72. After teaching the mother of a 7-month-old diagnosed with bronchiolitis, the nurse determines that the teaching has been effective when the mother states which of the following as a sign to report immediately?
client is being treated for acute low back pain. The nurse should report which of these
1. Seven wet diapers a day.
2. Temperature of 100°F (37.8°C) for 2 days.
3. Clear nasal discharge for longer than 2 days.
4. Longer periods of sleep than usual.
73. The results of which of the following serologic tests should the nurse have on the chart before a client is started on tissue plasminogen activator or alteplase recombinant (Activase)?
1. Partial thromboplastin time.
2. Potassium level.
3. Lee-White clotting time.
4. Fibrin split product.
92. A “read-back” procedure has been implemented on a nursing unit to prevent discrepancies in telephone prescriptions and reports. This procedure should be implemented when the:
1. Float nurse gives a written report to the oncoming nurse.
2.Nurse receives a critical lab value via phone or in person from the lab.
3. Lab report shows up on the computerized health record.
4. Unit clerk takes a telephone prescription for a stat lab test
110. A client is scheduled for a creatinine clearance test. Which one of the following preparations is appropriate for the nurse to make?
1. instruct the client about the need to collect urine for 24 hours.
2. Prepare to insert an indwelling urethral catheter.
3. Provide the client with a sterile urine collection container.
4. Instruct the client to force fluids to 3,000 mL/day.
117. After a child returns from the post anesthesia care unit after surgery, which of the following should the nurse assess first?
1. The IV fluid access site.
2. The child’s level of pain.
3.The surgical site dressing.
4. The functioning of the nasogastric tube.
118. The nurse is planning to complete the following assessments during the last half hour of the shift. Which of the following assessments has the highest priority and should be accomplished first?
1.A postpartum couplet with the infant who has had transient tachypnea of the newborn
(TTN) at birth and now has a respiratory rate of 60 breaths/min.
2. A newly admitted postpartum client who is receiving magnesium sulfate at 3 g an hour
initiated 10 hours ago for preeclampsia; her infant ate poorly previously and has not
eaten for 4 hours.
3. A mother who had a cesarean section and is 6 hours after birth with the baby in special
care nursery; the mother has not yet seen her baby.
A couplet with baby born at 36 weeks’ gestation; the 5-lb (2,268-g) infant had initial
4. blood glucose of 35 mg/dL (1.9 mmol/L) and when taken to the room had a glucose of 46 mg/dL (2.6 mmol/L).
119. The charge nurse on an antepartal unit is making staffing assignments for the day. There is a registered nurse (RN), licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP) to care for 15 clients. The nurse should assign which of the following clients to the LPN?
1. A newly admitted G5 P2 Ab 2 with second trimester bleeding, reportedly currently saturating one to two pads in 12 hours.
2. A 22-year-old G2 P1 with urinary retention who is being catheterized with an intermit- tent in and out every 4 to 6 hours PRN while awaiting urine cultures to be returned.
3. A G4 P2 with a twin pregnancy who was admitted in preterm labor and is now able to ambulate two to three times daily and having no contractions.
4. A 30-year-old G4 P0 who was admitted with sickle cell crisis currently receiving blood and pain medication.
120. Which of the following is true with regard to delegation of client care responsibilities? Select all that apply.
1.The nurse must know the nursing model that underlies care at the institution.
2. The nurse delegates in accordance with demands on his/her time.
3. The nurse validates with the nonregistered nurse (non-RN) caregiver that he/she has performed the same activity before.
4. The nurse retains the right to determine which tasks are delegated.
5. The nurse must document that the task has been delegated and to whom.
121. The nurse observes a nursing assistant sharing extensive stories of her own mother’s death with a dying client’s husband. Which of the following is appropriate feedback for the nurse to offer to the nursing assistant?
1.”I thought that was really great how you talked with him; he seemed really scared.”
2. You provided excellent client education by sharing your stories.”
3. “I think it helps clients to see us as real people, and friends too, when you share your
4. “It is probably best to avoid talking about your personal experience very much; keep
122. Which of the following would be true regard-ing medication reconciliation? Select all that apply.
1. Medication reconciliation is an important patient safety goal.
2. Medication reconciliation is designed to obtain and communicate an accurate list of a
client’s home medications across the continuum of care.
3. Only nurses or health care providers can be involved in medication reconciliation.
4. Medications are considered reconciled if a medication prescription exists that is therapeutically equivalent to the one prior to admission.
5. A medication is considered to be any medication prescribed by a primary care provider.
129. A client at 12 weeks’ gestation tells the nurse that she is a vegan and eats “lots of rice.” To help meet the client’s need for protein during pregnancy, the nurse suggests that the client combine the rice with which of the following?
2. Soy milk.
130. Which statement would most likely be made by a Mexican client with pain?
1. “Enduring pain is a part of God’s will.”
2. “This pain is killing me.”
3. “I’ve got to see a doctor right away.”
4. “I can’t go on in pain like this any longer.”
131. When assessing a child receiving tobramycin sulfate, which findings would indicate that the child is experiencing adverse effects? Select all that apply.
1. Increased blood pressure.
2. Weight gain.
5. Ringing in the ears.
6. Decreased heart rate.
132. A client has received an overdose of sym-pathomimetic agents. The nurse should assess the client for which of the following late signs of an overdose? Select all that apply.
4. Profound pyrexia.
133. A nulliparous client says that she and her husband plan to use a diaphragm with spermicide to prevent conception. Which of the following should the nurse include as the action of spermicides when teaching the client?
1. Destruction of spermatozoa before they enter the cervix.
2. Prevention of spermatozoa from entering the uterus.
3. A change in vaginal pH from acidic to alkaline.
4. Slowing of the movement of the migrating spermatozoa.
134. A client has been diagnosed with multi-infarct (or vascular) dementia (MID). When preparing a teaching plan for the client and family, which of the following should the nurse indicate as the most critical factor for slowing MID?
1. Administering anticoagulants such as warfarin (Coumadin).
2. Administering benzodiazepines such as lorazepam (Ativan) to decrease choreiform movements.
3. Managing related symptoms such as depression.
4. Managing the symptoms by increasing dopamine availability.
135. A 7-year-old has been diagnosed with bacterial meningitis. Which of the following should
1. All children at the school.2.
2. All household contacts and close contacts.
3. The entire community.
4. Household contacts only.
136. A client with a history of peptic ulcer disease is admitted to the hospital. Initial assessment reveals that his blood pressure is 96/60 mm Hg, his pulse rate is 120 bpm, and he has vomited coffee-ground material. Based on this assessment, what is the nurse’s priority action?
1. Administer an antiemetic.
2. Prepare to insert a nasogastric (NG) tube.
3. Collect data regarding recent client stressors.4.
4. Place the client in a modified Trendelenburg position.
137. The nurse instills 5 mL of normal saline before suctioning a client’s tracheostomy tube. The instillation is effective when:
1. The secretions are thinned.
2. The client coughs.
3. There is minimal friction when the catheter is passed into the tracheostomy tube.
4. There is humidification for the respiratory tract.
138. A client has had a cardiac catheterization. The left femoral dressing has a moderate amount of bloody drainage, and the client has severe pain in that area. The nurse should first:
1. Assess the airway.
2. Administer oxygen.
3. Apply pressure to the site.
4. Assess the pulse in the left extremity.
139. The father of an 18-month-old with no previous illness, who has been admitted to a surgery center for repair of an inguinal hernia, tells the nurse that his child is having trouble breathing. The father does not think the child choked. After telling the clerk to call the rapid response team, the nurse should do which of the following? Place in order from first to last.
1. Notify the surgeon.
2. Start an intravenous infusion.
3. Assess the effectiveness of the abdominal thrusts.
4. Perform the abdominal thrust maneuver.
5.Listen for breath sounds.
140. The nurse makes a home visit to a primiparous client and her neonate at 1 week after a vaginal birth. Which of the following findings should be reported to the primary care provider?
1.A scant amount of maternal lochia serosa.
2. The presence of a neonatal tonic neck reflex.
3. A nonpalpable maternal fundus.
4. Neonatal central cyanosis.
141. A client with emphysema is receiving continuous oxygen therapy. Depressed ventilation is likely to occur unless the nurse ensures that the oxygen is administered in which of the following ways?
3. At a low flow rate.
4. Through nasal cannula.
142. The nurse assesses for euphoria in a client with multiple sclerosis, looking for which of the following characteristic clinical manifestations?
1. Inappropriate laughter.
2. An exaggerated sense of well-being.
3. Slurring of words when excited.
4. Visual hallucinations.
143. Which of the following assessment finding is expected in a client with bacterial pneumonia?
1. Increased fremitus.
2. Bilateral expiratory wheezing.
3. Resonance on percussion.
4. Vesicular breath sounds.
144. A primiparous client who is breast-feeding develops endometritis on the third postpartum day. Which of the following instructions should the nurse give to the mother?
1. The neonate will need to be bottle-fed for the next few days.
2. The condition typically is treated with IV antibiotic therapy.
3. The client’s uterus may become “boggy,” requiring frequent massage and oxytocics.
4. The client needs to remain in bed in a side-lying position as much as possible.
145. Which of the following examples should the nurse use to describe bulimia to a group of parents at a local community center?
1. An adolescent male who uses calorie-counting to maintain his weight in the desirable
range for his height.
2. A college-age male who uses regular exercise to be able to eat and drink what he wants
without gaining weight.
3. A middle-aged female who uses diet pills occasionally to help her lose small amounts of
4. A college-age female who binges and then purges to prevent weight gain.
146. A client is voiding small amounts of urine every 30 to 60 minutes. Which of the following actions is the nurse’s first priority?
1. Palpate for a distended bladder.
2. Catheterize the client for residual urine.
3. Request a urine specimen for culture.
4. Encourage an increased fluid intake.
147. The nurse is giving care to an infant in an oxygen hood (see figure). The nurse should do
which of the following? Select all that apply.
1. Assure that the oxygen is not blowing directly on the infant’s face.
2. Place the butterfly mobile on the outside of the hood.
3. Immobilize the infant with restraints.
4. Remove the hood for 10 minutes every hour.
5. Encourage the parents to visit the child.