicating a need for further evaluation?
    • A. 

      Absence of Moro reflex

    • B. 

      Closed posterior fontanel

    • C. 

      Three pound weight gain in two months

    • D. 

      Moderate head lag when pulled to sitting position


  • 247. 
    The nurse is giving anticipatory guidance regarding safety and injury prevention to the parents of an 18-month-old toddler. Which of the following actions by the parents indicates understanding of the safety needs of a toddler?
    • A. 

      Supervise the child in outdoor, fenced play areas

    • B. 

      Teach the child swimming and water safety

    • C. 

      Use automobile booster seat with lap belt

    • D. 

      Allow child to cross the street with fouryear-old sibling.


  • 248. 
    The community health nurse is making a newborn follow-up home visit. During the visit the two-year-old sibling has a temper tantrum. The parent asks the nurse for guidance in dealing with the toddler's temper tantrums. Which of the following is the most appropriate nursing action?
    • A. 

      Help the child understand the rules

    • B. 

      Leave the child alone in his bedroom

    • C. 

      Suggest that the parent ignore the child's behavior .

    • D. 

      Explain that the toddler is jealous of the new baby


  • 249. 
    The parent of a three-year-old child brings the child to the clinic for a well child checkup. Which of these assessment findings made by the nurse is an area of concern and requires further investigation?
    • A. 

      Child is unable to ride a tricycle

    • B. 

      Hasn't developed the ability to hop on one foot

    • C. 

      Only uses gestures to indicate wants

    • D. 

      Weight gain of four pounds in last year


  • 250. 
    An adult woman is seen in the clinic for treatment of a minor burn. While assessing the woman the nurse obtains data suggesting that the client has developed hyperthyroidism. Which data are most suggestive of hyperthyroidism?
    • A. 

      "Nervousness, frequent crying, weight loss, and tachycardia.

    • B. 

      Intolerance to cold, cool clammy skin, and bradycardia.

    • C. 

      Weight gain, puffiness around eyes, and extreme fatigue

    • D. 

      Dry skin, constipation, and memory defects


  • 251. 
    Randy, age 8, is admitted with rheumatic fever. Which clinical finding indicates to the nurse that Randy needs to continue taking the salicylates he had received at home?
    • A. 

      Chorea

    • B. 

      Polyarthritis is characterized by swollen, painful, hot joints that respond to salicylates

    • C. 

      Subcutaneous nodules

    • D. 

      Erythema marginatum


  • 252. 
    The nurse is caring for a client with advanced cancer of the breast. She complains of hypoguesia. The nurse should recommend
    • A. 

      Eating dry crackers.

    • B. 

      Monitoring intake and output

    • C. 

      Using spices to enhance food flavors

    • D. 

      Weighing her before and after meals


  • 253. 
    An adult is admitted to the hospital to undergo a stapedectomy for the treatment of otosclerosis. Which findings elicited during physical assessment are most indicative of otosclerosis?
    • A. 

      Bone conduction is greater than air conduction

    • B. 

      Bone conduction is equal to air conduction

    • C. 

      Air conduction is greater than bone conduction

    • D. 

      Sound lateralizes to the unaffected ear.


  • 254. 
    Four-year-old Amy has been blind since birth. She has been attending a nursery program for the visually impaired. To continue independence in her activities of daily living, when her lunch tray arrives, the nurse will
    • A. 

      Offer to feed her in a good gesture

    • B. 

      Plan that foods on her tray are set up like a clock

    • C. 

      Put food on her fork and hand her the fork

    • D. 

      Tell her that two foods are in front of her, one at the top of the tray and one at the bottom.


  • 255. 
    7.    Bumping into a crib, the nurse notices that the newborn infant demonstrates the Moro (startle) reflex. This is seen as the following:
    • A. 

      Alternate flexion, adduction, and extension of the legs

    • B. 

      Extension of one side of the body while the other side is flexed

    • C. 

      Abduction, extension, and adduction of arms to an embracing position

    • D. 

      Flexion of the knees and hips with movement of the legs upward


  • 256. 
    The nurse realizes that the discharge instructions given to a woman with placenta previa are understood when the nurse overhears the client tell her husband,
    • A. 

      "We can't have sex for a few days"

    • B. 

      "I have to return in a few days for a vaginal exam."

    • C. 

      "I will have to have a cesarean for this and other pregnancies."

    • D. 

      "I can go back to part-time work beginning tomorrow."


  • 257. 
    9.    Miss Rodriguez is an 88-year-old client at a long-term care facility. Prior to administering any medication or treatment to this client the nurse must confirm identity by asking the client if she is Miss Rodriguez
    • A. 

      Asking the client if she is Miss Rodriguez

    • B. 

      Reading the client's identification bracelet

    • C. 

      Reading the client's medical record

    • D. 

      Asking the roommate to state the client's name


  • 258. 
    A young adult is involuntarily admitted to the psychiatric unit in a manic state. Upon arrival on the unit he is unable to sit, and it is very difficult to follow what he is saying because of the rate and content of speech. He is very provocative and refuses to eat or drink. The area of disturbance that poses the greatest physical danger to this client is
    • A. 

      Physical activity

    • B. 

      Perceptual input

    • C. 

      Sensory input

    • D. 

      Social activity


  • 259. 
    A young man was arrested by the police for indecent exposure, loitering, and disturbing the peace. He became hyperactive, stripped off his clothes, and terrorized people living in the area near the house. He was then admitted to the psychiatric unit. Upon admission he was speaking very rapidly, and moved quickly around the unit, never sitting. He refused to eat or drink. The nursing diagnosis that would most appropriately describe the behavior that is of greatest concern is :
    • A. 

      Self provoked anxiety episode

    • B. 

      Self potential for violence

    • C. 

      Spiritual distress

    • D. 

      Alteration in nutrition by less than body requirements


  • 260. 
    12.    A young woman with a history of bipolar disorder is admitted to the psychiatric unit. She is talking excitedly and walking rapidly around the unit. During the initial period of hospitalization, the nurse would most likely encourage the client to participate in group and therapeutic activities.
    • A. 

      Observe the client closely until she calms down

    • B. 

      Place the client in four-point restraints for protection of self and others

    • C. 

      Encourage the client to participate in group and therapeutic activities

    • D. 

      Place the client in seclusion but maintain frequent one-to-one contact with her


  • 261. 
    Which of the following is least likely to influence the potential for patient to comply with lithium therapy after discharge?
    • A. 

      The impact of lithium on the client's energy level and life-style

    • B. 

      The need for consistent blood level monitoring

    • C. 

      The potential side effects of lithium.

    • D. 

      What the client's friends think of his need to take medication


  • 262. 
    The nurse in the delivery room is caringfor the newborn. Which action is the most important and most immediate action for the nurse to take?
    • A. 

      Do the Apgar score within 1 hour of birth

    • B. 

      Dry the baby completely and cuddled the baby

    • C. 

      Place identification bracelets on the infant and the mother

    • D. 

      Prevent infection by doing eye care


  • 263. 
    The nurse is caring for a 30-week baby girl who is currently receiving 15 ml of breast milk via oral gastric tube every three hours. As part of the routine assessment the nurse should assess which of the following?
    • A. 

      Assess for heme in the stool at each bowel movement

    • B. 

      Assess abdominal girth once every three days

    • C. 

      Assess for residual once per shift

    • D. 

      Assess for tube placement once every 24 hours


  • 264. 
    19.    The nurse is caring for a 48-hour full-term infant whose mother abused cocaine and heroin throughout pregnancy. The mother does not wish to go into rehabilitation at this time. The nursing care plan should include which of the following?            
    • A. 

      Feeding the infant whenever it cries or acts hungry

    • B. 

      Allowing extra time to assist the woman with breastfeeding and promote attachment

    • C. 

      Organizing all necessary care around feeding times

    • D. 

      Covering the baby loosely with a blanket to prevent irritation


  • 265. 
    The mother of a two year-old hospitalized child asks the nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. The best response of the nurse would be to:    
    • A. 

      Request for the mother to remain with the child at all times

    • B. 

      Request for the mother to remain with the child at all times

    • C. 

      Help the mother understand that this is a normal response to hospitalization

    • D. 

      Suggest that the mother "sneak out" of the child's room when the child is asleep


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