EMT Practice Test

1. Question Content...

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Question1: A 14-year-old client has a history of lying, stealing, and destruction of property. Personal items of peers have been found missing. After group therapy, a peer approaches the nurse to report that he has seen the
14- year-old with some of the missing items. The best response of the nurse is to:

Question2: A client decided early in her pregnancy to breast-feed her first baby. She gave birth to a normal, full-term girl and is now progressing toward the establishment of successful lactation. To remove the baby from her breast, she should be instructed to:

Question3: What is the appropriate nursing action for a child with increased intracranial pressure?

Question4: A 70-year-old homeless woman is admitted with pneumonia. She is weak, emaciated, and febrile. The physician orders enteral feedings intermittently by nasogastric tube. When inserting the nasogastric tube, once the tube passes through the oropharynx, the nurse will instruct the client to:

Question5: A 15-year-old female adolescent is frequently breaking the rules of the unit. She has left the unit and was found smoking in the bathroom and spending a large amount of time in the male ward. Which statement by the nurse would best explain to the teenager why she must follow the rules of the unit?

Question6: Assessment of severe depression in a client reveals feelings of hopelessness, worthlessness; inability to feel pleasure; sleep, psychomotor, and nutritional alterations; delusional thinking; negative view of self; and feelings of abandonment. These clinical features of the client's depression alert the nurse to prioritize problems and care by addressing which of the following problems first:

Question7: A 5-year-old child cries continually in her bed. Her parents have been unsuccessful in assisting her in expressing her feelings. Which activity should the nurse provide the child to assist her in expressing her feelings?

Question8: A six-month-old infant has been admitted to the emergency room with febrile seizures. In the teaching of the parents, the nurse states that:

Question9: A type I diabetic client delivers a male newborn. The newborn is 45 minutes old. What is the primary nursing goal in the nursery during the first hours for this newborn?

Question10: A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the gravida and para system to record the client's obstetrical history, the nurse should record:

Question11: Which of the following findings would be abnormal in a postpartal woman?

Question12: The nurse begins morning assessment on a male client and notices that she is unable to palpate either of his dorsalis pedis pulses in his feet. What is the first nursing action after assessing this finding?

Question13: A client had abdominal surgery this morning. The nurse notices that there is a small amount of bloody drainage on his surgical dressing. The nurse would document this as what type of drainage?

Question14: A client in active labor asks the nurse for coaching with her breathing during contractions. The client has attended Lamaze birth preparation classes. Which of the following is the best response by the nurse?

Question15: When discussing the relationship between exercise and insulin requirements, a 26-year-old client with IDDM should be instructed that:

Question16: Discharge teaching was effective if the parents of a child with atopic dermatitis could state the importance of:

Question17: A 75-year-old client is hospitalized with pneumonia caused by gram-positive bacteria. Which one of the following best describes a gram-positive bacterial pneumonia?

Question18: A mother brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routine examination and screening. Which of these plans by the nurse would be most successful?

Question19: Nursing assessment of early evidence of septic shock in children at risk includes:

Question20: A physician's order reads: 0.25 normal saline at 50 mL/hr until discontinued. The nurse is using a microdrip tubing set. How many drops per minute should the nurse administer?

Question21: A 48-year-old client is being seen in her physician's office for complaints of indigestion, heartburn, right upper quadrant pain, and nausea of 4 days' duration, especially after meals. The nurse realizes that these symptoms may be associated with cholecystitis and therefore would check for which specific sign during the abdominal assessment?

Question22: Prior to an amniocentesis, a fetal ultrasound is done in order to:

Question23: Which of the following nursing actions is essential to prevent drug-resistant tuberculosis?

Question24: A schizophrenic client who is experiencing thoughts of having special powers states that "I am a messenger from another planet and can rule the earth." The nurse assesses this behavior as:

Question25: Assessment of a client reveals a 30% loss of preillness weight, lanugo, and cessation of menses for 3 months. Her vital signs are BP 90/50, P 96 bpm, respirations 30, and temperature 97 οF. She admits to the nurse that she has induced vomiting 3 times this morning, but she had to continue exercising to lose "just 5 more lb." Her symptoms are consistent with:

Question26: At 32 weeks' gestation, a client is scheduled for a fetal activity test (nonstress test). She calls the clinic and asks the RN, "How do I prepare for the test I am scheduled for?" The RN will most likely inform her of the following instructions to help prepare her for the test:

Question27: When teaching a sex education class, the nurse identifies the most common STDs in the United States as:

Question28: A 10-month-old infant's mother says that he takes fresh whole milk eagerly, but that when she offered him baby foods at 6 months of age, he pushed them out of his mouth. Because he has gained weight appropriately, she has quit trying to get him to eat other foods. The nurse's response is based on the knowledge that:

Question29: Following TURP, which of the following instructions would be appropriate to prevent or alleviate anxiety concerning the client's sexual functioning?

Question30: A client who was started on antipsychotic medication 2 weeks ago is preparing for discharge from the hospital. Compliance with the medication regimen is important despite the mild side effects encountered. In order to increase the likelihood of medication compliance, the nurse would:

Question31: Which of the following menu choices would indicate that a client with pressure ulcers understands the role diet plays in restoring her albumin levels?

Question32: An 80-year-old male client with a history of arteriosclerosis is experiencing severe pain in his left leg that started approximately 20 minutes ago. When performing the admission assessment, the nurse would expect to observe which of the following:

Question33: The day following his admission, the nurse sits down by a male client on the sofa in the dayroom. He was admitted for depression and thoughts of suicide. He looks at the nurse and says, "My life is so bad no one can do anything to help me." The most helpful initial response by the nurse would be:

Question34: A 40-year-old client has lived for 8 years with an abusive spouse. She married her husband in her senior year of high school after becoming pregnant. Shortly after the baby was born, he began to physically abuse her. She has attempted to leave him several times, but she has always returned. She is unable to support herself financially, and her husband threatens to kill her if she leaves him. This time, her husband has beaten her so badly she cannot stop the bleeding from the gash above her eye. She admits her husband caused her injury. In assessing a person after experiencing spousal abuse, which need has the highest priority?

Question35: Painless vaginal bleeding in the last trimester may be caused by:

Question36: A 30-year-old male client is admitted to the psychiatric unit with a diagnosis of bipolar disorder. For the last
2 months, his family describes him as being "on the move," sleeping 3-4 hours nightly, spending lots of money, and losing approximately 10 lb. During the initial assessment with the client, the nurse would expect him to exhibit which of the following?

Question37: A woman diagnosed with multiple sclerosis is disturbed with diplopia. The nurse will teach her to:

Question38: One week ago, a 21-year-old client with a diagnosis of bipolar disorder was started on lithium 300 mg po qid. A lithium level is ordered. The client's level is 1.3 mEq/L. The nurse recognizes that this level is considered to be:

Question39: A client tells the nurse that he has been hearing voices that tell him to kill his girlfriend because she is a spy. He further states that he is having difficulty not obeying the voices because, if he does not, his house will be burned down. The highest priority nursing diagnosis for him at this time is:

Question40: While the nurse is taking a male client's blood pressure, he makes flirtatious remarks to her. The nurse will handle this effectively if she:

Question41: A 29-year-old client is diagnosed with borderline personality disorder. He has aroused the nurse's anger by using a condescending tone of voice with other clients and staff persons. Which of the following statements from the nurse would be most appropriate in acknowledging feelings regarding the client's behavior?

Question42: A child receiving chemotherapeutic drugs experiences a loss of appetite directly related to the therapy.
Which of the following strategies should be most effective in encouraging the child to eat?

Question43: The priority nursing goal when working with an autistic child is:

Question44: The nurse is interviewing a client with a diagnosis of possible abdominal aortic aneurysm. Which of the following statements will be reflected in the client's chief complaint?

Question45: A 26-year-old client is in a treatment center for aprazolam (Xanax) abuse and continues to manifest moderate levels of anxiety 3 weeks into the rehabilitation program, often requesting medication for "his nerves." Included in the client's plan of care is to identify alternate methods of coping with stress and anxiety other than use of medication. After intervening with assistance in stress reduction techniques, identifying feelings and past coping, the nurse evaluates the outcome as being met if:

Question46: Degenerative disorders are attributed to many factors. As a nurse assigned to a convalescent home, one must often educate families about how such conditions occur. Which of the following statements might the nurse need to explore when a daughter tries to explain to her mother what caused her degenerative disorder?

Question47: Which of the following risk factors associated with breast cancer would a nurse consider most significant in a client's history?

Question48: A client has a chest tube placed in his left pleural space to re-expand his collapsed lung. In a closed-chest drainage system, the purpose of the water seal is to:

Question49: A child with celiac disease is being discharged from the hospital. The mother demonstrates knowledge of nutritional needs of her child when she is able to state the foods which are included in a:

Question50: A client had a myocardial infarction 5 days ago. His physician has ordered an echocardiogram to determine how his myocardial infarction has affected his ventricular wall motion. When the client asks if this test is painful, an appropriate response is:

Question51: A 52-year-old female client is admitted to the hospital in acute renal failure. She has been on hemodialysis for the past 2 years. Stat arterial blood gases are drawn on the client yielding the following results: pH
7.30, PCO2 51 mm Hg, HCO3, 18 mEq/L, PaO2, 84 mm Hg. The nurse would interpret these results as:

Question52: A 9-month-old infant visits her pediatrician for a routine visit. A developmental assessment was initiated by the nurse. Which skill would cause the nurse to be concerned about the infant's developmental progression?

Question53: A client is being discharged with albuterol (Proventil) and beclomethasone dipropionate (Vanceril) to be administered via inhalation three times a day and at bedtime. Client teaching regarding the sequential order in which the drugs should be administered includes:

Question54: A 27-year-old man was diagnosed with type I diabetes 3 months ago. Two weeks ago he complained of pain, redness, and tenderness in his right lower leg. He is admitted to the hospital with a slight elevation of temperature and vague complaints of "not feeling well." At 4:30 PM on the day of his admission, his blood glucose level is 50 mg; dinner will be served at 5:00 PM. The best nursing action would be to:

Question55: Based on your knowledge of genetic inheritance, which of these statements is true for autosomal recessive genetic disorders?

Question56: After performing a sterile vaginal exam on a client who has just been admitted to the unit in active labor and placed on an electronic fetal monitor, the RN assesses that the fetal head is at 21 station. She documents this on the monitor strip. Fetal head at 21 station means that the fetal head is located where in the pelvis?

Question57: A male client has been an insulin-dependent diabetic for approximately 30 years. He frequently indulges in highsugar foods and forgets to take his insulin. He has not experienced acute diabetic emergencies over the years but is now beginning to demonstrate symptoms of diabetic peripheral neuropathy. This distresses him because dancing is one of his favorite pastimes. He decides to question his wife's home health nurse about diabetic peripheral neuropathy. The nurse points out his noncompliance to his diabetic diet and insulin regimen. The client answers the nurse, "It has been my experience that the diabetic diet is very difficult to follow. As far as the insulin, isn't a fellow allowed to forget now and then?" The client's actions and response best demonstrate:

Question58: Primary nursing diagnoses for the antisocial client are:

Question59: A 15-year-old child is admitted to the pediatric unit with a diagnosis of thalassemia. Which of the following would be included in educating the mother and child as part of discharge planning?

Question60: A client was not using his seat belt when involved in a car accident. He fractured ribs 5, 6, and 7 on the left and developed a left pneumothorax. Assessment findings include:

Question61: A psychiatric nurse is providing an orientation to a new staff nurse. She reminds the nurse that psychiatrists often use categories of medications and that it is important that she recall that some categories of medications have synonyms. Another name used to describe minor tranquilizers is which of the following?

Question62: A 15-year-old client was diagnosed as having cystic fibrosis at 8 months of age. He is in the hospital for a course of IV antibiotic therapy and vigorous chest physiotherapy. He has a poor appetite. The nurse can best help him to meet the desired outcome of consuming a prescribed number of calories by:

Question63: A 4-week-old infant is admitted to the emergency room in respiratory distress. Which of the following statements indicates the nurse's knowledge of the anatomy of the respiratory system in pediatric clients?

Question64: Following a fracture of the left femur, a client develops symptoms of osteomyelitis. During the acute phase of osteomyelitis, nursing care is directed toward:

Question65: A primipara is assessed on arrival to the postpartum unit. The nurse finds her uterus to be boggy. The nurse's first action should be to:

Question66: Cystic fibrosis is transmitted as an autosomal recessive trait. This means that:

Question67: A type I diabetic client is diagnosed with cellulitis in his right lower extremity. The nurse would expect which of the following to be present in relation to his blood sugar level?

Question68: A 28-year-old client performs a long, involved ritual in getting up and preparing for the day. He became unable to get to his job before noon. His family, in desperation, has admitted him to the hospital's psychiatric unit. On the unit, he is always late for breakfast, which is served at 8 am. The nurse identifies that the best approach to this problem is to:

Question69: A seventh grader lost consciousness after being hit in the head with a basketball. In the emergency room his vital signs are stable, and he demonstrates no neurologic deficit. He will not be admitted to the hospital.
It is most important that you advise his mother to:

Question70: A mother frantically calls the emergency room (ER) asking what to do about her 3-year-old girl who was found eating pills out of a bottle in the medicine cabinet. The ER nurse tells the mother to:

Question71: Following a gastric resection, which of the following actions would the nurse reinforce with the client in order to alleviate the distress from dumping syndrome?

Question72: A client who has sustained a basilar skull fracture exhibits blood-tinged drainage from his nose. After establishing a clear airway, administering supplemental O2, and establishing IV access, the next nursing intervention would be to:

Question73: On an assessment of a client's mouth, the nurse notices white patches on the buccal mucosa. The nurse tries to obtain a sample for a culture, but the lesion cannot be rubbed off. The nurse would suspect that this lesion is:

Question74: A 2-day-old infant boy has been diagnosed with an atrial septal defect due to a persistent patent foramen ovale.
When explaining the diagnosis to the mother, the nurse includes in the discussion the function of the foramen ovale. In fetal circulation, the foramen ovale allows a portion of the blood to bypass the:

Question75: An 8-year-old child is admitted to the hospital for surgery. She has had no previous hospitalizations, and both she and her family appear anxious and fearful. It will be most helpful for the nurse to:

Question76: A 10-year-old has been diagnosed with acute poststreptococcal glomerulonephritis. The clinical findings were proteinuria, moderately elevated blood pressure, and periorbital edema. Which dietary plan is most appropriate for this client?

Question77: A 16-year-old female client is admitted to the hospital because she collapsed at home while exercising with videotaped workout instructions. Her mother reports that she has been obsessed with losing weight and staying slim since cheerleader try-outs 6 months ago, when she lost out to two of her best friends. The client is 5'4" and weighs 92 lb, which represents a weight loss of 28 lb over the last 4 months. The most important initial intervention on admission is to:

Question78: A normal 3-year-old child is suspected of having meningitis. The doctor has ordered a lumbar puncture. In light of this procedure and developmental characteristics of this age group, which nursing measure is most appropriate?

Question79: A male client is started on IV anticoagulant therapy with heparin. Which of the following laboratory studies will be ordered to monitor the therapeutic effects of heparin?

Question80: A 55-year-old client is unconscious, and his physician has decided to begin tube feeding him using a smallbore silicone feeding tube (Keofeed, Duo-Tube). After the tube is inserted, the nurse identifies the most reliable way to confirm appropriate placement is to:

Question81: A client is 6 weeks pregnant. During her first prenatal visit, she asks, "How much alcohol is safe to drink during pregnancy?" The nurse's response is:

Question82: On admission to the inpatient unit, a 34-year-old client is able to follow simple directions, but with great difficulty.
He is worried about how he can keep clean in such a public place and repeatedly dusts his bureau, straightens his bed, and adjusts the clothes in his closet. The client is experiencing a severe level of anxiety. Which response by the nurse would be most therapeutic in initially attempting to reduce his anxiety?

Question83: A chronic alcoholic client's condition deteriorates, and he begins to exhibit signs of hepatic coma. Which of the following is an early sign of impending hepatic coma?

Question84: A client with a head injury asks why he cannot have something for his headache. The nurse's response is based on the understanding that analgesics could:

Question85: A female client is started on warfarin (Coumadin) 5 mg po bid. To adequately evaluate the effectiveness of the warfarin therapy, the nurse must know that this medication:

Question86: A post-lung surgery client is placed on a chest tube drainage system. When explaining to the family how the system works, the nurse states that the water-seal bottle of a three-bottle chest drainage system serves which of the following purposes?

Question87: A 20-year-old male client is being treated for protein deficiency. If he likes all of the following foods, which one would the nurse recommend to increase in the diet?

Question88: A 6-year-old girl has been diagnosed with a urinary tract infection secondary to vesicoureteral reflux.
Which statement by her mother indicates a need for further teaching?

Question89: A 30-year-old female client is receiving antineoplastic chemotherapy. Which of the following symptoms should especially concern the nurse when caring for her?

Question90: A 25-year-old outpatient presents with a diagnosis of compulsive personality disorder. His coworkers become annoyed with his rigid, perfectionistic manner and preoccupation with trivial details and schedules.
A nursing intervention appropriate for this client would include:

Question91: On morning rounds, the nurse found a manic-depressive client who is taking lithium in a confused mental state, vomiting, twitching, and exhibiting a coarse hand tremor. Which one of the following nursing actions is essential at this time?

Question92: A 19-year-old male client arrived via ambulance to the emergency room following a motorcycle accident.
He is comatose. His face has evidence of dried blood. On assessment, the nurse notes an obvious injury to his left eye. The preferred positioning for a client with an obvious eye injury is:

Question93: A 10-year-old boy has been diagnosed with Legg-Calvé Perthes disease. Which of the client's responses would indicate compliance during initial therapy?

Question94: A depressed client is seen at the mental health center for follow-up after an attempted suicide 1 week ago.
She has taken phenelzine sulfate (Nardil), a monoamine oxidase (MAO) inhibitor, for 7 straight days. She states that she is not feeling any better. The nurse explains that the drug must accumulate to an effective level before symptoms are totally relieved. Symptom relief is expected to occur within:

Question95: The nurse practitioner determines that a client is approximately 9 weeks' gestation. During the visit, the practitioner informs the client about symptoms of physical changes that she will experience during her first trimester, such as:

Question96: A 22-year-old client is 16 weeks pregnant. She and her husband are expecting their first baby. The client tells the nurse that her last normal menstrual period was February 16, with 3 days of spotting on February
17, 18, and 19. The nurse calculates her expected date of delivery to be:

Question97: A client is experiencing muscle weakness and lethargy. His serum K+is 3.2. What other symptoms might he exhibit?

Question98: The nurse will be alert to the most potentially lifethreatening side effect associated with the administration of monoamine oxidase (MAO) inhibitor. This is:

Question99: A 3-year-old female client is brought into the pediatric clinic because she limps. She has not been to the clinic since she was 9 months old. The nurse practitioner describes the limp as a "Trendelenburg gait." This gait is characteristic of:

Question100: The nurse teaches a pregnant client that a high-risk symptom occurring at any time during pregnancy that needs to be reported immediately to a healthcare provider is:

Question101: A 4-year-old boy is brought to the emergency room with bruises on his head, face, arms, and legs. His mother states that he fell down some steps. The nurse suspects that he may have been physically abused.
In accordance with the law, the nurse must:

Question102: MgSO4 is ordered IV following the established protocol for a client with severe PIH. The anticipated effects of this therapy are anticonvulsant and:

Question103: One of the medications that is prescribed for a male client is furosemide (Lasix) 80 mg bid. To reduce his risk of falls, the nurse would teach him to take this medication:

Question104: Which of the following nursing care goals has the highest priority for a child with epiglottitis?

Question105: A client reports to the nurse that the voices are practically nonstop and that he needs to leave the hospital immediately to find his girlfriend and kill her. The best verbal response to the client by the nurse at this time is:

Question106: The nurse is caring for a client who has diabetes insipidus. The nurse would describe this client's urine output pattern as:

Question107: The primary reason for sending a burn client home with a pressure garment, such as a Jobst garment, is that the garment:

Question108: The nurse is teaching a mother care of her child's spica cast. The mother states that he complains of itching under the edge of the cast. One nonpharmacological technique the nurse might suggest would be:

Question109: The nurse would need to monitor the serum glucose levels of a client receiving which of the following medications, owing to its effects on glycogenolysis and insulin release?

Question110: As a postoperative cholecystectomy client completes tomorrow's dinner menu, the nurse knows that one of the following meal choices will best provide the essential vitamin(s) necessary for proper tissue healing?

Question111: A client is taught to eat foods high in potassium. Which food choices would indicate that this teaching has been successful?

Question112: A client confides to the nurse that he tasted poison in his evening meal. This would be an example of what type of hallucination?

Question113: A 48-year-old female client is going to have a cholecystectomy in the morning. In planning for her postoperative care, the nurse is aware that a priority nursing diagnosis for her will be high risk for:

Question114: When a client arrives on the labor and delivery unit, she informs the nurse that she has been having contractions for the last 5 hours. Now the pain is constant and not cyclical as it was earlier. The nurse considers the possibility of uterine rupture. Which of the following symptoms would be consistent with a uterine rupture?

Question115: A client delivered a term infant 1 hour ago. Her uterus on assessment is boggy and is U +1 in contrast to the previous assessment of U _2. The immediate nursing response is to:

Question116: A client's congestive heart failure has been treated, and he will soon be discharged. Discharge teaching should include instruction to call the physician if he notices a 2-lb weight gain in a 24-hour period.
Increased weight gain may indicate:

Question117: A client has been in labor for 10 hours. Her contractions have become hypoactive and slowed in duration.
The fetus is at 0 station, cervix is dilated 8 cm and effaced 90%. The physician orders an oxytocin (Pitocin) infusion to be started at once. The RN begins the oxytocin infusion. It is important that the RN discontinue the infusion if which one of the following occur?

Question118: Diabetes during pregnancy requires tight metabolic control of glucose levels to prevent perinatal mortality.
When evaluating the pregnant client, the nurse knows the recommended serum glucose range during pregnancy is:

Question119: A physician tells the nurse that he wants to orally intubate a client with a No. 8 endotracheal tube. The finding of normal breath sounds on the right side of the chest and diminished, distant breath sounds on the left side of the chest of a newly intubated client is probably due to:

Question120: The nurse would expect to include which of the following when planning the management of the client with Lyme disease?

Question121: On the third postpartum day, the nurse would expect the lochia to be:

Question122: A 42-year-old client on an inpatient psychiatric unit comments that he was brought to the hospital by his wife because he had taken too many pills and states, "I just couldn't take it anymore." The nurse's best response to this disclosure would be:

Question123: A first-trimester primigravida is diagnosed with anemia.
The nurse should suspect that this anemia is a result of:

Question124: When planning care for the passive-aggressive client, the nurse includes the following goal:

Question125: Following a bicycle accident, a 12-year-old client sustained a complete fracture of the left femur. He was placed in 90◦-90◦ skeletal traction with a pin in the distal end of the femur to achieve realignment and immobilization of the left femur. When providing nursing care, it is important for the nurse to remember that:

Question126: A client at 6 months' gestation complains of tiredness and dizziness. Her hemoglobin level is 10 g/dL, and her hematocrit value is 32%. Her nutritional intake is assessed as sufficient. The most likely diagnosis is:

Question127: A 25-year-old lawyer who is married with three young children works long hours in an effort to become a partner in the law firm. Following a recent hospitalization for a bleeding ulcer, he was referred for therapy to treat this psychophysiological disorder. On meeting with the therapist, he informed him or her that he was a busy man and did not have much time for this "psych stuff." When guiding the client to ventilate his feelings, the therapist can expect him to express feelings of:

Question128: The physician of an alcoholic client places him on a low-protein, high-carbohydrate diet. When choosing his menu, the client's best choice from the items below would be:

Question129: When administering phenytoin (Dilantin) to a child, the nurse should be aware that a toxic effect of phenytoin therapy is:

Question130: The nurse notes multiple bruises on the arms and legs of a newly admitted client with lupus. The client states, "I get them whenever I bump into anything." The nurse would expect to note a decrease in which of the following laboratory tests?

Question131: A 28-year-old client comes to the clinic for her first prenatal examination. In relating her obstetrical history, she tells the nurse that she has been pregnant twice before. She had a "miscarriage" with the first pregnancy after 6 weeks. With the second pregnancy, she delivered twin girls at 31 weeks' gestation. One of the twins was stillborn and the other twin died at 4 days of age. Using a five-digit system, the nurse records her as being:

Question132: When assessing a child with diabetes insipidus, the nurse should be aware of the cardinal signs of:

Question133: A female client is seeking counseling for personal problems. She admits to being very unhappy lately at both home and work. During the nursing assessment, she uses many defense mechanisms. Which statement or action made by the client is an example of adaptive suppression?

Question134: A 68-year-old woman is admitted to the hospital with chronic obstructive pulmonary disease (COPD). She is started on an aminophylline infusion. Three days later she is breathing easier. A serum theophylline level is drawn. Which of the following values represents a therapeutic level?

Question135: A client is diagnosed with Mycobacterium tuberculosis. He is placed in respiratory isolation, intubated, and receives mechanical ventilation. When performing suctioning, the nurse should:

Question136: A client develops complications following a hysterectomy. Blood cultures reveal Pseudomonas aeruginosa.
The nurse expects that the physician would order an appropriate antibiotic to treat P aeruginosa such as:

Question137: A client is admitted to the labor room. She is dilated 4 cm. She is placed on electric fetal monitoring. Which of the following observations necessitates notifying the physician?

Question138: Clinical manifestations seen in left-sided rather than in right-sided heart failure are:

Question139: A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the GTPAL system to record her obstetrical history, the nurse should record:

Question140: A client had a cardiac catheterization with angiography and thrombolytic therapy with streptokinase. The nurse should initiate which of the following interventions immediately after he returns to his room?

Question141: Prior to administering digoxin to a client with congestive heart failure, the nurse needs to assess:

Question142: A client is pleased about being pregnant, yet states, "It is really not the best time, but I guess it will be OK." The nurse's assessment of this response is:

Question143: A 5-year-old child was recently diagnosed as having acute lymphoid leukemia. She is hospitalized for additional tests and to begin a course of chemotherapy designed to induce a remission. She is scheduled to have a bone marrow aspiration tomorrow. She has had a bone marrow test previously and is apprehensive about having another. Which of the following interventions will be most effective in relieving her anxiety?

Question144: Priapism may be a sign of:

Question145: A client had a renal transplant 3 months ago. He has suddenly developed graft tenderness, an increased white blood cell count, and malaise. The client is experiencing which type of rejection?

Question146: Which of the following serum laboratory values would the nurse monitor during gentamicin therapy?

Question147: A primigravida is at term. The nurse can recognize the second stage of labor by the client's desire to:

Question148: A client is being discharged from the hospital tomorrow following a colon resection with a left colostomy.
The nurse knows that the client understands the discharge teaching about care of her colostomy when she says:

Question149: In assessing cardiovascular clients with progression of aortic stenosis, the nurse should be aware that there is typically:

Question150: A child becomes neutropenic and is placed on protective isolation. The purpose of protective isolation is to:

Question151: The nurse is aware that nutrition is an important aspect of care for a client with hepatitis. Which of the following diets would be most therapeutic?

Question152: A male client had a right below-the-knee amputation 4 days ago. His incision is healing well. He has gotten out of bed several times and sat at the side of the bed. Each time after returning to bed, he has experienced pain as if it were located in his right foot. Which nursing measure indicates the nurse has a thorough understanding of phantom pain and its management?

Question153: The physician orders haloperidol 5 mg IM stat for a client and tells the nurse that the dose can be repeated in 1-2 hours if needed. The most likely rationale for this order is:

Question154: The child with iron poisoning is given IV deforoxamine mesylate (Desferal). Following administration, the child suffers hypotension, facial flushing, and urticaria. The initial nursing intervention would be to:

Question155: A 52-year-old client is scheduled for a small-bowel resection in the morning. In conjunction with other preoperative preparation, the nurse is teaching her diaphragmatic breathing exercises. She will teach the client to:

Question156: A 2-year-old child will undergo a cardiac catheterization tomorrow to evaluate his ventricular septal defect.
Based on his developmental stage, the nurse:

Question157: A 14-year-old teenager is demonstrating behavior indicative of an obsessive-compulsive disorder. She is obsessed with her appearance. She will not leave her room until her hair, clothes, and makeup are perfect.
She always dresses immaculately. Recently, she expressed disgust over her appearance after she gained
5 lb. After observing a marked weight loss over a 2-week period, her mother suspects that she is experiencing bulimia. She eats everything on her plate, then runs to the bathroom. In interviewing the teenager, she discusses in great detail all of the events leading to her bulimia, but not her feelings. What defense mechanism is she using?

Question158: Parents of young children often need anticipatory guidance from the nurse. Parents may have little knowledge regarding growth and development. Which of the following toys and activities would the nurse suggest as appropriate for a toddler?

Question159: A hyperactive client is experiencing flight of ideas. The most therapeutic activity for him would be:

Question160: An 82-year-old former restaurant owner walks to the nursing station and states, "I have to go. The restaurant opens at 11 am." Which response by the nurse is the most appropriate?

Question161: A client with bipolar disorder taking lithium tells the nurse that he has ringing in his ears, blurred vision, and diarrhea. The nurse notices a slight tremor in his left hand and a slurring pattern to his speech. Which of the following actions by the nurse is appropriate?

Question162: Early in her ninth month of pregnancy, a client has been diagnosed as having mild preeclampsia. In counseling her about her diet, the nurse must emphasize the importance of:

Question163: A 24-year-old graduate student recognizes that he has a phobia. He suffers severe anxiety when he is in darkness. It has altered his lifestyle because he is unable to go to a movie theater, concert, and other events that may require absence of light. The client is seeking assistance because he is no longer able to socialize with friends due to his phobia. The psychologist working with him is using desensitization. He has asked the nursing staff to assist the client in muscle relaxation techniques. What result would indicate client education has been successful?

Question164: A 45-year-old male client experiences a sense of depression because he has not yet achieved his life's goals. His career has not been satisfying. He is still looking for the right job. His wife spends too much money, and his children seem to ignore him while being very selfish. He is tired of all of their attitudes and is considering buying a red Corvette convertible. While obtaining these data concerning the client's feelings about his life, the nurse is able to determine he is experiencing what psychological crisis according to Erikson's stages?

Question165: The parents of a 9-year-old child with acute lymphocytic leukemia expressed concern about his alopecia from cranial irradiation. The nurse explains that:

Question166: A female client who has chronic obstructive pulmonary disease (COPD) has presented in the emergency department with cough productive of yellow sputum and increasing shortness of breath. On room air, her blood gases are as follows: pH 7.30 mm Hg, PCO2 60 mm Hg, PO2 55 mm Hg, HCO3 32 mEq/L. These arterial blood gases reflect:

Question167: The nurse documents a client's surgical incision as having red granulated tissue. This indicates that the wound is:

Question168: During discharge planning, parents of a child with rheumatic fever should be able to identify which of the following as toxic symptoms of sodium salicylate?

Question169: A registered nurse is trying to determine the appropriate care that she should provide for her obstetrical clients. Which of the following documents is considered the legal standard of practice?

Question170: Diabetes mellitus is a disorder that affects 3.1 out of every 1000 children younger than 20 years old. It is characterized by an absence of, or marked decrease in, circulating insulin. When teaching a newly diagnosed diabetes client, the nurse includes information on the functions of insulin:

Question171: To prevent fungal infections of the mouth and throat, the nurse should teach clients on inhaled steroids to:

Question172: A 64-year-old client is admitted to the hospital with benign prostatic hypertrophy (BPH). He has a history of adult-onset diabetes and hypertension and is scheduled to undergo a resection of the prostate. When recording his health history, the nurse asks about his chief complaint. The most serious symptom that may accompany BPH is:

Question173: A client returns to the cardiovascular intensive care unit following his coronary artery bypass graft. In planning his care, the most important electrolyte the nurse needs to monitor will be:

Question174: A 26-year-old female client presents at 10 weeks' gestation. She currently is a G3 1-0-1-1. Her mother and grandmother have heart disease. Her grandmother also has insulin-dependent diabetes. The client's previous delivery was a term female infant weighing 9 lb 13 oz. The client is 5 ft 6 inches tall and her current weight is 130 lb. Based on her history, she is at risk for developing diabetes in pregnancy. Which of the following factors places her at risk for gestational diabetes?

Question175: A pregnant client complains of varicosities in the third trimester. Which of the following activities should she be advised to avoid?

Question176: A client's prenatal screening indicated that she has no immunity to rubella. She is now 10 weeks pregnant.
The best time to immunize her is:

Question177: A client is having episodes of hyperventilation related to her surgery that is scheduled tomorrow.
Appropriate nursing actions to help control hyperventilating include:

Question178: A male client is scheduled to have angiography of his left leg. The nurse needs to include which of the following when preparing the client for this procedure?

Question179: A 30-year-old client is exhibiting auditory hallucinations. In working with this client, the nurse would be most effective if the nurse:

Question180: Decreased pulmonary blood flow, right-to-left shunting, and deoxygenated blood reaching the systemic circulation are characteristic of:

Question181: A 3-year-old child is admitted with a diagnosis of possible noncommunicating hydrocephalus. What is the first symptom that indicates increased intracranial pressure?

Question182: A 4-year-old child with a history of sickle cell anemia is admitted to the nursing unit with dizziness, shortness of breath, and pallor. Nursing assessment findings reveal tenderness in the abdomen. The child is most likely experiencing a/an:

Question183: A client was exhibiting signs of mania and was recently started on lithium carbonate. She has no known physical problems. A teaching plan for this client would include which of the following?

Question184: Before completing a nursing diagnosis, the nurse must first:

Question185: Pin care is a part of the care plan for a client who is in skeletal traction. When assessing the site of pin insertion, which one of the following findings would the nurse know as an indicator of normal wound healing?

Question186: The nurse explains perineal hygiene self-care postpartum to the client. She should be instructed to:

Question187: The predominant purpose of the first Apgar scoring of a newborn is to:

Question188: The nurse writes the following nursing diagnosis for a client in acute renal failure-Impaired gas exchange related to:

Question189: When a client is receiving vasoactive therapy IV, such as dopamine (Intropin), and extravasation occurs, the nurse should be prepared to administer which of the following medications directly into the site?

Question190: A 45-year-old client has a permanent colostomy. Which of the following foods should he avoid?

Question191: A murmur has been discovered during the routine physical examination of a 1-year-old child. The parent is extremely concerned about this diagnosis. Which of the following explanations by the nurse indicates understanding of this dysfunction?

Question192: The nurse instructs a pregnant client (G2P1) to rest in a side-lying position and avoid lying flat on her back.
The nurse explains that this is to avoid "vena caval syndrome," a condition which:

Question193: A client with a C-3-4 fracture has just arrived in the emergency room. The primary nursing intervention is:

Question194: The family member of a child scheduled for heart surgery states, "I just don't understand this open-heart or closed-heart business. I'm so confused! Can you help me understand it?" The nurse explains that patent ductus arteriosus repair is:

Question195: The mother of a client is apprehensive about taking home her 2 year old who was diagnosed with asthma after being admitted to the emergency room with difficulty breathing and cyanosis. She asks the nurse what symptoms she should look for so that this problem will not happen again. The nurse instructs her to watch for the following early symptoms:

Question196: After 3 weeks of treatment, a severely depressed client suddenly begins to feel better and starts interacting appropriately with other clients and staff. The nurse knows that this client has an increased risk for:

Question197: The initial focus when providing nursing care for a child with rheumatic fever during the acute phase of the illness should be to:

Question198: A 45-year-old male client was admitted to a chemical dependency treatment center following legal problems related to alcohol abuse. He states, "I know that alcohol is a problem for some people, but I can stop whenever I want to. I'm never sick or miss work, and no one can complain about me." During the initial assessment, the best response by the nurse would be:

Question199: A client's physician has prescribed theophylline (Theo- Dur) to help control the bronchospasm associated with the client's COPD. Instructions that should be given to the client include:

Question200: A 5-year-old child has suffered second-degree thermal burns over 30% of her body. Forty-eight hours after the burn injury, the nurse must begin to monitor the child for which one of the following complications?

Question201: Which of the following medications requires close observation for bronchospasm in the client with chronic obstructive pulmonary disease or asthma?

Question202: A client has just received an epidural block. She is laboring on her right side. The nurse notes that her blood pressure has dropped from 132/68 to 78/42 mm Hg. The nurse's first action would be to:

Question203: A client is to have a coronary artery bypass graft performed in the morning using a saphenous vein. He wants to know why the physician does not use the internal mammary artery for his bypass graft because his friend's physician uses this artery. The nurse tells the client that the internal mammary artery:

Question204: A 16-month-old infant is being prepared for tetralogy of Fallot repair. In the nursing assessment, which lab value should elicit further assessment and requires notification of physician?

Question205: Loss of appetite for a child with leukemia is a major recurrent problem. The plan of care should be designed to:

Question206: The primary focus of nursing interventions for the child experiencing sickle cell crisis is aimed toward:

Question207: On admission to the postpartal unit, the nurse's assessment identifies the client's fundus to be soft, 2 fingerbreadths above the umbilicus, and deviated to the right. This is most likely an indication of:

Question208: A 1-year-old child is to receive an IM injection ordered by his pediatrician. He has fallen asleep in his mother's arms when the nurse approaches. Which approach is most appropriate at this time?

Question209: A 28-year-old multigravida has class II heart disease. At her prenatal visit at 34 weeks' gestation, all of the following observations are made. Which would require intervention?

Question210: The client has been in active labor for the last 12 hours. During the last 3 hours, labor has been augmented with oxytocin because of hypoactive uterine contractions. Her physician assesses her cervix as
95% effaced, 8 cm dilated, and the fetus is at 0 station. Her oral temperature is 100.2F at this time. The physician orders that she be prepared for a cesarean delivery. In preparing the client for the cesarean delivery, which one of the following physician's orders should the RN question?

Question211: When a client with pancreatitis is discharged, the nurse needs to teach him how to prevent another occurrence of acute pancreatitis. Which of the following statements would indicate he has an understanding of his disease?

Question212: On a mother's 2nd postpartum day after having a vaginal delivery, the RN is preparing to assess her perineum and anus as part of her daily assessment. The best position for the client to be placed in for this assessment is:

Question213: A 44-year-old female client is receiving external radiation to her scapula for metastasis of breast cancer.
Teaching related to skin care for the client would include which of the following?

Question214: A 42-year-old client with bipolar disorder has been hospitalized on the inpatient psychiatric unit. She is dancing around, talking incessantly, and singing. Much of the time the client is anorexic and eats very little from her tray before she is up and about again. The nurse's intervention would be to:

Question215: In discussing the plan of care for a child with chronic nephrosis with the mother, the nurse identifies that the purpose of weighing the child is to:

Question216: Which of the following would indicate the need for further teaching for the client with COPD? The client verbalizes the need to:

Question217: A postoperative TURP client is ordered continuous bladder irrigations. Later in the evening on the first postoperative day, he complains of increasing suprapubic pain. When assessing the client, the nurse notes diminished flow of bloody urine and several large blood clots in the drainage tubing. Which one of the following should be the initial nursing intervention?

Question218: A 14-year-old boy has had diabetes for 7 years. He takes 30 U of NPH insulin and 10 U of regular insulin every morning at 7 AM. He eats breakfast at 7:30 AM and lunch at noon. What time should he expect the greatest risk for hypoglycemia?

Question219: The nurse would teach a male client ways to minimize the risk of infection after eye surgery. Which of the following indicates the client needs further teaching?

Question220: A client is a victim of domestic violence. She is now receiving assistance at a shelter for battered women.
She tells the nurse about the cycle of violence that she has been experiencing in her relationship with her husband of 5 years. In the "tension-building phase," the nurse might expect the client to describe which of the following?

Question221: A client who has been diagnosed with anorexia nervosa reluctantly agrees to eat all prescribed meals. The most important intervention in monitoring her dietary compliance would be to:

Question222: A female client at 10 weeks' gestation complains to her physician of slight vaginal bleeding and mild cramps. On examination, her physician determines that her cervix is closed. The client is exhibiting signs of:

Question223: A client delivered a stillborn male at term. An appropriate action of the nurse would be to:

Question224: A 70-year-old female client is admitted to the medical intensive care unit with a diagnosis of cerebrovascular accident (CVA). She is semicomatose, responding to pain and change in position. She is unable to speak or cough. In planning her nursing care for the first 24 hours following a CVA, which nursing diagnosis should receive the highest priority?

Question225: A client has been instructed in how to take her nitroglycerin tablets. The nurse giving her instructions knows the client understands the information when she tells her:

Question226: A 2-year-old boy is in the hospital outpatient department for observation after falling out of his crib and hitting his head. The nurse calls the physician to report:

Question227: A family by court order undergoes treatment by a family therapist for child abuse. The nurse, who is the child's case manager knows that treatment has been effective when:

Question228: A 42-year-old male client has been treated at an alcoholic rehabilitation center for physiological alcohol dependence. The nurse will be able to determine that he is preparing for discharge and is effectively coping with his problem when he shares with her the following information:

Question229: A young child has been placed in a spica cast. The chief concern of the nurse during the first few hours is:

Question230: The physician has prescribed metoclopramide (Reglan). When assessing the client, the nurse would expect to find which of the following responses?

Question231: An 18-month-old child has been playing in the garage. His mother brings him to a nurse's home complaining of his mouth being sore. His lips and mouth are soapy and white, with small ulcerated areas beginning to form. The child begins to vomit. His pulse is rapid and weak. The nurse suspects that the child has:

Question232: Which of the following blood values would require further nursing action in a newborn who is 4 hours old?

Question233: A measurable outcome criterion in the nursing care of an adolescent with anorexia nervosa would be:

Question234: Two hours after the second injection of haloperidol, a client complains to the nurse of a stiff neck and inability to sit still. He is experiencing symptoms consistent with:

Question235: Which of the following changes in blood pressure readings should be of greatest concern to the nurse when assessing a prenatal client?

Question236: A child sustains a supracondylar fracture of the femur. When assessing for vascular injury, the nurse should be alert for the signs of ischemia, which include:

Question237: When caring for a postoperative cholecystectomy client, the nurse assesses patency and documents drainage of the T-tube. The nurse recognizes that the expected amount of drainage during the first 24 hours postoperatively is:

Question238: A 17-year-old pregnant client who is gravida 1, para 0, is at 36 weeks' gestation. Based on the nurse's knowledge of the maternal physiological changes in pregnancy, which of these findings would be of concern?

Question239: Nursing care for the substance abuse client experiencing alcohol withdrawal delirium includes:

Question240: A male client is experiencing auditory hallucinations. His nurse enters the room and he tells her that his mother is talking to him, and he will take his medicine after she leaves. The nurse looks around the room and sees that she and the client are the only ones in the room. The nurse's most therapeutic response will be:

Question241: A pregnant client is at the clinic for a third trimester prenatal visit. During this examination, it has been determined that her fetus is in a vertex presentation with the occiput located in her right anterior quadrant.
On her chart this would be noted as:

Question242: A 40-year-old client is admitted to the coronary care unit with chest pain and shortness of breath. The physician diagnosed an anterior wall myocardial infarction.
What tests should the nurse anticipate?

Question243: The therapeutic blood-level range for lithium is:

Question244: In evaluating the laboratory results of a client with severe pressure ulcers, the nurse finds that her albumin level is low. A decrease in serum albumin would contribute to the formation of pressure ulcers because:

Question245: The nurse is teaching a 10-year-old insulin-dependent diabetic how to administer insulin. Which one of the following steps must be taught for insulin administration?

Question246: A 33-year-old client is diagnosed with bipolar disorder, acute phase. This is her first psychiatric hospitalization, and she is being evaluated for treatment with lithium. Which of the following diagnostic tests are essential prior to the initiation of lithium therapy with this client?

Question247: Which of the following would have the physiological effect of decreasing intracranial pressure (ICP)?

Question248: The nurse is caring for a client who has had a tracheostomy for 7 years. The client is started on a fullstrength tube feeding at 75 mL/hr. Prior to starting the tube feeding, the nurse confirms placement of the tube in the stomach. The hospital policy states that all tube feeding must be dyed blue. On suctioning, the nurse notices the sputum to be a blue color. This is indicative of which of the following?

Question249: In a client with chest trauma, the nurse needs to evaluate mediastinal position. This can best be done by:

Question250: A child has a nursing diagnosis of fluid volume excess related to compromised regulatory mechanisms.
Which of the following nursing interventions is the most accurate measure to include in his care?

Question251: In cleansing the perineal area around the site of catheter insertion, the nurse would:

Question252: Which one of the following is considered a reliable indicator for assessing the adequacy of fluid resuscitation in a 3-year-old child who suffered partial- and fullthickness burns to 25% of her body?

Question253: A client with emphysema is placed on diuretics. In order to avoid potassium depletion as a side effect of the drug therapy, which of the following foods should be included in his diet?

Question254: During a client's first postpartum day, the nurse assessed that the fundus was located laterally to the umbilicus.
This may be due to:

Question255: An IDDM client's condition stabilizes. He begins to receive a daily injection of NPH insulin at 6:30 AM. The nurse can most likely expect a hypoglycemic reaction to occur that same day at:

Question256: The physician prescribes a medical regimen of isoniazid, rifampin, and vitamin B6 for a tuberculosis client.
The nurse instructs the client that B6 is given because it:

Question257: In the coronary care unit, a client has developed multifocal premature ventricular contractions. The nurse should anticipate the administration of:

Question258: A female client at 36 weeks' gestation is experiencing preterm labor. Her physician has prescribed two doses of betamethasone 12 mg IM q24h. The nurse explains that she is receiving this drug to:

Question259: A female client has been treated since childhood for mitral valve prolapse. The antibiotic of choice for her during pregnancy would be:

Question260: A six-month-old infant is receiving ribavirin for the treatment of respiratory syncytial virus. Ribavirin is administered via which one of the following routes?

Question261: MgSO4 blood levels are monitored and the nurse would be prepared to administer the following antidote for MgSO4 side effects or toxicity:

Question262: A 44-year-old client had an emergency cholecystectomy 3 days ago for a ruptured gallbladder. She complains of severe abdominal pain. Assessment reveals abdominal rigidity and distention, increased temperature, and tachycardia. Diagnostic testing reveals an elevated WBC count. The nurse suspects that the client has developed:

Question263: A 7-year-old girl has been diagnosed with juvenile arthritis and has been placed on daily aspirin. Which statement made by the parent indicates a need for further teaching?

Question264: A client is being discharged and will continue enteral feedings at home. Which of the following statements by a family member indicates the need for further teaching?

Question265: A couple is planning the conception of their first child.
The wife, whose normal menstrual cycle is 34 days in length, correctly identifies the time that she is most likely to ovulate if she states that ovulation should occur on day:

Question266: A 50-year-old male client is to receive chemotherapy. The physician's orders include antiemetics. When planning his care, the nurse should take into consideration that antiemetics are best administered in the following way:

Question267: A client had a ruptured abdominal aortic aneurysm that was repaired surgically. Her postoperative recovery progressed without complications, and she is ready for discharge. Client education in preparation for discharge began 7 days ago on her admission to the nursing unit. Evaluation of nursing care related to client education is based on evaluation of expected outcomes. Which statement made by the client would indicate that she is ready for discharge?

Question268: A 1000-mL dose of lactated Ringer's solution is to be infused in 8 hours. The drop factor for the tubing is
10 gtt/mL. How many drops per minute should the nurse administer?

Question269: A 68-year-old client developed acute respiratory distress syndrome while hospitalized for pneumonia. After a respiratory arrest, an endotracheal tube was inserted. Several days later, numerous attempts to wean him from mechanical ventilation were ineffective, and a tracheostomy was created. For the first 24 hours following tracheostomy, it is important to minimize bleeding around the insertion site. The nurse can accomplish this by:

Question270: A mother who is breast-feeding her newborn asks the RN, "How can I express milk from my breasts manually?" The RN tells her that the correct method for manual milk expression includes using the thumb and the index finger to:

Question271: What specific hormone must be present in serum or urine laboratory tests used to diagnose pregnancy?

Question272: A 35-year-old client has returned to her room following surgery on her right femur. She has an IV of D5 in onehalf normal saline infusing at 125 mL/hr and is receiving morphine sulfate 10-15 mg IM q4h prn for pain. She last voided 51/2 hours ago when she was given her preoperative medication. In monitoring and promoting return of urinary function after surgery, the nurse would:

Question273: An 18-year-old client enters the emergency room complaining of coughing, chest tightness, dyspnea, and sputum production. On physical assessment, the nurse notes agitation, nasal flaring, tachypnea, and expiratory wheezing. These signs should alert the nurse to:

Question274: Morphine sulfate 4 mg IV push q2h prn for chest pain was ordered for a client in the emergency room with severe chest pain. The nurse administering the morphine sulfate knows which of the following therapeutic actions is related to the morphine sulfate?

Question275: Medication is administered to a client who has been placed in restraints after a sudden violent episode, and his EPSs subside. Restraints can be removed when:

Question276: Following her surgery, a 5-year-old child will return to the pediatric unit with a long-arm cast. She experienced a supracondylar fracture of the humerus near the elbow. Which nursing action is most essential during the first
24 hours after surgery and cast application?

Question277: A 26-year-old male client is brought by his wife to the emergency department (ED) unconscious. Blood is drawn for a stat blood count (CBC), fasting blood sugar level, and electrolytes. An indwelling urinary catheter is inserted. He has a history of type 1 diabetes (insulindependent diabetes mellitus [IDDM]). A diagnosis of ketoacidosis is made. Stat lab values reveal a blood sugar level of 520 mg/dL. Which of the following should the nurse expect to administer in the ER?

Question278: A 30-year-old client has a history of several recent traumatic experiences. She presents at the physician's office with a complaint of blindness. Physical exam and diagnostic testing reveal no organic cause. The nurse recognizes this as:

Question279: A client presented herself to the mental health center, describing the following symptoms: a weight loss of
20 lb in the past 2 months, difficulty concentrating, repeated absences from work due to "fatigue," and not wanting to get dressed in the morning. She leaves her recorded message on her telephone and has lost interest in answering the phone or doorbell. The nurse's assessment of her behavior would most likely be:

Question280: During burn therapy, morphine is primarily administered IV for pain management because this route:

Question281: The nurse is caring for a 6-week-old girl with meningitis. To help her develop a sense of trust, the nurse should:

Question282: A female client was recently diagnosed with gastric cancer. She entered the hospital and had a total gastrectomy with esophagojejunostomy. Her postoperative recovery was uneventful. On conducting discharge teaching, the nurse discusses changes in bodily function and lifestyle changes with the client. In order to prevent pernicious anemia, the nurse stresses that the client must:

Question283: A psychotic client who believes that he is God and rules all the universe is experiencing which type of delusion?

Question284: The nurse has been caring for a 16-year-old female who recently experienced date rape. After having had crisis intervention and been hospitalized for 2 weeks, the nurse knows that the client is effectively coping with the rape when she tells the nurse:

Question285: A female client is admitted to the emergency department complaining of severe right-sided abdominal pain and vaginal spotting. She states that her last menstrual period was about 2 months ago. A positive pregnancy test result and ultrasonography confirm an ectopic pregnancy. The nurse could best explain to the client that her condition is caused by:

Question286: A male client is being treated in the burn unit for thirddegree burns on his head, neck, and upper chest received in the last 24 hours. The nurse is evaluating the effectiveness of fluid resuscitation. Which of the following indicates effective fluid balance?

Question287: Which classification of drugs is contraindicated for the client with hypertrophic cardiomyopathy?

Question288: A husband asks if he can visit with his wife on her ECT treatment days and what to expect after the initial treatment. The nurse's best response is:

Question289: A child is admitted to the emergency room with her mother. Her mother states that she has been exposed to chickenpox. During the assessment, the nurse would note a characteristic rash:

Question290: A 3-year-old child is in the burn unit following a home accident. The first sign of sepsis in burned children is:

Question291: A 22-year-old single woman was admitted to the psychiatric hospital by her mother, who reported bizarre behavior. Except for going to work, she spends all her time in her room and expresses concern over neighbors spying on her. She has fears of the telephone being "bugged." Her diagnosis is schizophrenia.
One nurse per shift is assigned to work with the client. The primary reason for this plan would be to:

Question292: In addition to changing the mother's position to relieve cord pressure, the nurse may employ the following measure (s) in the event that she observes the cord out of the vagina:

Question293: The nurse is teaching a client how to perform monthly testicular self-examination (TSE) and states that it is best to perform the procedure right after showering. This statement is made by the nurse based on the knowledge that:

Question294: A male client has experienced low back pain for several years. He is the primary support of his wife and six children. Although he would qualify for disability, he plans to continue his employment as long as possible.
His back pain has increased recently, and he is unable to control it with non-steroidal anti-inflammatory agents. He refuses surgery and cannot take narcotics and remain alert enough to concentrate at work. His physician has suggested application of a transcutaneous electrical nerve stimulation (TENS) unit. Which of the following is an appropriate rationale for using a TENS unit for relief of pain?

Question295: A 35-year-old client is admitted to the hospital with diabetic ketoacidosis. Results of arterial blood gases are pH 7.2, PaO2 90, PaCO2 45, and HCO3 16. The nursing assessment of arterial blood gases indicate the presence of:

Question296: Assessment of a newborn for Apgar scoring includes observation for:

Question297: The initial treatment for a client with a liquid chemical burn injury is to:

Question298: A premature infant needs supplemental O2 therapy. A nursing intervention that reduces the risk of retrolental fibroplasia is to:

Question299: When the nurse is evaluating lab data for a client 18-24 hours after a major thermal burn, the expected physiological changes would include which of the following?

Question300: Which type of insulin can be administered by a continuous IV drip?

Question301: A 35-year-old primigravida comes to the clinic for her first prenatal visit. The midwife, on examining the client, suspects that she is approximately 11 weeks pregnant. The pregnancy is positively confirmed by finding:

Question302: A 67-year-old man had a physical examination prior to beginning volunteer work at the hospital. A routine chest x-ray demonstrated left ventricular hypertrophy. His blood pressure was 180/110. He is 45 lb overweight. His diet is high in sodium and fat. He has a strong family history of hypertension. The client is placed on antihypertensive medication; a low-sodium, low-fat diet; and an exercise regimen. On his next visit, compliance would best be determined by:

Question303: A 42-year-old client presents with a diagnosis of paranoid schizophrenia. She has become increasingly restless and verbally argumentative, and her speech has become pressured. She is exhibiting signs of:

Question304: A 9-week-old female infant has a diagnosis of bilateral cleft lip and cleft palate. She has been admitted to the pediatric unit after surgical repair of the cleft lip. Which of the following nursing interventions would be appropriate during the first 24 hours?

Question305: A 7-year-old child is brought to the ER at midnight by his mother after symptoms appeared abruptly. The nurse's initial assessment reveals a temperature of 104.5◦F (40.3◦C), difficulty swallowing, drooling, absence of a spontaneous cough, and agitation. These symptoms are indicative of which one of the following?

Question306: A client had a vaginal delivery 3 days ago and is discharged from the hospital on the 2nd day postpartum.
She told the RN, "I need to start exercising so that I can get back into shape. Could you suggest an exercise I could begin with?'' The RN could suggest which one of the following?

Question307: Which of the following should the nurse anticipate receiving as an as-needed order for a postoperative carotid endarterectomy client?

Question308: An alcoholic client who is completing the inpatient segment of a substance abuse program was placed on disulfiram (Antabuse) drug therapy. What should the nurse include in the discharge instructions?

Question309: A 52-year-old client's abdominal aortic aneurysm ruptured. She received rapid massive blood transfusions for bleeding. One potential complication of blood administration for which she is especially at risk is:

Question310: A 33-year-old client was brought into the emergency room unconscious, and it is determined that surgery is needed. Informed consent must be obtained from his next of kin. The sequence in which the next of kin would be asked for the consent would be:

Question311: A client is admitted to the hospital with diabetic ketoacidosis.
The emergency room nurse should anticipate the administration of:

Question312: Which of the following lab data is representative of a client with aplastic anemia?

Question313: A 78-year-old female client has a total hip arthroplasty. Her nurse should know that which of the following is contraindicated?

Question314: The nurse assesses a client's monitor strip and finds the following: uterine contractions every 3-4 minutes, lasting 60-70 seconds; FHR baseline 134-146 bpm, with accelerations to 158 bpm with fetal movement.
Which nursing intervention is appropriate?

Question315: A 38-year-old female client with a history of chronic schizophrenia, paranoid type, is currently an outpatient at the local mental health and mental retardation clinic. The client comes in once a week for medication evaluation and/or refills. She self-administers haloperidol 5 mg twice a day and benztropine 1 mg once a day. During a recent clinic visit, she says to the nurse, "I can't stay still at night. I toss and turn and can't fall asleep." The nurse suspects that she may be experiencing:

Question316: A 65-year-old client who has a new colostomy is preparing for discharge from the hospital. As part of the instructions on colostomy care, the nurse explains to the client that to regulate the bowel, colostomy irrigation should be performed at the same time each day. The best time is:

Question317: At 30 weeks' gestation, a client is admitted to the unit in premature labor. Her contractions are every 5 minutes and last 60 seconds, her cervix is closed, and the suture placed around her cervix during her 16th week of gestation, when she had the MacDonald procedure, can still be felt by the physician. The amniotic sac is still intact. She is very concerned about delivering prematurely. She asks the RN, "What is the greatest risk to my baby if it is born prematurely?" The RN's answer should be:

Question318: A male client was diagnosed 6 months ago with amyotrophic lateral sclerosis (ALS). The progression of the disease has been aggressive. He is unable to maintain his personal hygiene without assistance.
Ambulation is most difficult, requiring him to use a wheelchair and rely on assistance for mobility. He recently has become severely dysphasic. Nursing interventions for dysphasia would be aimed toward prevention of:

Question319: A client has chronic obstructive pulmonary disease. She is slowly losing weight, and her daughter is very concerned about increasing her nutrition. The nurse helps the daughter devise a plan of care for her mother. The plan of care should include which of the following interventions to promote nutrition?

Question320: An 83-year-old client has been hospitalized following a fall in his home. He has developed a possible fecal impaction. Which of the following assessment findings would be most indicative of a fecal impaction?

Question321: A 2-year-old boy fell out of bed and has a subdural hematoma. When his mother leaves him for the first time, you will expect the child to:

Question322: After 7 hours in restraints and a total of 30-mg haloperidol in divided doses, a client complains of stiffness in his neck and his tongue "pulling to one side." These extrapyramidal symptoms (EPS) will most likely be relieved by the administration of:

Question323: An 80-year-old widow is living with her son and daughter- in-law. The home health nurse has been making weekly visits to draw blood for a prothrombin time test. The client is taking 5 mg of coumadin per day. She appears more debilitated, and bruises are noted on her face. Elder abuse is suspected. Which of the following are signs of persons who are at risk for abusing an elderly person?

Question324: The nurse working with a client who is out of control should follow a model of intervention that includes which of the following?

Question325: A 19-year-old primigravida is admitted to the labor and delivery suite of the hospital. Her husband is accompanying her. The couple tells the nurse that this is the first hospital admission for her. The client's vaginal exam indicates she is 3 cm dilated, 80% effaced, and at _0 station. Based on the vaginal exam, she is in:

Question326: A 26-year-old client is admitted to the labor, delivery, recovery, postpartum unit. The nurse completes her assessment and determines the client is in the first stage of labor. The nurse should instruct her:

Question327: The physician orders fluoxetine (Prozac) for a depressed client. Which of the following should the nurse remember about fluoxetine?

Question328: Two weeks after a client's admission for depression, the physician orders a consult for electroconvulsive therapy (ECT). Which of the following conditions, if present, would be a contraindication for ECT?

Question329: A client's behavior is annoying other clients on the unit. He is meddling with their belongings and dominating the group. The best approach by the nurse is to:

Question330: A client who is a breast-feeding mother develops mastitis. The clinical signs and symptoms of mastitis include:

Question331: A female client presents to the obstetric-gynecology clinic for a pregnancy test, the result which turns out to be positive. Her last menstrual period began December 10, 1993. Using Nägele's rule, the nurse estimates her date of delivery to be:

Question332: A client has just been transferred to the floor from the labor and delivery unit following delivery of a stillborn term infant. She is very despondent. When the nurse attempts to take her vital signs, she responds in anger, stating, "You leave me alone. You don't care anything about me. It's people like you who let my baby die." The nurse's best course of action is to:

Question333: When assessing a female child for Turner's syndrome, the nurse observes for which of the following symptoms?

Question334: A 28-year-old woman was admitted to the hospital for a thyroidectomy. Postoperatively she is taken to the postanesthesia care unit for several hours. In preparing for the client's return to her room, which nursing measure best demonstrates the nurse's thorough understanding of possible postthyroidectomy complications?

Question335: A 58-year-old client on a general surgery unit is scheduled for transurethral resection of the prostate (TURP) in 2 hours. The nurse explains to the client that this procedure means:

Question336: Which of the following physician's orders would the nurse question on a client with chronic arterial insufficiency?

Question337: When evaluating a client with symptoms of shock, it is important for the nurse to differentiate between neurogenic and hypovolemic shock. The symptoms of neurogenic shock differ from hypovolemic shock in that:

Question338: A 45-year-old client diagnosed with major depression is scheduled for electroconvulsive therapy (ECT) in the morning. Which of the following medications are routinely administered either before or during ECT?

Question339: A client who is gravida 1 para 1 vaginally delivered a 7- lb girl. She received a midline episiotomy at delivery. When assessing the level of her uterus immediately following delivery, the nurse would expect the fundus to be located:

Question340: An 11-month-old infant is admitted with a possible diagnosis of pyloric stenosis. Which of the following best describes the characteristic clinical manifestations of pyloric stenosis?

Question341: A 47-year-old client comes to the emergency department complaining of moderate flank, abdominal, and testicular pain with nausea of 4 hours' duration. After physical examination and obtaining the client's history, the physician suspects urethral obstruction by calculi. The nurse realizes that the physician will order which one of the following diagnostic studies to best confirm the diagnosis?

Question342: The most appropriate method of evaluating whether the diet of a child with cystic fibrosis is meeting his caloric needs is:

Question343: A mother is unsure about the type of toys for her 17-month-old child. Based on knowledge of growth and development, what toy would the nurse suggest?

Question344: A primigravida with a blood type A negative is at 28 weeks' gestation. Today her physician has ordered a RhoGAM injection. Which statement by the client demonstrates that more teaching is needed related to this therapy?

Question345: When assessing a client, the nurse notes the typical skin rash seen with systemic lupus erythematosus.
Which of the following descriptions correctly describes this rash?

Question346: A physician's order reads: Administer furosemide oral solution 0.5 mL stat. The furosemide bottle dosage is 10 mg/mL. What dosage of furosemide should the nurse give to this infant?

Question347: A 50-year-old depressed client has recently lost his job. He has been reluctant to leave his hospital room.
Nursing care would include:

Question348: A 20-year-old client presents to the obstetrics-gynecology clinic for the first time. She tells the nurse that she is pregnant and wants to start prenatal care. After collecting some initial assessment data, the nurse measures her fundal height to be at the level of the umbilicus. The nurse estimates the fetal gestational age to be approximately:

Question349: Hematotympanum and otorrhea are associated with which of the following head injuries?

Question350: A client's membranes have just ruptured spontaneously. Which of the following nursing actions should take priority?

Question351: The nurse is admitting an infant with bacterial meningitis and is prepared to manage the following possible effects of meningitis:

Question352: The physician prescribes phenytoin (Dilantin) for a client with seizure disorders. Phenytoin can only be mixed with which of the following solutions?

Question353: The cardiac client who exhibits the symptoms of disorientation, lethargy, and seizures may be exhibiting a toxic reaction to:

Question354: A female client plans to bottle-feed her newborn. Her physician has ordered bromocriptine (Parlodel) to suppress lactation. Which of the following instructions about bromocriptine should be given by the nurse?

Question355: A 54-year-old client is admitted to the hospital with a possible gastric ulcer. He is a heavy smoker. When discussing his smoking habits with him, the nurse should advise him to:

Question356: After several days, an IDDM client's serum glucose stabilizes, and the registered nurse continues client teaching in preparation for his discharge. The nurse helps him plan an American Diabetes Association diet and explains how foods can be substituted on the exchange list. He can substitute 1 oz of poultry for:

Question357: A client suspects that she is pregnant. She reports two missed menstrual periods. The first day of her last menstrual period was August 3. Her estimated date of confinement would be:

Question358: Nursing interventions designed to decrease the risk of infection in a client with an indwelling catheter include:

Question359: Which of the following symptoms might the nurse observe in a client with a lithium blood level over 2.0?

Question360: A pregnant client experiences a precipitous delivery. The nursing action during a precipitous delivery is to:

Question361: The following medications were noted on review of the client's home medication profile. Which of the medications would most likely potentiate or elevate serum digoxin levels?

Question362: The nurse is developing a plan of care for a client with an electrolyte imbalance and identifies a nursing diagnosis of decreased physical mobility. Which alteration is most likely the etiology?

Question363: A 79-year-old client with Alzheimer's disease is exhibiting significant memory impairment, cognitive impairment, extremely impaired judgment in social situations, and agitation when placed in a new situation or around unfamiliar people. The nurse should include the following strategy in the client's care:

Question364: A 14-year-old boy fell off his bike while "popping a wheelie" on the dirt trails. He has sustained a head injury with laceration of his scalp over his temporal lobe. If he were to complain of headache during the first
24 hours of his hospitalization, the nurse would:

Question365: A female client has experienced varying degrees of depression throughout her life. Now that she is postmenopausal, her depression has increased. She is unable to motivate herself to clean her house or even to get out of bed and get dressed in the morning. The client was begun on fluoxetine (Prozac) therapy. When educating her about fluoxetine, what might the nurse caution her about?

Question366: A laboratory technique specific for diagnosing Lyme disease is:

Question367: A newborn has been delivered with a meningomyelocele. The nursery nurse should position the newborn:

Question368: A client has been admitted to the nursing unit with the diagnosis of severe anemia. She is slightly short of breath, has episodes of dizziness, and complains her heart sometimes feels like it will "beat out of her chest." The physician has ordered her to receive 2 U of packed red blood cells. The most important nursing action to be taken is:

Question369: An expected response to sodium polystyrene sulfonate (Kayexalate) is:

Question370: Prenatal clients are routinely monitored for early signs of pregnancy-induced hypertension (PIH). For the prenatal client, which of the following blood pressure changes from baseline would be most significant for the nurse to report as indicative of PIH?

Question371: A 35-year-old client is receiving psychopharmacological treatment of his major depression with tranylcypromine sulfate (Parnate), a monoamine oxidase (MAO) inhibitor. The nurse teaches the client that while he is taking this type of antidepressant, he needs to restrict his dietary intake of:

Question372: Discharge teaching for the client who has a total gastrectomy should include which of the following?

Question373: A 2-year-old child is recovering from surgery. Considering growth and development according to Erikson, the nurse identifies which of the following play activities as most appropriate?

Question374: A client has received digoxin 0.25 mg po daily for 2 weeks. Which of the following digoxin levels indicates toxicity?

Question375: A client returned to the unit following a pneumonectomy. As the nurse is assessing her incision, she notices fresh blood on the dressing. The nurse should first:

Question376: A client is 2 hours post ventriculoperitoneal shunt placement. How should the nurse position the client?

Question377: A parent told the public health nurse that her 6-year-old son has been taking tetracycline for a chronic skin condition. The parent asked if this could cause any problems for the child. What should the nurse explain to the parent?

Question378: A 32-year-old mother of two was brought to the hospital by her husband. He reported that his wife could no longer manage the house and children. She does not sleep and talks day and night. She has purchased some very expensive clothes. The nurse noted that the client speaks rapidly and changes the subject irrationally. This is an example of:

Question379: Parents of children receiving chemotherapy should be warned that alopecia is a side effect and that:

Question380: Signs and symptoms of an allergy attack include which of the following?

Question381: A 26-year-old client has no children. She has had an abdominal hysterectomy. In the first 24 hours postoperatively, the nurse would be concerned if the client:

Question382: One of the most dramatic and serious complications associated with bacterial meningitis is Waterhouse- Friderichsen syndrome, which is:

Question383: A term neonate has experienced no distress at birth and has an Apgar score of 9. Her mother has asked to breastfeed her following delivery. Immediately after birth, the neonate was most susceptible to heat loss.
The most appropriate intervention to conserve heat loss and promote bonding is to:

Question384: The physician of a client diagnosed with alcoholism orders neomycin 0.5 g q6h to prevent hepatic coma.
Neomycin decreases serum ammonia levels by:

Question385: A pregnant client continues to visit the clinic regularly during her pregnancy. During one of her visits while lying supine on the examining table, she tells the RN that she is becoming light-headed. The RN notices that the client has pallor in her face and is perspiring profusely.
The first intervention the RN should initiate is to:

Question386: A child is to receive atropine 0.15 mg (1/400 g) as part of his preoperative medication. A vial containing atropine 0.4 mg (1/150 g)/mL is on hand. How much atropine should be given?

Question387: A client is to be discharged from the hospital and is to continue taking warfarin 2.5 mg po bid. Which of the following should be included in her discharge teaching concerning the warfarin therapy?

Question388: The nurse is teaching a child's parents how to protect the child from lead poisoning. The nurse knows that a common source of lead poisoning in children is:

Question389: A 2-month-old infant is receiving IV fluids with a volume control set. The nurse uses this type of tubing because it:

Question390: A 16-year-old diabetic girl has been selected as a cheerleader at her school. She asks the nurse whether she should increase her insulin when she is planning to attend cheerleading practice sessions lasting from
8 to 11 AM. The most appropriate answer would be:

Question391: A female client at 30 weeks' gestation is brought into the emergency department after falling down a flight of stairs. On examination, the physician notes a rigid, boardlike abdomen; FHR in the 160s; and stable vital signs. Considering possible abdominal trauma, which obstetric emergency must be anticipated?

Question392: Which of the following should be included in discharge teaching for a client with hepatitis C?

Question393: On admission, the client has signs and symptoms of pulmonary edema. The nurse places the client in the most appropriate position for a client in pulmonary edema, which is:

Question394: A client with cystic fibrosis exhibits activity intolerance related to the pulmonary problems associated with his disease. However, he needs to be encouraged to participate in daily physical exercise. The ultimate aim of exercise is to:

Question395: A client is in early labor. Her fetus is in a left occipitoanterior (LOA) position; fetal heart sounds are best auscultated just:

Question396: A schizophrenic client has made sexual overtures toward her physician on numerous occasions. During lunch, the client tells the nurse, "My doctor is in love with me and wants to marry me." This client is using which of the following defense mechanisms?

Question397: To facilitate maximum air exchange, the nurse should position the client in:

Question398: A 3-year-old child was hospitalized for acute laryngotracheobronchitis. During her hospitalization, the child was placed under an oxygen mist tent. The nurse's frequent monitoring of the child's temperature frightened her parents. Which response by the nurse would be most appropriate?

Question399: Dietary planning is an essential part of the diabetic client's regimen. The American Diabetes Association recommends which of the following caloric guidelines for daily meal planning?

Question400: To prevent transmission of bacterial meningitis, the nurse would instruct an infected baby's mother to:

Question401: A gravida 2 para 1 client delivered a full-term newborn 12 hours ago. The nurse finds her uterus to be boggy, high, and deviated to the right. The most appropriate nursing action is to:

Question402: A client has been taking lithium 300 mg po bid for the past two weeks. This morning her lithium level was 1 mEq/L. The nurse should:

Question403: A 27-year-old male client is admitted to the acute care mental health unit for observation. He has recently lost his job, and his wife told him yesterday that she wants a divorce. The client is placed on suicide precautions. In assessing suicide potential, the nurse should pay close attention to the client's:

Question404: A pregnant client is having a nonstress test (NST). It is noted that the fetal heart beat rises 20 bpm, lasting
20 seconds, every time the fetus moves. The nurse explains that:

Question405: At 16 weeks' gestation, a pregnant client is admitted to the maternity unit to have a McDonald procedure (cerclage) done. She tells the RN who is admitting her to the unit that her physician had explained what this procedure was, but that she did not understand. The RN explains to the client that the purpose for this procedure is to:

Question406: A client is pregnant with her second child. Her last menstrual period began on January 15. Her expected date of delivery would be:

Question407: A baby who was diagnosed with pyloric stenosis has continued to have projectile vomiting. With prolonged vomiting, the infant is prone to:

Question408: A 4 days postpartum client who is gravida 3, para 3, isexamined by the home health nurse during her first postpartum home visit. The nurse notes that she has a pink vaginal discharge with a serosanguineous consistency. The nurse would most accurately chart the client's lochia as:

Question409: A common complication of cirrhosis of the liver is prolonged bleeding. The nurse should be prepared to administer?

Question410: The physician has ordered that a daily exercise program be instituted by a client with type I diabetes following his discharge from the hospital. Discharge instructions about exercise should include which of the following?

Question411: The nurse is assessing and getting a history from a client treated for depression with a monoamine oxidase (MAO) antidepressant. The most serious side effect associated with this antidepressant and the ingestion of tyramine in aged foods may be:

Question412: In assisting preconceptual clients, the nurse should teach that the corpus luteum secretes progesterone, which thickens the endometrial lining in which of the phases of the menstrual cycle?

Question413: An 8-week-old infant has been diagnosed with gastroesophageal reflux. The nurse is teaching the infant's mother to care for the infant at home. Which one of the following statements by the nurse is appropriate regarding the infant's home care?

Question414: An elective saline abortion has been performed on a 3- week primigravida. Following the procedure, the nurse should be alert for which early side effect?

Question415: Forty-eight hours after a thyroidectomy, a female client complains of numbness and tingling of the toes and fingers. The nurse notes upper arm and facial twitching. The nurse needs to:

Question416: The usual treatment for diabetes insipidus is with IM or SC injection of vasopressin tannate in oil. Nursing care related to the client receiving IM vasopressin tannate would include:

Question417: Home-care instructions for the child following a cardiac catheterization should include:

Question418: A 48-year-old client is in the surgical intensive care unit after having had three-vessel coronary artery bypass surgery yesterday. She is extubated, awake, alert and talking. She is receiving digitalis for atrial arrhythmias. This morning serum electrolytes were drawn. Which abnormality would require immediate intervention by the nurse after contacting the physician?

Question419: A 52-year-old client who underwent an exploratory laparotomy for a bowel obstruction begins to complain of hunger on the third postoperative day. His nasogastric (NG) tube was removed this morning, and he has an IV of D5W with 0.45% normal saline running at 125 mL/hr. He asks when he can get rid of his IV and start eating. The nurse recognizes that he will be able to begin taking oral fluids and nourishment when:

Question420: An infant with a congenital heart defect is being discharged with an order for the administration of digoxin elixir every 12 hours. The parents need to be taught when administering digoxin to the infant that:

Question421: A 67-year-old client will be undergoing a coronary arteriography in the morning. Client teaching about postprocedure nursing care should include that:

Question422: A nurse is performing a vaginal exam on a client in active labor. An important landmark to assess during labor and delivery are the ischial spines because:

Question423: A 2-year-old toddler is hospitalized with epiglottitis. In assessing the toddler, the nurse would expect to find:

Question424: The nurse working in a prenatal clinic needs to be alert to the cardinal signs and symptoms of PIH because:

Question425: A client develops an intestinal obstruction postoperatively. A nasogastric tube is attached to low, intermittent suction with orders to "Irrigate NG tube with sterile saline q1h and prn." The rationale for using sterile saline, as opposed to using sterile water to irrigate the NG tube is:

Question426: A male client tells his nurse that he has had an ulcer in the past and is afraid it is "flaring up again." The nurse begins to ask him specific questions about his symptoms. The nurse knows that a symptom that might indicate a serious complication of an ulcer is:

Question427: Assessment of parturient reveals the following: cervical dilation 6 cm and station 22; no progress in the last
4 hours. Uterine contractions decreasing in frequency and intensity. Marked molding of the presenting fetal head is described. The physician orders, "Begin oxytocin induction at 1 mU/min." The nurse should:

Question428: The nurse should know that according to current thinking, the most important prognostic factor for a client with breast cancer is:

Question429: A client is having an amniocentesis. Prior to the procedure, an ultrasound is performed. In preparing the client, the nurse explains the reason for a sonogram in this situation to be:

Question430: A client was admitted to the hospital after falling in her home. At the time of admission, her blood alcohol level was 0.27 mg%. Her family indicates that she has been drinking a fifth of vodka a day for the past 9 months. She had her last drink 30 minutes prior to admission. Alcohol withdrawal symptoms would most likely be exhibited by her:

Question431: A neonate was admitted to the hospital with projectile vomiting. According to the parents, the baby had experienced vomiting episodes after feeding for the last 2 days. A medical diagnosis of hypertrophic pyloric stenosis was made. On assessment, the infant had poor skin turgor, sunken eyeballs, dry skin, and weight loss. Identify the number-one priority nursing diagnosis.

Question432: A client has been admitted to the labor and delivery unit in active labor. After assessing her, the RN notes that the client's fetus position is left occipital posterior. Which of the following statements best describes what this means to the labor process:

Question433: Chorioamnionitis is a maternal infection that is usually associated with:

Question434: A client is receiving IV morphine 2 days after colorectal surgery. Which of the following observations indicate that he may be becoming drug dependent?

Question435: In performing the initial nursing assessment on a client at the prenatal clinic, the nurse will know that which of the following alterations is abnormal during pregnancy?

Question436: One afternoon 3 weeks into his alcohol treatment program, a client says to the nurse, "It's really not all my fault that I have a drinking problem. Alcoholism runs in my family. Both my grandfather and father were heavy drinkers." The nurse's best response would be:

Question437: A mother came to the pediatric clinic with her 17- month-old child. The mother would like to begin toilet training. What should the nurse teach her about implementing toilet training?

Question438: On the third postpartum day, a client complains of extremely tender breasts. On palpation, the nurse notes a very firm, shiny appearance to the breasts and some milk leakage. She is bottle feeding. The nurse should initially recommend to her to:

Question439: A client has begun to exhibit signs of alcohol withdrawal. Her blood pressure has risen from 120/60 to
190/100, pulse is increased from 88 to 110 bpm, and she is irritable and agitated and has gross motor tremors of the hands. The nurse notifies the doctor. The nurse can anticipate that the doctor will order which of the following?

Question440: The nurse is caring for a client with pancreatitis. Which of the following IV medications would the nurse expect the physician to prescribe for control of pain in this client?

Question441: The nurse is notified that a 27-year-old primigravida diagnosed with complete placenta previa is to be admitted to the hospital for a cesarean section. The client is now at 36 weeks' gestation and is presently having bright red bleeding of moderate amount. On admission, the nursing intervention that the nurse should give the highest priority to is:

Question442: After a 10-year-old child with insulin-dependent diabetes mellitus receives her dinner tray, she tells the nurse that she hates broccoli and wants some corn on the cob. The nurse's appropriate response is:

Question443: As a nurse works with an adolescent with cystic fibrosis, the nurse begins to notice that he appears depressed and talks about suicide and feelings of worthlessness. This is an important factor to consider in planning for his care because:

Question444: A client is diagnosed with diabetic ketoacidosis. The nurse should be prepared to administer which of the following IV solutions?

Question445: When teaching a mother of a 4-month-old with diarrhea about the importance of preventing dehydration, the nurse would inform the mother about the importance of feeding her child:

Question446: A client has returned to the unit from the recovery room after having a thyroidectomy. The nurse knows that a major complication after a thyroidectomy is:

Question447: Which of the following activities would be most appropriate during occupational therapy for a client with bipolar disorder?

Question448: A 3-year-old child is hospitalized with burns covering her trunk and lower extremities. Which of the following would the nurse use to assess adequacy of fluid resuscitation in the burned child?

Question449: Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack?

Question450: A client's transfusion of packed red blood cells has been infusing for 2 hours. She is complaining of a raised, itchy rash and shortness of breath. She is wheezing, anxious, and very restless. The nurse knows these assessment findings are congruent with:

Question451: The nurse observes a client crying quietly. She has just experienced a spontaneous abortion at nine weeks' gestation. An appropriate response by the nurse would be:

Question452: After the RN is finished the initial assessment of a newborn baby and after the initial bonding between the newborn and the mother has taken place in the delivery room, the RN will bring the newborn to the well- baby nursery. Before the newborn is taken from the delivery room and brought to the well-baby nursery, the RN makes sure that which of the following interventions was completed?

Question453: To ensure proper client education, the nurse should teach the client taking SL nitroglycerin to expect which of the following responses with administration?

Question454: A client has been uncomfortable in crowds all her life. After the birth of her child, she has been housebound unless her husband can accompany her to the grocery store and for medical appointments.
His schedule will not allow for this, and he has insisted that she must be more independent. Her anxiety has increased to the point of panic. The client has been diagnosed with agoraphobia. Which statement is true about this disorder?

Question455: The nurse is trying to help a mother understand what is happening with her son who has recently been diagnosed with paranoid schizophrenia. At present, he is experiencing hallucinations and delusions of persecution and suffers from poor hygiene. The nurse can best help her understand her son's condition by which of the following statements?

Question456: A 16-year-old client with a diagnosis of oppositional defiant disorder is threatening violence toward another child. In managing a potentially violent client, the nurse:

Question457: A client admitted with a diagnosis of possible myocardial infarction is admitted to the unit from the emergency room. The nurse's first action when admitting the client will be to:

Question458: A client presents to the psychiatric unit crying hysterically. She is diagnosed with severe anxiety disorder.
The first nursing action is to:

Question459: A 74-year-old female client is 3 days postoperative. She has an indwelling catheter and has been progressing well. While the nurse is in the room, the client states, "Oh dear, I feel like I have to urinate again!" Which of the following is the most appropriate initial nursing response?

Question460: When preparing insulin for IV administration, the nurse identifies which kind of insulin to use?

Question461: The nurse is caring for a 2-year-old girl with a subdural hematoma of the temporal area as a result of falling out of bed and notices that she has a runny nose. The nurse should:

Question462: A mother brings her 3-year-old child who is unconscious but breathing to the ER with an apparent drug overdose. The mother found an empty bottle of aspirin next to her child in the bathroom. Which nursing action is the most appropriate?

Question463: A gravida 2 para 1 client is hospitalized with severe preeclampsia. While she receives magnesium sulfate (MgSO4) therapy, the nurse knows it is safe to repeat the dosage if:

Question464: The nurse is assessing breath sounds in a bronchovesicular client. She should expect that:

Question465: An 8-year-old boy has been diagnosed with hemophilia. Which of the following diagnostic blood studies is characteristically abnormal in this disorder?

Question466: The nurse notes scattered crackles in both lungs and 1+ pitting edema when assessing a cardiac client.
The physician is notified and orders furosemide (Lasix) 80 mg IV push stat. Which of the following diagnostic studies is monitored to assess for a major complication of this therapy?

Question467: In acute episodes of mania, lithium is effective in 1-2 weeks, but it may take up to 4 weeks, or even a few months, to treat symptoms fully. Sometimes an antipsychotic agent is prescribed during the first few days or weeks of an acute episode to manage severe behavioral excitement and acute psychotic symptoms. In addition to the lithium, which one of the following medications might the physician prescribe?

Question468: In admitting a client to the psychiatric unit, the nurse must explain the rules and regulations of the unit. A client with antisocial personality disorder makes the following remark, "Forget all those rules. I always get along well with the nurses." Which nursing response to him would be most effective?

Question469: A client with severe PIH receiving MgSO4 is placed in a quiet, darkened room. The nurse bases this action on the following understanding:

Question470: Several months after antibiotic therapy, a child is readmitted to the hospital with an exacerbation of osteomyelitis, which is now in the chronic stage. The mother appears anxious and asks what she could have done to prevent the exacerbation. The nurse's response is based on the knowledge that chronic osteomyelitis:

Question471: In the client with a diagnosis of coronary artery disease, the nurse would anticipate the complication of bradycardia with occlusion of which coronary artery?

Question472: The most commonly known vectors of Lyme disease are:

Question473: While changing the dressing on a client's central line, the nurse notices redness and warmth at the needle insertion site. Which of the following actions would be appropriate to implement based on this finding?

Question474: A diagnosis of hepatitis C is confirmed by a male client's physician. The nurse should be knowledgeable of the differences between hepatitis A, B, and C.
Which of the following are characteristics of hepatitis C?

Question475: A 30-year-old client has been admitted to the psychiatric service with the diagnosis of schizophrenia. He tells the nurse that when the woman he had been dating broke up with him, the CIA had replaced her with an identical twin. The client is experiencing:

Question476: The nurse knows that children are more susceptible to respiratory tract infections owing to physiological differences. These childhood differences, when compared to an adult, include:

Question477: A 3-year-old child has had symptoms of influenza including fever, productive cough, nausea, vomiting, and sore throat for the past several days. In caring for a young child with symptoms of influenza, the mother must be cautioned about:

Question478: A client with IDDM is given IV insulin for a blood glucose level of 520 mg/dL. Life-threatening complications may occur initially, so the nurse will monitor him closely for serum:

Question479: A dose of theophylline may need to be altered if a client with COPD:

Question480: The FHR pattern in a laboring client begins to show early decelerations. The nurse would best respond by:

Question481: A client is being discharged on warfarin (Coumadin), an oral anticoagulant. The nurse instructs him about using this drug. Which following response by the client indicates the need for further teaching?

Question482: A 34-year-old client who is gravida 1, para 0 has a history of infertility and conceived this pregnancy while taking fertility drugs. She is at 32 weeks' gestation and is carrying triplets. She is complaining of low back pain and a feeling of pelvic pressure. Her cervical exam reveals a long, closed cervix. The nurse notes that the client is experiencing mild uterine contractions every 7-8 minutes after the nurse has placed her on the fetal monitor. Her condition should indicate that:

Question483: Nursing care of the infant prior to surgical closure of a meningomyelocele would include:

Question484: A 10-year-old client with a pin in the right femur is immobilized in traction. He is exhibiting behavioral changes including restlessness, difficulty with problem solving, inability to concentrate on activities, and monotony. Which of the following nursing implementations would be most effective in helping him cope with immobility?

Question485: A 4-year-old child has Down syndrome. The community health nurse has coordinated a special preschool program. The nurse's primary goal is to:

Question486: A 12-year-old girl has been diagnosed with insulindependent diabetes mellitus. Which of these principles would best guide her nutritional management?

Question487: A client is pregnant for the fourth time and has had three normal vaginal deliveries. She is in active labor and fully dilated. Suddenly she calls, "Nurse, the baby is coming." As the nurse responds to her call, which one of the following observations should the nurse make first?

Question488: A female client decides on hemodialysis. She has an internal vascular access device placed. To ensure patency of the device, the nurse must:

Question489: At 30 weeks' gestation, a client is admitted to the unit in premature labor. Her physician orders that an IV be started with 500 mL D5W mixed with 150 mg of ritodrine stat. The RN prepares the IV solution with the medication. The RN knows that clients receiving the medication ritodrine IV should be observed closely for which one of the following side effects:

Question490: The serial sevens test is often used to determine delirium and dementia. This test aids in assessing which of the following?

Question491: The mother of a child taking phenytoin will need to plan appropriate mouth care and gingival stimulation.
When tooth-brushing is contraindicated, the next most effective cleansing and gingival stimulation technique would be:

Question492: When providing dietary teaching to an individual who has diabetes mellitus, type II, the nurse discusses the importance of consuming the recommended daily allowance of which of the following electrolytes?

Question493: The physician has ordered that ampicillin 250 mg IV be given over 30 minutes. The medication is diluted as recommended in 10 mL in the volume control chamber of a set that has a tubing of 12 mL. Which nursing measure is most accurate considering these facts?

Question494: An obstructing stone in the renal pelvis or upper ureter causes:

Question495: A female client is exhibiting signs of respiratory distress. Which of the following signs indicate a possible pneumothorax?

Question496: A female client is anticipating a visit with her parents over the Thanksgiving holidays. She has recently begun experiencing periods of extreme shortness of breath, which her physician has labeled as panic attacks. Which of the following statements by the nurse would enhance therapeutic communication?

Question497: A 23-year-old college student seeks medical attention at the college infirmary for complaints of severe fatigue. Her skin is pale, and she reports exertional dyspnea. She is admitted to the hospital with possible aplastic anemia. Laboratory values reflect anemia, and the client is prepared for a bone marrow biopsy.
She refuses to sign the biopsy consent and states, "Can't you just get the doctor to give me a transfusion and let me go. This weekend begins spring break, and I have plans to go to Florida." At this time the nurse's greatest concern is that:

Question498: At 12 hours postvaginal delivery, a female client is without complications. Which of the following assessment findings would warrant further nursing interventions?

Question499: When giving discharge instructions to a 24-year-old client who had a short-arm cast applied for a fractured right ulna, the nurse recognizes the importance of telling him that the drying time for a plaster of Paris cast is approximately:

Question500: A schizophrenic is admitted to the psychiatric unit. What affect would the nurse expect to observe?

Question501: On the first postpartal day, a client tells the nurse that she has been changing her perineal pads every 1/2 hour because they are saturated with bright red vaginal drainage. When palpating the uterus, the nurse assesses that it is somewhat soft, 1 fingerbreadth above the umbilicus, and midline. The nursing action to be taken is to:

Question502: A client was prescribed a major tranquilizer 2 months ago. One month ago she was placed on benztropine (Cogentin). What would indicate that benztropine therapy is effective?

Question503: A 9-month-old infant was diagnosed with nonorganic failure to thrive. During her hospitalization, primary nurses were assigned to initiate all infant feedings. The infant's parents question why they cannot feed their own child. Which of the following responses would be most appropriate by the nurse?

Question504: When interviewing parents who are suspected of child abuse, the nurse would use which of the following interview techniques?

Question505: Newborns are routinely screened for phenylketonuria. The nursery nurse ensures that this screening test is performed:

Question506: A 1000-mL dose of D5W 1⁄2 normal saline is to be infused in 8 hours. The drop factor for the tubing is 60 gtt/min. How many drops per minute should the nurse administer?

Question507: A 27-year-old primigravida stated that she got up from the chair to fix dinner and bright red blood was running down her legs. She denies any pain previously or currently. The client is very concerned about whether her baby will be all right. Her vital signs include P 120 bpm, respirations 26 breaths/min, BP
104/58 mm Hg, temperature 98.2_F, and fetal heart rate 146 bpm. Laboratory findings revealed hemoglobin 9.0 g/dL, hematocrit 26%, and coagulation studies within normal range. On admission, the peripad she wore was noted to be half saturated with bright red blood. A medical diagnosis of placenta previa is made. The priority nursing diagnosis for this client would be:

Question508: The nurse is admitting a client with folic acid deficiency anemia. Which of the following questions is most important for the nurse to ask the client?

Question509: A 2-year-old child with a scalp laceration and subdural hematoma of the temporal area as a result of falling out of bed should be prevented from:

Question510: A 23-year-old borderline client is admitted to an inpatient psychiatric unit following an impulsive act of self- mutilation. A few hours after admission, she requests special privileges, and when these are not granted, she stands up and angrily shouts that the people on the unit do not care, and she storms across the room.
The nurse should respond to this behavior by:

Question511: A client takes warfarin (Coumadin) 15 mg po daily. To evaluate the medication's effectiveness, the nurse should monitor the:

Question512: At her first prenatal visit, a 21-year-old woman who is gravida 2, para 0, ab 1, is currently at 32 weeks' gestation and has a history of drug abuse, smoking, and occasional ethyl alcohol use. Fetal ultrasound tests indicate poor fetal growth. The most likely reason for the infant's intrauterine growth retardation is:

Question513: The postpartum nurse should include which of the following instructions to breast-feeding mothers?

Question514: A 9-month-old infant is being examined in the general pediatric clinic for a routine well-child checkup. His immunizations are up to date, and his mother reports that he has had no significant illnesses or injuries.
Which of the following signs would lead the nurse to believe that he has had a cerebral injury?

Question515: A client on the infectious disease unit is discussing transmission of human immunodeficiency virus (HIV).
The nurse would need to provide more client education based on which client statement?

Question516: The most important reason to closely assess circumferential burns at least every hour is that they may result in:

Question517: The nurse is caring for a laboring client. Assessment data include cervical dilation 9 cm; contractions every
1-2 minutes; strong, large amount of "bloody show." The most appropriate nursing goal for this client would be:

Question518: A 55-year-old woman entered the emergency room by ambulance. Her primary complaint is chest pain.
She is receiving O2 via nasal cannula at 2 L/min for dyspnea. Which of the following findings in the client's nursing assessment demand immediate nursing action?

Question519: A 23-year-old male client is admitted to the chemical dependency unit with a medical diagnosis of alcoholism. He reports that the last time he drank was 3 days ago, and that now he is starting to "feel kind of shaky." Based on the information given above, nursing care goals for this client will initially focus on:

Question520: A female client has just died. Her family is requesting that all nursing staff leave the room. The family's religious leader has arrived and is ready to conduct a ceremony for the deceased in the room, requesting that only family members be present. The nurse assigned to the client should perform the appropriate nursing action, which might include:

Question521: A client is experiencing mucosal cell damage secondary to chemotherapy. Because of mucosal ulcers, eating has become increasingly uncomfortable for her. Which of the following interventions would be most effective in getting her to eat?

Question522: A newborn is admitted to the newborn nursery with tremors, apnea periods, and poor sucking reflex. The nurse should suspect:

Question523: A client has had amniocentesis. One of the tests performed on the amniotic fluid is a lecithin/sphingomyelin (L/S) ratio. The results show a ratio of 1:1. This is indicative of:

Question524: Parents of a child with rheumatic fever express concern that she will always be arthritic. The nurse discusses their concerns and tells them the joint pain usually:

Question525: A client's renal calculi are identified as consisting of calcium phosphate. Which of the following diets would be appropriate?

Question526: A 48-year-old male client is hospitalized with mild ascites, bruising, and jaundice. He has a 20-year history of alcohol abuse. The client is diagnosed with cirrhosis. His serum ammonia level is high, indicating hepatic encephalopathy. He has esophageal varices. Which of the following may cause the varices to rupture?

Question527: A client undergoes a transurethral resection, prostate (TURP). He returns from surgery with a three-way continuous Foley irrigation of normal saline in progress. The purpose of this bladder irrigation is to prevent:

Question528: Goal setting for a client with Meniere's disease should include which of the following?

Question529: In working with a manipulative client, which of the following nursing interventions would be most appropriate?

Question530: A 60-year-old male client was hospitalized 3 days ago with the diagnosis of acute anterior wall myocardial infarction. Today he has been complaining of increasing weakness and shortness of breath. Crackles in both lung bases are audible on auscultation. He is developing:

Question531: A client has returned to the unit following a left femoral popliteal bypass graft. Six hours later, his dorsalis pedis pulse cannot be palpated, and his foot is cool and dusky. The nurse should:

Question532: In healthcare settings, nurses must be familiar with primary, secondary, and tertiary levels of care. As a nurse in the community, which of the following interventions might be a primary prevention strategy?

Question533: A male client is scheduled for a liver biopsy. In preparing him for this test, the nurse should:

Question534: A client is admitted to the labor unit. On vaginal examination, the presenting part in a cephalic presentation was at station plus two. Station 12 means that the:

Question535: A male client was involved in a motor vehicle accident earlier in the day. The nurse caring for him on evenings notices that on admission to the hospital, he lost a lot of blood and required multiple blood transfusions. The nurse would anticipate which blood product would be ordered when a large blood loss has occurred?

Question536: At her monthly prenatal visit, a client reports experiencing heartburn. Which nursing measure should be included in her plan of care to help alleviate it?

Question537: The nurse is assisting a 4th-day postoperative cholecystectomy client in planning her meals for tomorrow's menu. Which vitamin is the most essential in promoting tissue healing?

Question538: A 6-year-old child is attending a pediatric clinic for a routine examination. What should the nurse assess for while conducting a vision screening?

Question539: For the past several months, an elderly female client with Alzheimer's disease has experienced paranoia; hallucinations; and aggressive, disruptive behavior. The family is utilizing haloperidol as needed to control her behavior. On nursing assessment, you note that the client demonstrates involuntary movements of the tongue and fingers. This may most likely indicate:

Question540: A 56-year-old psychiatric inpatient has had recurring episodes of depression and chronic low self-esteem.
She feels that her family does not want her around, experiences a sense of helplessness, and has a negative view of herself. To assist the client in focusing on her strengths and positive traits, a strategy used by the nurse would be to:

Question541: While the RN is assessing a mother's perineum on her 2nd postpartum day after having a vaginal delivery, the RN notes a large ecchymotic area located to the left of the mother's perineum. Which one of the following interventions should the RN initiate at this time?

Question542: Stat serum electrolytes ordered for a client in acute renal failure revealed a serum potassium level of 6.4.
The physician is immediately notified and orders 50 mL of dextrose and 10 U of regular insulin IV push.
The nurse administering these drugs knows the Rationale for this therapy is to:

Question543: A client is placed on lithium therapy for her manicdepressive illness. When monitoring the client, the nurse assesses the laboratory blood values. Toxicity may occur with lithium therapy when the blood level is above:

Question544: A 24-year-old client presents to the emergency department protesting "I am God." The nurse identifies this as a:

Question545: Which of the following would the nurse expect to find following respiratory assessment of a client with advanced emphysema?

Question546: A 24-hours' postpartum client complains of discomfort at the episiotomy site. On assessment, the nurse notes the episiotomy is without signs of infection. To relieve the discomfort, the nurse should first:

Question547: When planning care for a 9-year-old client, the nurse uses which of the most effective means of helping siblings cope with their feelings about a brother who is terminally ill?

Question548: The nurse assesses a postoperative mastectomy client and notes that breath sounds are diminished in both posterior bases. The nurse's action should be to:

Question549: In working with mental health clients who are prescribed medication that must be taken on a routine basis, it is important for education to begin when the drug therapy is initiated. One of the first steps in the teaching process is to:

Question550: The nurse recognizes that a client with the diagnosis of cholecystitis and cholelithiasis would expect to have stools that are:

Question551: A 6-year-old child returned to the surgical floor 20 hours ago after an appendectomy for a gangrenous appendix. His mother tells the nurse that he is becoming more restless and is anxious. Assessment findings indicate that the child has atelectasis. Appropriate nursing actions would include:

Question552: A female client has married recently. A month ago she visited her physician with complaints of burning on urination. She was given a prescription for trimethoprim- sulfamethoxazole (Bactrim) DS bid for 10 days.
She was admitted through the emergency room on Saturday evening complaining of flank pain. Her temperature was 104_F. A preliminary urinalysis revealed 31 bacteria along with red and white blood cells in the urine. A preliminary diagnosis of pyelonephritis was made. During a nursing admission assessment, which statement by the client demonstrates a possible cause for pyelonephritis?

Question553: A male client has asthma and his physician has prescribed beclomethasone (Vanceril) 3 puffs tid in addition to his other medications. After taking his beclomethasone, the client should be instructed to:

Question554: A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints?

Question555: A male client is undergoing cardiac tests. He has been instructed to wear a Holter monitor. The nurse knows she has included the appropriate information in her teaching when the client tells her:

Question556: Which of the following procedures is necessary to establish a definitive diagnosis of breast cancer?

Question557: A client is admitted to the hospital with a diagnosis of aplastic anemia and placed on isolation. The nurse notices a family member entering the room without applying the appropriate apparel. The nurse will approach the family member using the following information as a basis for discussion:

Question558: Respiratory function is altered in a 16-year-old asthmatic. Which of the following is the cause of this alteration?

Question559: When assessing fetal heart rate status during labor, the monitor displays late decelerations with tachycardia and decreasing variability. What action should the nurse take?

Question560: During an examination, the nurse notes that an infant has diaper rash on the convex surfaces of his buttocks, inner thighs, and scrotum. Which of the following nursing interventions will be most effective in resolving the condition?

Question561: The nurse provides a male client with diet teaching so that he can help prevent constipation in the future.
Which food choices indicate that this teaching has been understood?

Question562: A 47-year-old client has been admitted to the general surgery unit for bowel obstruction. The doctor has ordered that an NG tube be inserted to aid in bowel de-compression. When preparing to insert a NG tube, the nurse measures from the:

Question563: A 22-year-old client presents with a diagnosis of antisocial personality disorder and a history of using drugs, writing numerous checks with insufficient funds, and stealing. He appears charming and intelligent, and the other clients are impressed and want to be liked by him. The greatest problem that may arise from this situation is that:

Question564: A male client is experiencing extreme distress. He begins to pace up and down the corridor. What nursing intervention is appropriate when communicating with the pacing client?

Question565: A client suspected of having anorexia nervosa is placed on bed rest with an IV infusion and a high- carbohydrate liquid diet. Within 72 hours, the results of her lab work show a return to normal limits. She is transferred to the psychiatric service for further treatment. A behavior modification plan is initiated. Three days after her transfer, the client tells the nurse, "I haven't exercised in 6 days. I won't be eating lunch today." This statement by her most likely reflects:

Question566: A client suffering from schizophrenia has been taking chlorpromazine (Thorazine) for 6 months. On one of his follow-up visits to the mental health center, the nurse reports to the physician that he has developed tardive dyskinesia. Which of the following symptoms might she have observed in the client to support this conclusion?

Question567: The nurse has been assigned a client who delivered a 6- lb, 12-oz baby boy vaginally 40 minutes ago. The initial assessment of greatest importance for this client would be:

Question568: Clients receiving antipsychotic drug therapy will often exhibit extrapyramidal side effects that are reversible with which of the following agents ordered by the physician?

Question569: A 74-year-old client seen in the emergency room is exhibiting signs of delirium. His family states that he has not slept, eaten, or taken fluids for the past 24 hours. The planning of nursing care for a delirious client is based on which of the following premises?

Question570: After instructing a female client on circumcision care, the nursery nurse asks her to restate some of the key points covered. Which statement shows that the client will properly care for her son's circumcision?

Question571: A 48-hour-old male infant is ordered to have phototherapy. When his mother questions the nurse about its purpose, the nurse explains that phototherapy:

Question572: Provide the 1-minute Apgar score for an infant born with the following findings: Heart rate: Above 100 Respiratory effort: Slow, irregular Muscle tone: Some flexion of extremities Reflex irritability: Vigorous cry Color: Body pink, blue extremities

Question573: A client is receiving peritoneal dialysis. He has been taught to warm the dialyzing fluid prior to instilling it because:

Question574: When teaching a class of nursing students, the nurse asks why the embryonic period (weeks 4-8) of pregnancy is so critical.

Question575: A husband and wife and their two children, age 9 and age 5, are requesting family therapy. Which of the following strategies is most therapeutic for the nurse to use during the initial interaction with a family?

Question576: A 27-year-old healthy primigravida is brought to the labor and birthing room by her husband at 32 weeks' gestation. She experienced a sudden onset of painless vaginal bleeding. Following an ultrasound examination, the diagnosis of bleeding secondary to complete placenta previa is made. Expected assessment findings concerning the abdomen would include:

Question577: A nasogastric (NG) tube inserted preoperatively is attached to low, intermittent suctions. A client with an NG tube exhibits these symptoms: He is restless; serum electrolytes are Na 138, K 4.0, blood pH 7.53.
This client is most likely experiencing:

Question578: The 4th of July holiday comes while a client is in the hospital being treated for schizophrenia. She is taking chlorpromazine and has improved to the point of being allowed to go with a group to the park for a picnic.
The side effect of chlorpromazine that the nurse needs to keep in mind during this outing is:

Question579: A 19-month-old child is admitted to the hospital for surgical repair of patent ductus arteriosus. The child is being given digoxin. Prior to administering the medication, the nurse should:

Question580: The nurse instructs a client on the difference between true labor and false labor. The nurse explains, "In true labor:

Question581: A 66-year-old female client has smoked 2 packs of cigarettes per day for 20 years. Her arterial blood gases on room air are as follows: pH 7.35; PO2 70 mm Hg; PCO2 55 mm Hg; HCO3 32 mEq/L. These blood gases reflect:

Question582: The nurse in the mental health center is instructing a depressed client about the dietary restrictions necessary in taking her medication, which is a monoamine oxidase (MAO) inhibitor. Which of the following is she restricting from the client's diet?

Question583: A 29-year-old client delivered her fifth child by the Lamaze method and developed a postpartal hemorrhage in the recovery room. What are the initial symptoms of shock that she may experience?

Question584: A group of nursing students at a local preschool day care center are going to screen each child's fine and gross motor, language, and social skills. The students will use which one of the most widely used screening tests?

Question585: On assessment, the nurse learns that a chronic paranoid schizophrenic has been taking "the blue pill" (haloperidol) in the morning and evening, and "the white pill" (benztropine) right before bedtime. The nurse might suggest to the client that she try:

Question586: Often children are monitored with pulse oximeter. The pulse oximeter measures the:

Question587: A client has been diagnosed as being preeclamptic. The physician orders magnesium sulfate. Magnesium sulfate (MgSO4) is used in the management of preeclampsia for:

Question588: The nurse is collecting a nutritional history on a 28- year-old female client with iron-deficiency anemia and learns that the client likes to eat white chalk. When implementing a teaching plan, the nurse should explain that this practice:

Question589: The physician decides to prescribe both a short-acting insulin and an intermediate-acting insulin for a newly diagnosed 8-year-old diabetic client. An example of a short-acting insulin is:

Question590: Except for initial explosiveness on admission, a client diagnosed with schizophrenia stays in her room. She continues to believe other people are out to get her. A nursing intervention basic to improving withdrawn behavior is:

Question591: Following a gastric resection, a 70-year-old client is admitted to the postanesthesia care unit. He was extubated prior to leaving the suite. On arrival at the postanesthesia care unit, the nurse should:

Question592: Which stage of labor lasts from delivery of the baby to delivery of the placenta?

Question593: A male client received a heart-lung transplant 1 month ago at a local transplant center. While visiting the nursing center to have his blood pressure taken, he complains of recent weakness and fatigue. He also tells the nurse that he is considering stopping his cyclosporine because it is expensive and is causing his face to become round. He fears he will catch viruses and be more susceptible to infections. The nurse responds to this last statement by explaining that cyclosporine:

Question594: Cheyne-Stokes respiratory pattern can be associated with which of the following conditions?

Question595: A couple is experiencing difficulties conceiving a baby. The nurse explains basal body temperature (BBT) by instructing the female client to take her temperature:

Question596: Diagnostic assessment findings for an infant with possible coarctation of the aorta would include:

Question597: A client has renal failure. Today's lab values indicate he has an elevated serum potassium. What additional priority information does the nurse need to obtain?

Question598: A 14-year-old teenager is hospitalized for anorexia nervosa. She is admitted to the adolescent mental health unit and placed on a behavior modification program. Nursing interventions for the teenager will most likely include:

Question599: A 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these nursing measures should be included in the postoperative care?

Question600: A 74-year-old obese man who has undergone open reduction and internal fixation of the right hip is 8 days postoperative. He has a history of arthritis and atrial fibrillation. He admits to right lower leg pain, described as "a cramp in my leg." An appropriate nursing action is to:

Question601: A 37-year-old client has been taking antipsychotic medication for the past 10 days. The nurse observes her walking with a shuffling gait and postural rigidity and notes a masklike expression on her face. Which side effect is this client exhibiting?

Question602: A client is in active labor and has been admitted to the labor and delivery unit. The RN has just done a sterile vaginal exam and determines that the client is dilated 5 cm, effaced 85%, and the fetus's head is at
0 station. She asks if she could have a lumbar epidural now. The epidural is started, and the anesthetic agent used is bupivacaine (Marcaine). After the client has received her lumbar epidural, it is important for the RN to monitor her for which of the following side effects:

Question603: A 29-year-old client is admitted for a hysterectomy. She has repeatedly told the nurses that she is worried about having this surgery, has not slept well lately, and is afraid that her husband will not find her desirable after the surgery. Shortly into the preoperative teaching, she complains of a tightness in her chest, a feeling of suffocation, lightheadedness, and tingling in her hands. Her respirations are rapid and deep.
Assessment reveals that the client is:

Question604: A client is experiencing visual problems at school. She has complained of difficulty seeing the blackboard and squinting. She no longer likes to participate in physical activities such as softball. The client has displayed possible classic symptoms of which refractive error?

Question605: A client has been in labor 10 hours and is becoming very tired. She has dilated to 7 cm and is at 0 station with the fetus in a right occipitoposterior position. She is complaining of severe backache with each contraction. One comfort measure the nurse can employ is to:

Question606: The nurse and prenatal client discuss the effects of cigarette smoking on pregnancy. It would be correct for the nurse to explain that with cigarette smoking there is increased risk that the baby will have:

Question607: A client presents to the emergency room with cyanosis, coughing, tachypnea, and tachycardia. She has a history of asthma. Arterial blood gas values are pH 7.28, PaO2 54, PaCO2 60, and HCO3 24. The nursing assessment of arterial blood gases indicate the presence of:

Question608: In evaluating the effectiveness of magnesium sulfate (MgSO4), which of the following might indicate that the client was developing MgSO4 toxicity?

Question609: Which of the following ECG changes would be seen as a positive myocardial stress test response?

Question610: A psychiatric client has been stabilized and is to be discharged. The nurse will recognize client insight and behavioral change by which of the following client statements?

Question611: An infant weighing 15 lb has just been treated for severe diarrhea in the hospital. Discharge instructions by the nurse will include maintenance fluid requirements for the pediatric client. Which of the following values best indicates the nurse's understanding of normal fluid requirements for this infant?

Question612: A 13-year-old hemophiliac is hospitalized for hemarthrosis of his right knee. To relieve the pain, the nurse should:

Question613: The nurse is preparing a 6-year-old child for an IV insertion. Which one of the following statements by the nurse is appropriate when preparing a child for a potentially painful procedure?

Question614: A postoperative prostatectomy client is preparing for discharge from the hospital the next morning. The nurse realizes that additional instructions are necessary when he states:

Question615: A 40-year-old client is admitted to the hospital for tests to diagnose cancer. Since his admission, he has become dependent and demanding to the nursing staff. The nurse identifies this behavior as which defense mechanism?

Question616: A female client has a chest tube placed. It is accidentally pulled out of the intrapleural space when she is ambulating. The first action the nurse should take is to:

Question617: Which of the following blood gas parameters primarily reflects respiratory function?

Question618: A family is experiencing changes in their lifestyle in many ways. The invalid grandmother has moved in with them. The couple have a 2-year-old son by their marriage, and the wife has two children by her previous marriage. The older children are in high school. In applying systems theory to this family, it is important for the nurse to remember which of the following principles?

Question619: A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving oxytocin.
The nurse's first intervention should be to:

Question620: After an infant is delivered by cesarean delivery and placed on the warmer, the RN dries and assesses the infant. At 1 and 5 minutes after birth, the RN does the Apgar scoring of the infant. The RN knows that because this infant was delivered by cesarean section, he is at increased risk for having which one of the following:

Question621: A 35-weeks-pregnant client is undergoing a nonstress test (NST). During the 20-minute examination, the nurse notes three fetal movements accompanied by accelerations of the fetal heart rate, each 15 bpm, lasting
15 seconds. The nurse interprets this test to be:

Question622: A client is hyperactive and not sleeping. She will not remain at the table during mealtime. She is getting very limited calories and is using a lot of energy in her hyperactive state. The most therapeutic nursing action is to:

Question623: A 17-year-old client has a T-4 spinal cord injury. At present, he is learning to catheterize himself. When he says, "This is too much trouble. I would rather just have a Foley.'' An appropriate response for the RN teaching him would be:

Question624: A client is admitted to the psychiatric unit after lavage and stabilization in the emergency room for an overdose of antidepressants. This is her third attempt in 2 years. The highest priority intervention at this time is to:

Question625: A female client has been diagnosed with chronic renal failure. She is a candidate for either peritoneal dialysis or hemodialysis and must make a choice between the two. Which information should the nurse give her to help her decide?

Question626: Other drugs may be ordered to manage a client's ulcerative colitis. Which of the following medications, if ordered, would the nurse question?

Question627: Which of the following signs and symptoms indicates a tension pneumothorax as compared to an open pneumothorax?

Question628: A mother called the physician's office to ask if it would help relieve her small daughter's abdominal pain if she gave an enema and placed a heating pad on the abdomen. Her daughter has a fever and has vomited twice.
The nurse's response is based on the knowledge that:

Question629: A laboring client presents with a prolapsed cord. The nurse should immediately place the client in what position?

Question630: The parents of a 2-year-old child are ready to begin toilet training activities with him. His parents feel he is ready to train because he is now 2 years old. What would the nurse identify as readiness in this child?

Question631: A behavioral modification program is recommended by the multidisciplinary team working with a 15-year- old client with anorexia nervosa. A nursing plan of care based on this modality would include:

Question632: The client will be more comfortable and the results more accurate when the nurse prepares the client for Leopold's maneuvers by having her:

Question633: Following a vaginal delivery, the postpartum nurse should observe for:

Question634: The pediatric nurse charts that the parents of a 4-yearold child are very anxious. Which observation would indicate to the nurse unhealthy coping by these parents:

Question635: A male client is admitted to the medical-surgical unit from the emergency room with a diagnosis of acute pancreatitis. The nurse performs the admission nursing assessment. He is NPO with IV fluids infusing at
100 mL/hour. He is experiencing excruciating abdominal pain. Based on an analysis of these data, which nursing diagnosis would receive the highest priority?

Question636: The physician is preparing to induce labor on a 40-week multigravida. The nurse should anticipate the administration of:

Question637: A male client has burns over 90% of his body after an automobile accident resulting in a fire. He was trapped inside the auto and pulled out by a bystander. After several months in the hospital and over 20 surgeries, discharge planning has begun. Throughout his hospitalization the nursing staff has been aware of psychological changes the client faces after burns over a large portion of his body resulting in disfigurement. The nursing staff can best foster the client's self-esteem by:

Question638: A female client has been recently diagnosed as bipolar. She has taken lithium for the past several weeks to control mania. What must be included in client education regarding lithium toxicity?

Question639: The medication that best penetrates eschar is:

Question640: A female client comes for her second prenatal visit. The nurse-midwife tells her, "Your blood tests reveal that you do not show immunity to the German measles." Which notation will the nurse include in her plan of care for the client? "Will need . . .

Question641: An 11-year-old boy has received a partial-thickness burn to both legs. He presents to the emergency room approximately 15 minutes after the accident in excruciating pain with charred clothing to both legs. What is the first nursing action?

Question642: Azulfidine (Sulfasalazine) may be ordered for a client who has ulcerative colitis. Which of the following is a nursing implication for this drug?

Question643: The client tells the nurse, "I have pain in my left shoulder."
This is considered:

Question644: A 55-year-old client is admitted with a diagnosis of renal calculi. He presented with severe right flank pain, nausea, and vomiting. The most important nursing action for him at this time is:

Question645: A mother continues to breast-feed her 3-month-old infant. She tells the nurse that over the past 3 days she has not been producing enough milk to satisfy the infant. The nurse advises the mother to do which of the following?

Question646: A long-term goal for the nurse in planning care for a depressed, suicidal client would be to:

Question647: A baby is circumcised. Immediate postoperative care should include:

Question648: A client delivered her first-born son 4 hours ago. She asks the nurse what the white cheeselike substance is under the baby's arms. The nurse should respond:

Question649: A 60-year-old woman exhibits forgetfulness, emotional lability, confusion, and decreased concentration.
She has been unable to perform activities of daily living without assistance. After a thorough medical evaluation, a diagnosis of Alzheimer's disease was made. An appropriate nursing intervention to decrease the anxiety of this client would include:

Question650: A burn victim's immunization history is assessed by the nurse. Which immunization is of priority concern?

Question651: A client is having a vertical partial laryngectomy, and the nurse is planning his postoperative care. A priority postoperative nursing diagnosis for a client having a vertical partial laryngectomy would be:

Question652: A client was admitted to the hospital for a TURP. Within 48 hours of admission and 12 hours postoperatively, both the blood pressure and pulse increased. He became agitated, thought snakes were crawling on his arms and legs, and generally became unmanageable. He pulled out his IV and urinary catheter in attempt to rid himself of the snakes. He was sweating profusely. The admission nurse's notes indicated that the client admitted to "having a few drinks now and then." He is probably experiencing which of the following?

Question653: A 48-year-old client presents with a long history of severedepression unrelieved by medication. He is admitted to the hospital for electroconvulsive therapy. Familymembers are very concerned about this therapy and are requesting information about aftereffects of the treatment. The nurse informs the family that he will:

Question654: An 18-year-old girl is admitted to the hospital with a depressed skull fracture as a result of a car accident. If the nurse were to observe a rising pulse rate and lowering blood pressure, the nurse would suspect that the client:

Question655: A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use, and haloperidol (Haldol) 5 mg IM is administered. After 1 hour, his behavior is more subdued, but he tells the nurse, "The devil followed me into this room, I see him standing in the corner with a big knife. When you leave the room, he's going to cut out my heart." The nurse's best response is:

Question656: Succinylcholine chloride (Anectine) is ordered prior to electroconvulsive therapy treatment for depressed clients. The nurse explains that the purpose of the drug is to:

Question657: A client returns for her 6-month prenatal checkup and has gained 10 lb in 2 months. The results of her physical examination are normal. How does the nurse interpret the effectiveness of the instruction about diet and weight control?

Question658: The nurse assesses a client on the second postpartum day and finds a dark red discharge on the peripad.
The stain appears to be about 5 inches long. Which of the following correctly describes the character and amount of lochia?

Question659: To prevent thrombophlebitis in a client on complete bed rest, the nursing care plan should include:

Question660: Nursing care for the parents of a child with a congenital heart defect would include:

Question661: A pregnant woman at 36 weeks' gestation is followed for PIH and develops proteinuria. To increase protein in her diet, which of the following foods will provide the greatest amount of protein when added to her intake of 100 mL of milk?

Question662: Which of the following statements relevant to a suicidal client is correct?

Question663: The primary reason that an increase in heart rate (100 bpm) detrimental to the client with a myocardial infarction (MI) is that:

Question664: A complication for which the nurse should be alert following a liver biopsy is:

Question665: The nurse is in the hallway and one of the visitors faints. The nurse should:

Question666: A client is scheduled for a magnetic resonance imaging (MRI) to locate a cerebral lesion. It is important for the nurse to find out if he has a(n):

Question667: A 25-year-old client believes she may be pregnant with her first child. She schedules an obstetric examination with the nurse practitioner to determine the status of her possible pregnancy. Her last menstrual period began May 20, and her estimated date of confinement using Nägele's rule is:

Question668: A client states to his nurse that "I was told by the doctor not to take one of my drugs because it seems to have caused decreasing blood cells." Based on this information, which drug might the nurse expect to be discontinued?

Question669: Which of the following would differentiate acute from chronic respiratory acidosis in the assessment of the trauma client?

Question670: A child is admitted with severe headache, fever, vomiting, photophobia, drowsiness, and stiff neck associated with viral meningitis. She will be more comfortable if the nurse:

Question671: A cardinal symptom of the schizophrenic client is hallucinations. A nurse identifies this as a problem in the category of:

Question672: A 16-year-old client with anorexia nervosa is on an inpatient psychiatric unit. She has a fear of gaining weight and is refusing to eat sufficient amounts to maintain body weight for her age, height, and stature. To assist with the problem of powerlessness and plan for the client to no longer need to withhold food to feel in control, the nurse uses the following strategy:

Question673: A young boy tells the nurse, "I don't like my Dad to kiss or hug my Mom. I love my Mom and want to marry her." The nurse recognizes this stage of growth and development as:

Question674: A 55-year-old man is admitted to the hospital with complaints of fatigue, jaundice, anorexia, and clay- colored stools. His admitting diagnosis is "rule out hepatitis." Laboratory studies reveal elevated liver enzymes and bilirubin. In obtaining his health history, the nurse should assess his potential for exposure to hepatitis.
Which of the following represents a high-risk group for contracting this disease?

Question675: A client had a transurethral resection of the prostate yesterday. He is concerned about the small amount of blood that is still in his urine. The nurse explains that the blood in his urine:

Question676: During the active phase of rheumatic fever, the nurse teaches parents of a child with acute rheumatic fever to assist in minimizing joint pain and promoting healing by:

Question677: In assessing the nature of the stool of a client who has cystic fibrosis, what would the nurse expect to see?

Question678: During the assessment, the nurse observes a client scratching his skin. He has been admitted to rule out Laennec's cirrhosis of the liver. The nurse knows the pruritus is directly related to:

Question679: A 26-year-old client is diagnosed with an astrocytoma, a benign brain tumor. From the nurse's knowledge of the central nervous system, the nurse knows that benign tumors:

Question680: The nurse teaches a male client ways to reduce the risks associated with furosemide therapy. Which of the following indicates that he understands this teaching?

Question681: A 24-year-old woman who is gravida 1 reports, "I can't take iron pills because they make me sick." She continues, "My bowels aren't moving either." In counseling her based on these complaints, the nurse's most appropriate response would be, "It would be beneficial for you to eat . . .

Question682: The nurse is caring for a 3-month-old girl with meningitis. She has a positive Kernig's sign. The nurse expects her to react to discomfort if she:

Question683: A nurse is taking a maternal history for a client at her first prenatal visit. Her pregnancy test was positive, she has two living children, she had one spontaneous abortion, and one infant died at the age of 3 months.
Which of the following best describes the client at the present?

Question684: A 16-year-old client reports a weight loss of 20% of her previous weight. She has a history of food binges followed by self-induced vomiting (purging). The nurse should suspect a diagnosis of:

Question685: A 32-year-old female client is being treated for Guillain- Barré syndrome. She complains of gradually increasing muscle weakness over the past several days. She has noticed an increased difficulty in ambulating and fell yesterday. When conducting a nursing assessment, which finding would indicate a need for immediate further evaluation?

Question686: A 71-year-old client fell and injured her left leg while cooking in the kitchen. Her husband calls the ambulance, and she is taken to the emergency department at a local hospital. X-ray reports confirm that she has an intertrochanteric fracture of the left femur. Her left leg will require skeletal traction initially and then surgery. The nurse knows that this type of traction will be used:

Question687: A client sustained second- and third-degree burns to his face, neck, and upper chest. Which of the following nursing diagnoses would be given the highest priority in the first 8 hours' postburn?

Question688: A new mother experiences strong uterine contractions while breast-feeding her baby. She excitedly rings for the nurse. When the nurse arrives the mother tells her, "Something is wrong. This is like my labor." Which reply by the nurse identifies the physiological response of the client?

Question689: The nurse would be concerned if a client exhibited which of the following symptoms during her postpartum stay?

Question690: When a client questions the nurse as to the purpose of exercise electrocardiography (ECG) in the diagnosis of cardiovascular disorders, the nurse's response should be based on the fact that:

Question691: A client is having a pneumonectomy done today, and the nurse is planning her postoperative care. Nursing interventions for a postoperative left pneumonectomy would include:

Question692: A 6-year-old girl is visiting the outpatient clinic because she has a fever and a rash. The doctor diagnoses chickenpox. Her mother asks the nurse how many baby aspirins her daughter can have for fever. The nurse should:

Question693: A client who is 7 months pregnant is diagnosed with pyelonephritis. The nurse anticipates the physician ordering:

Question694: Which nursing implication is appropriate for a client undergoing a paracentesis?

Question695: The physician prescribes amitriptyline (Elavil) for a client. What does the patient need to know about this medication?

Question696: Three hours postoperatively, a 27-year-old client complains of right leg pain after knee reduction. The first action by the nurse will be to:

Question697: Which of the following nursing orders has the highest priority for a child with epiglottitis?

Question698: A female client was employed as a client care technician in a hemodialysis unit. She recently began to experience extreme fatigue, being able to sleep for 16-20 hours at a time. She also noted that her urine was tea colored, which she rationalized was a result of the vitamins she began taking to alleviate fatigue.
She was diagnosed with hepatitis B After a brief hospital stay, she is discharged to her parent's home. Her mother asks the nurse if any precautions are necessary to prevent transmission to the client's family. The nurse explains necessary precautions, which include:

Question699: The nurse needs to be aware that the most common early complication of a myocardial infarction is:

Question700: A client has developed congestive heart failure secondary to his myocardial infarction. Discharge diet instructions should emphasize the reduction or avoidance of:

Question701: A client experiencing delusions states, "I came here because there were people surrounding my house that wanted to take me away and use my body for science." The best response by the nurse would be:

Question702: Following the delivery of a healthy newborn, a client has developed thrombophlebitis and is receiving heparin IV. What are the signs and symptoms of a heparin overdose for which the nurse would need to observe during postpartum care of the client?

Question703: A successful executive left her job and became a housewife after her marriage to a plastic surgeon. She started doing volunteer work for a charity organization. She developed pain in her legs that advanced to the point of paralysis. Her physicians can find no organic basis for the paralysis. The client's behavior can be described as:

Question704: In teaching the client about proper umbilical cord care, the nurse recommends that:

Question705: With a geriatric client, the nurse should also assess whether he has been obtaining a yearly vaccination against influenza. Why is this assessment important?

Question706: A client is a depressed, 48-year-old salesman. A serious concern for the nurse working with depressed clients is the potential of suicide. The time that suicide is most likely to occur is:

Question707: A 15-year-old client is admitted to the adolescent unit. The nurse recognizes that encouraging a client to speak openly depends on how clearly questions are phrased. Which of the following statements is most desirable in eliciting information from an adolescent client?

Question708: During his hospitalization, a 3-year-old child has become unusually aggressive in his play activities. His parents report this change in behavior to the primary nurse. How could the nurse explain the child's change in behavior?

Question709: A client's record from the ED indicates that she overdosed on phenelzine sulfate (Nardil), a monoamine oxidase (MAO) inhibitor. Which diet would be the most appropriate at this time?

Question710: What is the most effective method to identify early breast cancer lumps?

Question711: A school-age child with asthma is ready for discharge from the hospital. His physician has written an order to continue the theophylline given in the hospital as an oral home medication. Immediately prior to discharge, he complains of nausea and becomes irritable. His vital signs were normal except for tachycardia. What first nursing actions would be essential in this situation?

Question712: At 38 weeks' gestation, a client is in active labor. She is using her Lamaze breathing techniques. The RN is coaching her breathing and encouraging her to relax and work with her contractions. Which one of the following complaints by the client will alert the RN that she is beginning to hyperventilate with her breathing?

Question713: A 16-year-old client comes to the prenatal clinic for her monthly appointment. She has gained 14 lb from her 7th to 8th month; her face and hands indicate edema. She is diagnosed as having PIH and referred to the high-risk prenatal clinic. The client's weight increase is most likely due to:

Question714: A newborn infant is exhibiting signs of respiratory distress. Which of the following would the nurse recognize as the earliest clinical sign of respiratory distress?

Question715: A 22-year-old client who is being seen in the clinic for a possible asthma attack stops wheezing suddenly as the nurse is doing a lung assessment. Which one of the following nursing interventions is most important?

Question716: The health team needs to realize that the compulsive concern with cleanliness that a client with severe anxiety exhibits is most likely an attempt to:

Question717: A 49-year-old obese woman has been admitted to the general surgery unit with choledocholithiasis. As the nurse is admitting her to the unit, she states, "The doctor said I have stones that need to be removed; where are they?" The nurse knows that the best explanation for this is to tell her that:

Question718: The nurse assists a client with advanced emphysema to the bathroom. The client becomes extremely short of breath while returning to bed. The nurse should:

Question719: A female client has been hospitalized for several months following major abdominal surgery for a ruptured colon. A colostomy was created, and the large abdominal wound was left open and allowed to heal through granulation. She is receiving gentamicin IV for treatment of wound infection. Knowing this drug is ototoxic, the nurse would implement which of the following measures?

Question720: A male client is admitted to the psychiatric unit after experiencing severe depression. He states that he intends to kill himself, but he asks the nurse not to repeat his intentions to other staff members. Which response demonstrates understanding and appropriate action on the part of the nurse?

Question721: The mother of a 7-year-old mental health center client reports that the client has refused to attend gymnastics for the past 2 weeks. Prior to that time, the child liked going to this class and was attending 3 times a week. In talking with the client, the nurse would:

Question722: A client has ascites, which is caused by:

Question723: Due to his prolonged history of alcohol abuse, an alcoholic client will most likely have deficiencies of which of the following nutrients?

Question724: Proper positioning for the child who is in Bryant's traction is:

Question725: A postoperative TURP client returns from the recovery room to the general surgery unit and is in stable condition. One hour later the nurse assesses him and finds him to be confused and disoriented. She recognizes that this is most likely caused by:

Question726: Plans for the care of a client with an ulcer caused by emotional problems need to take into consideration that:

Question727: A client is started on prednisone 2.5 mg po bid. Which of the following instructions should be included in her discharge teaching specific to this medication?

Question728: When inspecting a cardiovascular client, the nurse notes that he needs to sit upright to breathe. This behavior is most indicative of:

Question729: A client had a hemicolectomy performed 2 days ago. Today, when the nurse assesses the incision, a small part of the abdominal viscera is seen protruding through the incision. This complication of wound healing is known as:

Question730: A 30-year-old client in the third trimester of her pregnancy asks the nurse for advice about upper respiratory discomforts. She complains of nasal stuffiness and epistaxis, most noticeable on the left side.
Which reply by the nurse is correct?

Question731: The nurse notes hyperventilation in a client with a thermal injury. She recognizes that this may be a reaction to which of the following medications if applied in large amounts?

Question732: When assessing residual volume in tube feeding, the feeding should be delayed if the amount of gastric contents (residual) exceeds:

Question733: A 6-month-old infant has developmental delays. His weight falls below the 5th percentile when plotted on a growth chart. A diagnosis of failure to thrive is made. What behaviors might indicate the possibility of maternal deprivation?

Question734: A 68-year-old man was recently diagnosed with endstage renal disease. He has not yet begun dialysis but is experiencing severe anemia with associated symptoms of dyspnea on exertion and chest pain. Which statement best describes the management of anemia in renal failure?

Question735: A 24-year-old male client is admitted with a diagnosis of sickle cell anemia. The nurse discusses his disease with him and emphasizes the following information:

Question736: To appropriately monitor therapy and client progress, the nurse should be aware that increased myocardial work and O2 demand will occur with which of the following?

Question737: Seven days ago, a 45-year-old female client had an ileostomy. She is self-sufficient and well otherwise.
Which of the following long-term objectives would be unrealistic?

Question738: A client with cirrhosis of the liver becomes comatose and is started on neomycin 300 mg q6h via nasogastric tube. The rationale for this therapy is to:

Question739: A nurse should carefully monitor a client for the following side effect of MgSO4:

Question740: A female client at 37 weeks' gestation has just undergone a nonstress test. The results were two fetal movements with a corresponding increase in fetal heart rate (FHR) of 15 bpm lasting 15 seconds within a
20-minute period. Her results would be classified as:

Question741: During the admitting mental health assessment, a client demonstrates involuntary muscular activity. He has a marked facial tic around the mouth that is distracting to the nurse during the interview. The nurse recognizes the behavior and documents it as:

Question742: Children often experience visual impairments. Refractive errors affect the child's visual activity. The main refractive error seen in children is myopia. The nurse explains to the child's parents that myopia may also be described as:

Question743: Because a client is taking an MAO inhibitor, it is necessary to discuss the need for adherence to a low- tyramine diet. Which of the following are foods that she should avoid?

Question744: A client has been diagnosed with congestive heart failure. His fluid intake and output are strictly regulated.
For lunch, he drank 8 oz of milk, 4 oz of tea, and 6 oz of coffee. His intake would be recorded as:

Question745: A pregnant client during labor is irritable and feels the urge to vomit. The nurse should recognize this as the:

Question746: Parents should be taught not to prop the bottle when feeding their infants. In addition to the risk of choking, it puts the infant at risk for:

Question747: A client has been diagnosed with thrombophlebitis. She asks, "What is the most likely cause of thrombophlebitis during my pregnancy?" The nurse explains:

Question748: The nurse is planning a reality orientation program for a group of clients with organic brain syndrome at the mental health center. Props that could be used for this program are:

Question749: A client is going to have a pneumonectomy in the morning. She had a previous negative surgical experience, is talking rapidly, and has an increased pulse and respiratory rate. Nursing interventions for this client should include:

Question750: Before giving methergine postpartum, the nurse should assess the client for:

Question751: A female client is concerned that she is in a "high-risk" group for the development of acquired immunodeficiency syndrome (AIDS). She wants to know about the advisability of donating blood. Which of the following responses is correct?

Question752: The physician recommends immediate hospital admission for a client with PIH. She says to the nurse, "It's not so easy for me to just go right to the hospital like that." After acknowledging her feelings, which of these approaches by the nurse would probably be best?

Question753: As a nurse in the emergency room, you receive an outside call from an elderly woman who states she has just been raped. She states, "I know I must come to the hospital, but what do I do next?" You advise her to call the police, then come to the hospital emergency room. What action by the nurse would indicate an understanding of the examination process once the victim enters the emergency room?

Question754: A client diagnosed with bipolar disorder continues to be hyperactive and to lose weight. Which of the following nutritional interventions would be most therapeutic for him at this time?

Question755: The nurse who is caring for a client with pneumonia assesses that the client has become increasingly irritable and restless. The nurse realizes that this is a result of:

Question756: A client who has gout is most likely to form which type of renal calculi?

Question757: The nurse observes that a client has difficulty chewing and swallowing her food. A nursing response designed to reduce this problem would include:

Question758: A 38-year-old pregnant woman visits her nurse practitioner for her regular prenatal checkup. She is 30 weeks' gestation. The nurse should be alert to which condition related to her age?

Question759: A client has consented to have a central venous catheter placed. The best position in which to place the client is the Trendelenburg position. The reason is that the Trendelenburg position:

Question760: A client is being discharged from the hospital today. The discharge teaching for care of her colostomy included which of the following basic principles for protecting the skin around her stoma:

Question761: A 30-year-old client has just been treated in the ER for bruises and abrasions to her face and a broken arm from domestic violence, which has been increasing in frequency and intensity over the last few months.
The nurse assesses her as being very anxious, fearful, bewildered, and feeling helpless as she states, "I don't know what to do, I'm afraid to go home." The best response by the nurse to the client would be:

Question762: A 4 year old has an imaginary playmate, which concerns the mother. The nurse's best response would be:

Question763: A female client at 36 weeks' gestation has been treated successfully for premature labor for 4 weeks. She has begun having uterine contractions today and has been admitted to the labor and delivery suite. Her amniocentesis results reveal a lecithin/sphingomyelin (L/S) ratio of 2 and positive phosphatidylglycerol (PG). These lab values indicate:

Question764: A newborn girl's father expresses concern that the newborn does not have good control of her hands and arms. It is important for the father to realize certain neurological patterns that characterize the newborn:

Question765: A 70-year-old client has pneumonia and has just had a respiratory arrest. He has just been intubated with an 8- mm endotracheal tube. During auscultation of his chest, breath sounds were found to be absent on the left side. The nurse identifies the most likely cause of this as:

Question766: Which behavior by a female client feeding her newborn demonstrates that she needs more teaching related to safety and infant feeding?

Question767: The mother of a preschooler reports to the nurse that he frequently tells lies. The admission assessment of the child indicates possible child abuse. The nurse knows that his:

Question768: A client who has been diagnosed with anorexia nervosa refuses to eat lunch. The most therapeutic response by the nurse to her refusal is:

Question769: A 47-year-old male client is admitted for colon surgery. Intravenous antibiotics are begun 2 hours prior to surgery. He has no known infection. The rationale for giving antibiotics prior to surgery is to:

Question770: The nurse caring for a client who has pneumonia, which is caused by a gram-positive bacteria, inspects her sputum. Because the client's pneumonia is caused by a gram-positive bacteria, the nurse experts to find the sputum to be:

Question771: A 5-year-old child is hospitalized for an acute illness. The nurse encourages the family to bring her favorite objects from home. What is the nurse's rationale?

Question772: A client is now pregnant for the second time. Her first child weighed 4536 g at delivery. The client's glucose tolerance test shows elevated blood sugar levels. Because she only shows signs of diabetes when she is pregnant, she is classified as having:

Question773: In caring at home for a child who just ingested a caustic alkali, the nurse would immediately tell the mother to:

Question774: After the fetal activity test (nonstress test) is completed, the RN is looking at the test results on the monitor strip. The RN observes that the fetal heart accelerated 5 beats/min with each fetal movement. The accelerations lasted ≥15 seconds and occurred 3 times during the 20- minute test. The RN knows that these test results will be interpreted as:

Question775: The healthcare team determines that an elderly client has had progressive changes in memory over the last 2 years that have interfered with her personal, social, or occupational functioning. Her memory, learning, attention, and judgment have all been affected in some way. These symptoms describe which of the following conditions?

Question776: Blood work reveals the following lab values for a client who has been diagnosed with anorexia nervosa:
hemoglobin 9.6 g/dL, hemocrit 27%, potassium 2.7 mEq/L, sodium 126 mEq/L. The greatest danger to her at this time is:

Question777: A client hospitalized with a medical diagnosis of adjustment disorder versus personality disorder states,
"Nobody cares about the clients." The nurse's most effective response would be:

Question778: A 55-year-old man has recently been diagnosed with hypertension. His physician orders a low-sodium diet for him. When he asks, "What does salt have to do with high blood pressure?'' the nurse's initial response would be:

Question779: A male infant is to be discharged home this morning. Which instruction related to his cord care should be included in his mother's discharge teaching plan?

Question780: A client is dilated 8 cm and entering the transition phase of labor. Common behaviors of the laboring woman during transition are:

Question781: The following nursing diagnosis is written for a comatose client with cirrhosis of the liver and secondary splenomegaly-High risk for injury: Increased susceptibility to bleeding related to:

Question782: In counseling a client, the nurse emphasizes the danger signals during pregnancy. On the next visit, the client identifies which of the following as a danger signal that should be reported immediately?

Question783: A 67-year-old postoperative TURP client has hematuria. The nurse caring for him reviews his postoperative orders and recognizes that which one of the following prescribed medications would best relieve this problem?

Question784: After a liver biopsy, the best position for the client is:

Question785: A 6-month-old infant who was diagnosed at 4 weeks of age with a ventricular septal defect, was admitted today with a diagnosis of failure to thrive. His mother stated that he had not been eating well for the past month. A cardiac catheterization reveals congestive heart failure. All of the following nursing diagnoses are appropriate. Which nursing diagnosis should have priority?

Question786: The nurse discovers that a 78-year-old client who received hydralazine (Apresoline) 20 mg 45 minutes ago has a blood pressure of 70/40 mm Hg. The client has been on this dose of the medication for 3 years.
Which of the following data is most likely significant in relation to the cause of the low blood pressure?

Question787: A 72-year-old client with a new colostomy is being evaluated at the clinic today for constipation. When discussing diet with the client, the nurse recognizes that which one of the following foods most likely caused this problem?

Question788: As the nurse assesses a male adolescent with chlamydia, the nurse determines that a sign of chlamydia is:

Question789: A 20-year-old female client delivers a stillborn infant. Following the delivery, an appropriate response by the labor nurse to the question, "Why did this happen to my baby?" is:

Question790: A male client has heart failure. He has been instructed to gradually increase his activities. Which signs and symptoms of worsening heart failure should the nurse tell him to watch for that would indicate a need for him to lower his activity level?

Question791: A client tells the nurse that she has had a history of urinary tract infections. The nurse would do further health teaching if she verbalizes she will:

Question792: A 70-year-old client is almost finished receiving her second unit of packed red blood cells. The client, who weighs 80 lb, has started complaining of being short of breath and now has crackles in the bases of her lungs. After slowing or stopping the transfusion, the most appropriate initial nursing action would be to:

Question793: A client at 9 weeks' gestation comes for an initial prenatal visit. On assessment, the nurse discovers this is her second pregnancy. Her first pregnancy resulted in a spontaneous abortion. She is 28 years old, in good health, and works full-time as an elementary school teacher. This information alerts the nurse to which of the following:

Question794: The nurse should facilitate bonding during the postpartum period. What should the nurse expect to observe in the taking-hold phase?

Question795: A 19-year-old client has sustained a C-7 fracture, which resulted in his spinal cord being partially transected. By 2 weeks' postinjury, his neck has been surgically stabilized, and he has been transferred from the intensive care unit. A potential life-threatening complication the nurse monitors the client for is:

Question796: A 27-year-old primigravida at 32 weeks' gestation has been diagnosed with complete placenta previa.
Conservative management including bed rest is the proper medical management. The goal for fetal survival is based on fetal lung maturity. The test used to determine fetal lung maturity is:

Question797: Hypoxia is the primary problem related to near-drowning victims. The first organ that sustains irreversible damage after submersion in water is the:

Question798: A 4-year-old child is being discharged from the hospital after being treated for severe croup. Which one of the following instructions should the nurse give to the child's mother for the home treatment of croup?

Question799: The nurse would be sure to instruct a client on the signs and symptoms of an eye infection and hemorrhage. These signs and symptoms would include:

Question800: A 19-year-old client fell off a ladder approximately 3 ft to the ground. He did not lose consciousness but was taken to the emergency department by a friend to have a scalp laceration sutured. The nurse instructs the client to:

Question801: A client is resting comfortably after delivering her first child. When assessing her pulse rate, the nurse would recognize the following finding to be typical:

Question802: A client has received preoperative teaching for the vertical partial laryngectomy that he is scheduled to have in the morning. The nurse determines that the teaching has been effective when the client states:

Question803: In planning daily care for a client with multiple sclerosis, the nurse would take into consideration that multiple sclerosis:

Question804: A client's wife is concerned over his behavior in recent months. He has been diagnosed with Parkinson's disease, and she is telling his nurse that he has been doing "strange things." The nurse reassures the wife that the following behavior is normal with Parkinson's disease:

Question805: A postpartum client complains of rectal pressure and severe pain in her perineum; this may be indicative of:

Question806: A male client seeks counseling after his wife of 19 years threatened to divorce him. For most of their marriage, he has physically and verbally abused her. When asked about his behavior in the process of the nursing assessment, the client states, "I was mean to my wife because she insists on cooking meals and wearing clothes that I do not like." This defense mechanism is an example of:

Question807: A male client receives 10 U of regular human insulin SC at 9:00 AM. The nurse would expect peak action from this injection to occur at:

Question808: A female client with major depression stated that "life is hopeless and not worth living." The nurse should place highest priority on which of the following questions?

Question809: The physician orders medication for a client's unpleasant side effects from the haloperidol. The most appropriate drug at this time is:

Question810: In client teaching, the nurse should emphasize that fetal damage occurs more frequently with ingestion of drugs during:

Question811: A male client has a history of diverticulosis. He has questions about the foods that he should eat. His nurse gives him the following information:

Question812: A female client admitted to the labor and delivery unit thinks her bag of water "broke" approximately 2 hours ago. She is having mild contractions 5 minutes apart. The most immediate nursing intervention would be to:

Question813: A female baby was born with talipes equinovarus. Her mother has requested that the nurse assigned to the baby come to her room to discuss the baby's condition. The nurse knows that the pediatrician has discussed the baby's condition with her mother and that an orthopedist has been consulted but has not yet seen the baby. What should the nurse do first?

Question814: A 25-year-old client is admitted for a tonsillectomy. She tells the nurse that she has had episodes of muscle cramps, weakness, and unexplained temperature elevation. Many years ago her father died shortly after surgery after developing a high fever. She further tells the nurse that her surgeon is having her take dantrolene sodium (Dantrium) prophylactically prior to her tonsillectomy. Dantrolene sodium is ordered preoperatively to reduce the risk or prevent:

Question815: A client diagnosed with severe anemia is to receive 2 U of packed red blood cells. Prior to starting the blood transfusion, the nurse must:

Question816: A 23-year-old female client is brought to the emergency room by her roommate for repeatedly making superficial cuts on her wrists and experiencing wide mood swings. She is very angry and hostile. Her medical diagnosis is adjustment disorder versus borderline personality disorder. The client comments to the nurse, "Nobody in here seems to really care about the clients. I thought nurses cared about people!" The client is exhibiting the ego defense mechanism:

Question817: A 35-year-old client is admitted to the hospital for elective tubal ligation. While the nurse is doing preoperative teaching, the client says, "The anesthesiologist said she was going to give me balanced anesthesia. What exactly is that?" The best explanation for the nurse to give the client would be that balanced anesthesia:

Question818: A client is medically cleared for ECT and is tentatively scheduled for six treatments over a 2-week period.
Her husband asks, "Isn't that a lot?" The nurse's best response is:

Question819: In an interview for suspected child abuse, the child's mother openly discusses her feelings. She feels her husband is too aggressive in disciplining their child. The child's father states, "Being a school custodian, I see kids every day that are bad because they did not get enough discipline at home. That will not happen to our child." Based on this remark, the nurse would make the following nursing diagnosis:

Question820: A male client has been hospitalized with congestive heart failure. Medical management of heart failure focuses on improving myocardial contractility. This can be achieved by administering:

Question821: One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is:

Question822: A client is being treated for congestive heart failure. His medical regimen consists of digoxin (Lanoxin) 0.25 mg po daily and furosemide 20 mg po bid. Which laboratory test should the nurse monitor?

Question823: A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and report:

Question824: The nurse enters the playroom and finds an 8-year-old child having a grand mal seizure. Which one of the following actions should the nurse take?

Question825: Iron dextran (Imferon) is a parenteral iron preparation.
The nurse should know that it:

Question826: A male client is diagnosed with hypoparathyroidism. He has been on dialysis for several years. He is experiencing symptoms such as numbness of the lips, muscle weakness, carpopedal spasms, and wheezing. Given the client's symptoms, nursing assessment would focus on:

Question827: As soon as a child has been diagnosed as "hearing impaired," special education should begin. Which of the following special education tasks is the most difficult for a severely hearing-impaired child?

Question828: The nurse would assess the client's correct understanding of the fertility awareness methods that enhance conception, if the client stated that:

Question829: A client has a history of alcoholism. He is currently diagnosed with cirrhosis of the liver. The nurse would expect him to be on which type of diet?

Question830: The most important goal in the care plan for a child who was hospitalized with an accidental overdose would be to:

Question831: A client calls the prenatal clinic to schedule an appointment. She states she has missed three menstrual periods and thinks she might be pregnant. During her first visit to the prenatal clinic, it is confirmed that she is pregnant. The registered nurse (RN) learns that her last menstrual period began on June 10. According to Nägele's rule, the estimated date of confinement is:

Question832: A 9-year-old child was in the garage with his father, who was repairing a lawnmower. Some gasoline ignited and caused an explosion. His father was killed, and the child has split-thickness and full-thickness burns over 40% of his upper body, face, neck, and arms. All of the following nursing diagnoses are included on his care plan. Which of these nursing diagnoses should have top priority during the first 24-48 hours postburn?

Question833: A 72-year-old male client had the Foley catheter that was inserted during the transurethral resection of his prostate removed today. He is concerned about the urinary incontinence he is having since removal of the Foley catheter. The nurse explains that:

Question834: Assessment of the client with pericarditis may reveal which of the following?

Question835: A client is being admitted to the labor and delivery unit. She has had previous admissions for "false labor." Which clinical manifestation would be most indicative of true labor?

Question836: A client had a right below-the-knee amputation 4 days ago. He is complaining of pain in his right lower leg.
The nurse should:

Question837: Three weeks following discharge, a male client is readmitted to the psychiatric unit for depression. His wife stated that he had threatened to kill himself with a handgun. As the nurse admits him to the unit, he says, "I wish I were dead because I am worthless to everyone; I guess I am just no good." Which response by the nurse is most appropriate at this time?

Question838: A 43-year-old client is admitted to the hospital with a diagnosis of peripheral vascular disorder. She arrives in her room via stretcher and requires assistance to move to her bed. The nurse notes that her left leg is cold to touch. She complains of having recently experienced muscle spasms in that leg. To determine if these muscle spasms are indicative of intermittent claudication, the nurse would begin her assessment with the following question:

Question839: A 16-year-old student has a long history of bronchial asthma and has experienced several severe asthmatic attacks during the school year. The school nurse is required to administer 0.2 mL of 1/1000 solution of epinephrine SC during an asthma attack. How does the school nurse evaluate the effectiveness of this intervention?

Question840: A client is diagnosed with organic brain disorder. The nursing care should include:

Question841: The pediatrician has diagnosed tinea capitis in an 8- year-old girl and has placed her on oral griseofulvin.
The nurse should emphasize which of these instructions to the mother and/or child?

Question842: A 56-year-old client is admitted to the psychiatric unit in a state of total despair. She feels hopeless and worthless, has a flat affect and very sad appearance, and is unable to feel pleasure from anything. Her husband has been assisting her at home with the housework and cooking; however, she has not been eating much, lies around or sits in a chair most of the day, and is becoming confused and thinks her family does not want her around anymore. In assessing the client, the nurse determines that her behavior is consistent with:

Question843: Which of the following signs might indicate a complication during the labor process with vertex presentation?

Question844: Prior to his discharge from the hospital, a cardiac client is started on digoxin (Lanoxin) 25 mg po qd. The nurse initiates discharge teaching. Which of the following statements by the client would validate an understanding of his medication?

Question845: Which of the following nursing orders should be included in the plan of care for a client with hepatitis C?

Question846: The most frequent cause of early postpartum hemorrhage is:

Question847: Pregnant women with diabetes often have problems related to the effectiveness of insulin in controlling their glucose levels during their second half of pregnancy. The nurse teaches the client that this is due to:

Question848: The nurse enters the room of a client on which a "do not resuscitate" order has been written and discovers that she is not breathing. Once the husband realizes what has occurred he yells, "please save her!" The nurse's action would be:

Question849: A 14-year-old boy has a head injury with laceration of his scalp over his ear. The nurse should call the physician to report:

Question850: An 8-year-old child comes to the physician's office complaining of swelling and pain in the knees. His mother says, "The swelling occurred for no reason, and it keeps getting worse." The initial diagnosis is Lyme disease. When talking to the mother and child, questions related to which of the following would be important to include in the initial history?

Question851: Endotracheal tube cuff pressure should never exceed:

Question852: The doctor has ordered a restricted fluid intake for a 2- year-old child with a head injury. Normal fluid intake for a child of 2 years is:

Question853: Which of the following findings would necessitate discontinuing an IV potassium infusion in an adult with ketoacidosis?

Question854: A pregnant client experiences spontaneous rupture of membranes. The first nursing action is to:

Question855: A client was admitted with rib fractures and a pneumothorax, which were sustained as a result of a motor vehicle accident. A chest tube was placed on the left side to reinflate his lung, and he was transferred to a client unit. Twenty-four hours after admission he continues to have bloody sputum, develops increasing hypoxemia, and his chest x-ray shows patchy infiltrates. The nurse analyzes these symptoms as being consistent with:

Question856: A 40-year-old client has been admitted to the hospital with severe substernal chest pain radiating down his left arm. The nurse caring for the client establishes the following priority nursing diagnosis-Alteration in comfort, pain related to:

Question857: A physician's order reads: Administer KCl 10% oral solution 1.5 mL. The KCl bottle reads 20 mEq/15 mL.
What dosage should the nurse administer to the infant?

Question858: A 32-year-old male client is a marketing representative. His job requires him to have a tremendous amount of energy during the day. He frequently uses cocaine to sustain his energy level. Lately he has increased his use of cocaine and even experimented with crack cocaine. Realizing he can no longer continue this destructive behavior, he is seeking treatment for cocaine addiction. In planning nursing care for the client's inpatient stay, which expected outcome is most appropriate?

Question859: A 3-month-old infant has had a unilateral cleft lip repair. He has resumed feedings of oral formula. The nurse should feed the infant with: