NCSBN NCLEX Questions and Answers Elaborated Spring 2024 | Exams Nursing | Docsity (2024)

Download NCSBN NCLEX Questions and Answers Elaborated Spring 2024 and more Exams Nursing in PDF only on Docsity! NCSBN NCLEX Q uestions and Answers Elaborated Spring 2024. A LPN complains to the charge nurse that an unlicensed assistive person (UAP) consistently leaves the work area untidy and does not restock supplies. What is the best initial response by the charge nurse? 1Write down potential solutions to the problems today by shift's end 2Add this concern to the agenda of the next unit meeting 3Assure the staff nurse that the complaint will be investigated 4Explore for further identification about the nature of the problem - answers>4 Explore for further identification about the nature of the problem The nurse assists with the reinforcement of information about breast self-examination to a group of college students. A female student asks when to perform the monthly exam. The appropriate reply by the nurse should include which statement? 1"Ovulation, or midcycle is the best time to detect changes." 2"Do the exam at the same time every month." 3"Right after the period, when your breasts are less tender." 4"The first of every month, because it will be easiest to remember." - answers>3 The nurse is caring for a 75 year-old client with type 2 diabetes mellitus. The client should be instructed to contact the outpatient clinic immediately if which findings are present? 1An open wound on the heel with minimal discomfort 2Occasional hiccups and sneezing 3Sustained insomnia and daytime fatigue 4Persistent dryness and itching of the perineal area - answers>1An open wound on the heel with minimal discomfort- A pregnant woman has been advised to alter her diet during pregnancy by increasing the intake of protein and vitamin C to meet the needs of the growing fetus. Which diet choice would best meet the woman's needs? 1. 1 cup of macaroni, three-fourths cup of peas, glass whole milk, medium pear 2. Scrambled egg, hash browned potatoes, one-half glass of buttermilk, large nectarine 3. 3 oz. chicken, one-half cup of corn, lettuce salad, small banana 4. Beef, one-half cup of lima beans, glass of skim milk, three-fourths cup of strawberries - answers>4. Beef, one-half cup of lima beans, glass of skim milk, three-fourths cup of strawberries - A nurse is taking a health history from parents of a child admitted with possible Reye's syndrome. Which recent illness should the nurse recognize as being associated with an increased the risk for the development of Reye's syndrome? 1. Varicella 2. Meningitis 3. Hepatitis 4. Rubeola - answers>1. Varicella - A Native American chief visits his newborn son and performs a traditional ceremony that involves feathers and chanting. The nurse comments to a colleague: "I wonder if he has any idea how ridiculous he looks - he's a grown man!" The nurse's comment is an example of what type of attitude? 1. Prejudice 2. Ethnocentrism 3. Discrimination 4. Stereotyping - answers>1. Prejudice- A nursing student asks the licensed practical nurse (LPN) to explain the forces that drive health care reform. When responding to the student's question, what information should the nurse emphasize? 1. Increased competition between health care insurers 4"I have never had tuberculosis." - answers>2 A nurse is caring for a client with pneumococcal pneumonia. Which breath sounds would the nurse expect to disappear as the client responds to the antibiotic treatment? 1Wheezes 2Friction rubs 3Rhonchi 4Diminished sounds - answers>3 A young adult seeks treatment in an outpatient mental health center. The client tells a nurse, "I am a government official and spies are following me." Upon further questioning, the client reveals that warnings must be heeded to prevent nuclear war. What is the initial therapeutic approach that the nurse should use? 1Listen quietly without comment 2Ask for further information on the spies 3Confront the client about the delusions 4Contact security for potential safety concerns - answers>1Listen quietly without comment - Lactulose has been prescribed for a client with advanced liver disease. Which finding should the nurse use to evaluate the effectiveness of this treatment? 1Less jaundice 2Increased appetite 3Decreased lethargy 4Less edema - answers>3 The LPN is unsure about an assignment by the charge nurse to hang an intravenous (IV) infusion that contains potassium. What resource should the LPN check first to determine if LPNs can administer IV medications? 1Employer policy and procedures manuals 2Nursing faculty from a local nursing program 3The nurse practice act of the state in which the practice takes place 4American Nurses Association (ANA) professional standards - answers>3 The nurse is assisting with the delivery of a newborn infant. What is the priority nursing intervention for a normal newborn immediately after delivery? 1Dry off infant with a warm blanket or towel 2Apply identification bracelets 3Assign the one-minute APGAR score 4Obtain vital signs - answers>1Dry off infant with a warm blanket or towel - The registered nurse is teaching a childbirth education class about postpartum depression. Which statement, made by a class member, indicates that more teaching is needed? 1"I will make an effort to talk with someone about my feelings if I start to feel overwhelmed." 2"It's common for women with postpartum depression to have delusions about the infant." 3"Women with postpartum depression have feelings of guilt and worthlessness." 4"I may experience postpartum depression up to a year after delivery." - answers>2 The nurse is reinforcing information about the side effects of fluoxetine to a client. Which group of findings should be included? 1Diarrhea, dry mouth, weight loss, reduced libido 2Tachycardia, blurred vision, hypotension, anorexia 3Orthostatic hypotension, vertigo, reactions to tyramine, nausea 4Photosensitivity, seizures, edema, hyperglycemia - answers>1Diarrhea, dry mouth, weight loss, reduced libido A client has a diagnosis of heart failure. Which intervention is most important for the nurse to implement prior to the administration of digoxin? 1Use the pulse reading from the electronic blood pressure device 2Take a radial pulse, counting for a full 60 seconds 3Check for a pulse deficit at least twice with another nurse 4Assess the apical pulse, counting for a full 60 seconds - answers>4Assess the apical pulse, counting for a full 60 seconds - A client diagnosed with bipolar disorder refuses to take the prescribed medication. Which is the most therapeutic response by a nurse to the client's refusal of the medication? 1"You need to take your medicine. This is how you get better." 2"What is it about the medicine that you don't like?" 3"I can see that you are uncomfortable right now; let's talk about it tomorrow." 4"If you refuse your medicine, tell me how do you think you will get better?" - answers>2 A parent expresses frustration and anger about the toddler constantly saying "no" and refusing to follow directions. The nurse should help the parent understand that this behavior meets which developmental need? 1Self-esteem 2Initiative 3Independence 4Trust - answers>3 The LPN is assisting the RN to provide care for a client diagnosed with a traumatic brain injury. Using the Glasgow Coma Scale, when the client does not obey verbal commands to move, which technique will the RN use to evaluate motor function? 1Squeeze the trapezius muscle firmly 2Lift the client's arm and observe for pronation and drift 3Apply finger tip pressure for 10 seconds 4Rub the sternum with the knuckles - answers>1Squeeze the trapezius muscle firmly - 4Achieve a client's therapeutic goals - answers>4Achieve a client's therapeutic goals - A client tells a nurse, "I have something very important to tell you if you promise not to tell anyone." Which statement by the nurse would be the most appropriate response? 1"That depends on what you tell me." 2"I must report everything to the treatment team." 3"All right, I promise." 4"I can't make such a promise." - answers>4"I can't make such a promise." - A client is discharged with a prescription for warfarin. A nurse recognizes that additional teaching is needed if the client makes which incorrect comment? 1"I know I must avoid crowds." 2"I will report any bruises or bleeding." 3"I plan to use an electric razor for shaving." 4"I will keep all laboratory appointments." - answers>1"I know I must avoid crowds." - The nurse discovers an unresponsive client and determines there is no pulse. This nurse then activates the code notification button to alert all personnel about the code and begins chest compressions. What is the function of the second nurse on the scene? 1Validate the client's advance directive 2Participate with the compressions or breathing as requested by the first nurse 3Bring the code cart - 4Relieve the first nurse on the scene and continue single person CPR - answers>3 The nurse and client are discussing the client's progress toward understanding the client's behavioral responses to stressful events. This is typical of which phase in the therapeutic relationship? 1Termination 2Working - 3Orientation 4Pre-interaction - answers>2 The nurse is collecting data on a group of clients in a long-term health care facility. Which client is at a highest risk for the development of pressure ulcers? 1Ambulatory client who had three incontinent diarrhea stools in the past 24 hours 2Ambulatory older adult diagnosed with type 2 diabetes for the past 20 years 3Obese client who uses a wheelchair throughout the facility 4Malnourished older adult client who is on bed rest - answers>4 A client diagnosed with head trauma is in a non-responsive state. Vital signs are stable and breathing is regular and spontaneous. What should the nurse document to accurately describe the client's status? 1Glasgow Coma Scale 13, no ventilator required 2Glasgow Coma Scale 8, respirations regular - 3Appears to be sleeping, vital signs stable 4Comatose, breathing unlabored; is resting - answers>2 A client with heart failure is newly referred to a home health care agency. The nurse determines that the client has not been following the prescribed diet. It would be most appropriate for the nurse to take which action at this time? 1Notify the health care provider of the client's failure to follow the prescribed diet 2Make a referral to Meal-on-Wheels for delivery of one meal three times a week 3Discuss the diet with the client to learn the reasons for not following the diet - 4Recommend a release from home health care related to noncompliance - answers>3 A client has chronic renal failure and is being treated at home. During weekly home visits, which factor is the most accurate indicator of fluid balance? 1Trends in daily weights - 2Skin turgor over at least two areas of the body 3Changes in mucous membrane moistness 4Difference between intake and output - answers>1Trends in daily weights - The client is receiving a thrombolytic agent to open a clot-occluded coronary artery following a myocardial infarction. Which finding would be the greatest concern and should be immediately reported to the registered nurse? 1Hematemesis - 2Pink-tinged saliva 3Serosanguinous drainage from the IV site 4Slight rust-colored urine - answers>1Hematemesis - The nurse is caring for a postoperative client following a closed reduction of distal tibia and mid-femur fractures. The client has a long leg plaster cast. Thirty-six hours after surgery, the client suddenly becomes confused, short of breath and spikes a temperature of 103 F (39.4 C). What should be the first action by the nurse? 1Check the distal circulation of the casted extremity 2Obtain the pulse oximetry reading 3Measure the client's blood pressure in the supine and Fowler's positions 4Check the orientation to time, place and person - answers>2 The client has an order for intermittent gastrostomy tube (G-tube) feedings. What is the priority action by the nurse to accurately assess correct placement of the G-tube? 1Listen for active bowel sounds in all four quadrants 2Measure the pH of stomach content aspirate 3Auscultate the abdomen while instilling 10 mL of air into the G-tube 4Measure the length of tubing from the insertion site each shift - answers>1Listen for active bowel sounds in all four quadrants 2Measure the pH of stomach content aspirate - 4Contact the family member indicated in the admission forms - answers>1 The nurse is caring for a client who has just been admitted to the inpatient mental health unit with severe depression. Which concern should be a priority of care? 1Safety 2Elimination 3Rest 4Nutrition - answers>1 A nurse is discussing with a client the precautions with warfarin. The nurse should tell the client to avoid foods with excessive amounts of what substance? 1Iron 2Calcium 3Vitamin E 4Vitamin K - answers>4 The nurse has established a therapeutic relationship with a client. Which observation would indicate that the nurse-client relationship has passed from the orienting phase to the working phase? 1The client revitalizes a relationship with the family to help in coping with a child's death 2The client recognizes feelings and expresses them appropriately 3The client expresses a desire to be mothered and pampered 4The client recognizes regression as a part of a defense mechanism - answers>2 During the working phase, problems are identified and the client is able to focus on unpleasant feelings and express them appropriately. During the working phase, problems are identified and the client is able to focus on unpleasant feelings and express them appropriately. - answers>An advance health care directive is also known as a living will. It is a legal document in which a person specifies his or her wishes concerning medical treatments at the end-of-life, when s/he is unable to make those decisions. Advance care planning involves sharing personal values and wishes with loved ones and selecting someone, (called a medical power of attorney or health care proxy) who will eventually make medical decisions on the client's behalf A nurse is talking to a group of parents about how to reduce risks in the home. What is the most important factor for the nurse to consider during the discussion? 1Proximity to emergency services 2Number of children in the home 3Knowledge level of the parents 4Age of children in the home - answers>4 When reviewing the medication lithium with a client, the client asks, "How long will it take before I can feel the effects of the medication?" Which response by the nurse is the best? 1"About two weeks" 2"One month" 3"Immediately" 4"Several days" - answers>1 A client has completed a renal biopsy. Which nursing intervention is appropriate after a renal biopsy? 1Ambulate the client within four hours after procedure 2Change the dressing when it becomes saturated 3Monitor vital signs using post-op protocols 4Maintain client on NPO status for 24 hours - answers>3 The nurse is caring for a client who is one-day postoperative with a T-tube following a cholecystectomy. What color would the nurse expect the drainage from the client's T-tube to be? 1Dark brown 2Green 3Yellowish-brown 4Orange - answers>3 A newly admitted client reports taking phenytoin for several months. Which of the following assessments should the nurse be sure to include in the admission report? (Select all that apply.) - answers>Serious adverse outcomes of antiseizure medications such as phenytoin (Dilantin) are unsteady gait, slurred speech, extreme fatigue, blurred vision or feelings of suicide. Increased hunger (not anorexia), increased thirst or increased urination are additional serious side effects. The nurse is giving a morning bath to a client who has a colostomy. While giving the bath, the nurse should reinforce that the collection pouch should be emptied at what time? 1Prior to going to sleep at night 2After each fecal elimination 3At the same time each day 4When it is one-third to one-half full - answers>4 A client is scheduled to have blood drawn for serum cholesterol and triglycerides tomorrow morning. What information should the nurse reinforce to the client about the test? 1"Be sure to eat a fat-free diet until the test, and drink lots of water." 2"Stay at the laboratory so that two blood samples can be drawn an hour apart." 3"Do not eat or drink anything but water for 12 hours before the blood test." 4"Have the blood drawn within two hours of eating breakfast." - answers>3 The nurse is caring for a hospitalized adolescent. The nurse recognizes that which of these concerns will be the greatest for a hospitalized adolescent? 1Restricted physical activity 2Separation from family 3Altered body image 1Arrange to change client-care assignments 2Discuss with the parent the appropriate use of "time-out" 3Explain to the mother that the child needs extra attention 4Explain to the parent that this behavior is expected - answers>4 The mother of a hospitalized 2 year-old child asks a nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. The best advice by the nurse would include which approach? 1Explain that this behavior will stop with in a few days 2Suggest that the mother "sneak out" of the child's room when the child is asleep 3Request for the mother to remain with the child at all times 4Help the mother understand that this is a normal response to hospitalization - answers>4 A client has a percutaneous endoscopic gastrostomy (PEG) tube that is used to administer feedings and medications. Which nursing action is best to ensure patency of the tube? 1Encouraging the client to cough to relieve abdominal bloating prior to or following a feeding 2Adequately flushing the tube with water before and after use 3Completely crushing all medications prior to administration 4Squeezing the tube to dislodge obstructions - answers>2 A nurse is observing an 8 month-old client. Which behavior would the nurse anticipate the infant to be able to display? 1Pull up to stand 2Use a spoon 3Say two words 4Sit without support - answers>4 A client is admitted with newly diagnosed hypothyroidism. A nurse would expect the client to exhibit which finding until the client achieves a euthyroid state with therapy? 1Heat intolerance 2Diarrhea 3Tachycardia 4Lethargy - answers>4 The licensed practical nurse is caring for a client with advanced cirrhosis of the liver. Which finding should receive immediate follow-up by the charge nurse? 1Jaundice 2Anorexia 3Hematemesis 4Ascites - answers>3 A nurse discusses the healthy use of both conscious and unconscious defense mechanisms with a group of clients. An appropriate goal for these clients would be to use these mechanisms for which purpose? 1Foster independence with better communication 2Protect the ego and diminish anxiety 3Eliminate anxiety and apprehension 4Avoid conflict and unpleasant consequences - answers>2 A 3 year-old child is brought to the health clinic. The grandmother reports that the child is always "scratching his bottom" and is "extremely irritable." Based on this information, which health issue would the nurse assess for initially? 1Pinworm 2Scabies 3Ringworm 4Allergies - answers>1 The nurse is caring for a client diagnosed with acute angina. The client reports substernal chest pain, diaphoresis and nausea. What should be the first action by the nurse? 1Administer PRN pain medication as ordered 2Determine the origin of the pain 3Draw blood for for troponin/CK and CBC per standing orders 4Order ECG per standing orders - answers>1 The client is diagnosed with Parkinson's disease (PD) and takes more than one hour to dress for scheduled therapies. Based on this finding, what is the most appropriate nursing intervention? 1Allow the client the time needed to dress 2Encourage the client to dress more quickly 3Ask family members to dress the client 4Demonstrate methods on how to dress more quickly - answers>1 A pregnant client asks the nurse about the scheduled blood test for alpha-fetoprotein (AFP). The nurse's explanation should include which of these comments? 1"It tells us how far along your pregnancy is." 2"It can help identify potential neurological defects." 3"The results help determine if the baby is growing normally." 4"The placental exchange of oxygen is measured." - answers>2 A client is diagnosed with a severe mental illness. What is the priority goal of involuntary hospitalization? 1Protection from harm to self and others 2Return to independent functioning 3Elimination of negative findings 4Reorientation to reality - answers>1 3"I will put my right leg through a full range of motion." 4"I might feel a throbbing pain in my right leg." - answers>3 The nurse is assisting in the application of a plaster cast for a client with a broken arm. Which action is a priority? 1The cast material should be dipped several times into warm water 2The cast should be uncovered until it dries 3The casted extremity should be placed on a supporting surface 4The wet cast should be handled with the palms of hands for 48 to 72 hours - answers>4 The client undergoes a gastrectomy. Several hours after surgery, the nasogastric (NG) tube stops draining. What action does the LPN anticipate the RN will take first? 1Reposition the tube 2Increase the amount of suction 3Gently irrigate the tube with sterile normal saline 4Notify the surgeon - answers>3 A 12 year-old child, admitted with a broken arm, is waiting for a scheduled surgery. The nurse finds the child crying and unwilling to talk. What would be the most appropriate initial response by the nurse? 1Reassure the child that the surgery will go fine with no problems 2Provide privacy with encouragement to work through feelings 3Distract the child with a choice of activities to do while waiting for surgery 4Make arrangements for friends to visit as soon as possible - answers>2 A nurse is caring for a client with a sigmoid colostomy. The client requests assistance in removing the flatus from a one-piece drainable ostomy pouch. Which intervention should the nurse use? 1Pierce the plastic at the top of the ostomy pouch with a pin to vent the flatus 2Pull the adhesive seal around the ostomy pouch to allow the flatus to escape 3Open the bottom of the pouch to allow the flatus to be expelled 4Assist the client to ambulate to reduce the flatus in the pouch - answers>3 A client returns from the operating room after a right orchiectomy. What is the priority nursing intervention during the immediate postoperative period? 1Manage postoperative pain 2Maintain fluid and electrolyte balance 3Control bladder spasms with PRN medication 4Ambulate the client within a few hours after surgery - answers>1 The nurse enters the room of a postpartum mother and observes the baby lying at the edge of the bed while the mother sits in a chair. The mother states, "This is not my baby, and I do not want it." How should the nurse respond? 1"What a beautiful baby! The baby's eyes are just like yours." 2"This is a common occurrence after birth. Let's talk about how to accept the baby." 3"You seem upset, tell me about how you are feeling"? 4"Many women have postpartum blues and need some time to love the baby." - answers>3 The client calls the clinic nurse and reports nausea, headache and fatigue. The client also reports seeing yellow halos around lights. What is the best response by the nurse? 1"Do your eyes appear bloodshot and is there any itching?" 2"Tell me about your prescription for digoxin. Are you still taking the medication?" 3"Call back in a week and schedule an appointment if your symptoms don't improve." 4"Is there anyone else at home who has the same symptoms?" - answers>2 A client is admitted to the mental health inpatient unit with a diagnosis of major depression after a suicide attempt. In addition to expressions of sadness and hopelessness, the nurse anticipates observing which characteristics? 1Meticulous attention to hygiene, grooming 2Anxiety, hostility 3Psychom*otor retardation, agitation 4Guilt, indecisiveness - answers>3 A nurse is assigned to care for a 10 month-old infant with the new diagnosis of anemia. Which of these findings should the nurse anticipate? 1Behavior consistent with hyperactivity 2Slow heart rate when sleeping 3Pale mucosa inside the mouth 4High hemoglobin level - answers>3 The nurse is assisting a withdrawn client to begin to develop relationship skills. Which nursing intervention should be most effective? 1Assist the client to analyze the meaning of behaviors 2Remind the client frequently to interact with other clients 3Offer the client frequent opportunities to interact with the nurse 4Initiate client interactions with one or two other clients - answers>3 A female client admitted for a breast biopsy says tearfully to a nurse, "If this turns out to be cancer and I have to have my breast removed, my partner will never come near me." What would be the most appropriate response to this statement? 1"Are you questioning the depth of your relationship?" 2"Why are you concerned that you will be rejected?" 3"You sound worried that the surgery might change your relationship with your partner." 4"I'm sure your companion will understand." - answers>3 The client is diagnosed with asthma. What information should the nurse reinforce that the client should monitor on a daily basis? A nurse gathers data related to delayed gross motor development in a 3 year-old client. Which observation by the nurse should confirm this finding? 1Cannot ride a bicycle 2Cannot catch a ball 3Cannot skip on alternate feet 4Cannot stand on one foot - answers>4 A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes lost when outside of the home. Which statement would provide the best reality orientation for this client? 1"Hello. My name is Elaine Jones and I am your nurse for today." 2"Good morning. You're in the hospital. I am your nurse Elaine Jones." 3"How are you today? Remember, you're in the hospital. I will be your nurse all day. My name is Elaine Jones." 4"Good morning. I am Elaine Jones, your nurse. Do you remember where you are?" - answers>2 A client is diagnosed with a Salmonella infection. What is a primary nursing intervention to be taken to minimize the transmission of disease from this client? 1Double glove when in contact with feces or emesis 2Wash hands thoroughly before and after any client contact 3Wear gloves when disposing of contaminated linens 4Use gloves when in contact with body secretions - answers>2 A 6 month-old infant is being treated for developmental hip dysplasia and has been placed in a hip spica plaster cast. Which discharge information is important for the nurse to reinforce with the parents? 1Turn the baby every two hours using the abduction stabilizer bar 2Check frequently for swelling in the baby's feet 3Gently rub the skin with a cotton swab to relieve itching 4Place favorite books and push-pull toys in the crib - answers>2 A nurse is talking to parents about the side effects of routine immunizations. Which finding should the nurse reinforce about calling the health care provider if it occurs within 24 to 48 hours after a routine immunization? 1Localized tenderness at the injection site 2Tympanic temperature of 104 F (40 C) 3Some irritability and fussiness 4Swelling at the injection site - answers>2 A 28-year-old is transferred to the emergency department (ED) via ambulance with a traumatic head injury. The client is awake and reports having a headache and some amnesia. What are the priority nursing interventions for this client? (Select all that apply.) - answers>Correct Response Assess vital signs and neurological function Assess the airway Prepare for CT imaging of the head Assess the wound for presence of drainage or bruising on the head A client exhibits many delusional thoughts. As the nurse assists the client to prepare for breakfast, the client comments, "Don't waste good food on me. I'm dying from this disease I have." Which response by the nurse would be the best? 1"None of the laboratory reports show that you have any physical disease." 2"Try to eat a little bit. Breakfast is the most important meal of the day." 3"I know you believe that you have an incurable disease." 4"What has your primary health care provider told you?" - answers>3 The family member tells an admitting nurse that the client values the practice of Chinese medicine. The nurse must understand that for this family and client a priority goal should take which focus? 1Achieve harmony 2Respect life in old age 3Maintain energy balance 4Restore yin and yang - answers>4 The nurse is reinforcing dietary instructions to the parents of a child diagnosed with cystic fibrosis. The nurse will emphasize which of the following characteristics of this diet? 1A gluten-free diet, avoiding foods that contain wheat, rye and barley 2Balanced, high calorie diet with extra fat, salt, protein and calcium 3Foods low in sodium, potassium and phosphorus 4Carbohydrate counting, selecting foods from the bread/starch, fruit, or milk group - answers>2 The nurse works in a psychiatric inpatient setting. What information should the nurse be aware of as one of the most frequent reasons for suicide in adolescents? 1Progressive failure to adapt to peer pressure 2Reunion wish or a fantasy of some sort 3Feelings of anger or hostility toward others 4Feelings of alienation or isolation from peers - answers>4 When a client returns from surgery after an open reduction with cast application for a femur fracture, a small blood stain is noted on the cast by the nurse. Four hours later, the nurse observes that the stain has doubled in size. What is the initial action for the nurse to take at this time? 1Ask the family members to call you when they notice the spot getting larger 2Record the findings in the nurse's notes 3Outline the spot with a pen and note the time and date on the cast 4Report the finding to the registered nurse (RN) charge nurse - answers>3 3Low calcium level 4Metabolic alkalosis - answers>2 The client is instructed to collect stool specimens at home using the guaiac test. In addition to explaining how to collect the specimens, the nurse instructs the client to avoid certain substances prior to obtaining the stool specimens. Which of the following substances should the client avoid? (Select all that apply.) - answers>a false positive test and should be avoided for at least 3 days before the fecal occult blood test; Fruits and vegetables with high peroxidase activity, such as red radishes, broccoli, and cauliflower should also be avoided several days prior to obtaining specimens. Clients should also limit their intake of vitamin C because too much can lead to a false negative result. A client with a fracture of the radius had a plaster cast applied two days ago. The client calls the clinic to report constant pain and swelling of the fingers since the cast was applied. What should be the next action of a nurse? 1Suggest to elevate the arm higher than heart level 2Ask if numbness is present in the fingers and if the client can move the fingers 3Have the client make an appointment with the surgeon for the next day 4Approve the application of a cool cloth to the fingers of the affected arm - answers>2 The client is seen in the emergency one day after falling in his bathroom at home. The client reports having "a few drinks" prior to the fall. Which finding requires the nurse's immediate attention? 1Bruise behind one ear 2Blurred vision 3Nausea and vomiting 4Headache - answers>1 Diagnosed with heart failure, the client had an implantable cardioverter-defibrillator (ICD) implanted several years ago. The client now has end-stage heart failure and is receiving home hospice care. Which end-of-life care option could have the greatest impact on client comfort? 1Encouraging the client to sit upright in bed 2Confirming advanced directives and plans for resuscitation 3Deactivating the implantable cardioverter-defibrillator (ICD) 4Assisting the client to eat several small meals - answers>3 The client is prescribed alendronate (Fosamax). What information about medication administration should the nurse be sure to reinforce? 1Take on an empty stomach 2Take with milk, two hours after meals 3Take with calcium 4Take after meals - answers>1 A couple experienced a miscarriage at seven months of pregnancy. The nurse makes a home visit one week after discharge from the hospital. What intervention should the nurse emphasize to the couple during the home visit? 1Plan another pregnancy as soon as possible 2Seek causes of the death for prevention purposes 3Focus on the other healthy children at home 4Discuss feelings with support persons and each other - answers>4 A nurse is reinforcing information to a mother who is breast-feeding a newborn infant diagnosed with oral candidiasis. Which statement by the mother would be incorrect and indicate a need for reinforcement of information? 1"The therapy can be discontinued when the spots disappear." 2"I will boil the nipples and pacifiers for 20 minutes." 3"Expressed breast milk should be used immediately or frozen." 4"Nystatin should be given four times a day after my baby eats." - answers>1 The nurse is to administer meperidine 100 mg, atropine 0.4 mg, and promethazine 50 mg IM to a client preoperatively. Which action should the nurse take initially? 1Place the bed in the low position 2Instruct the client to remain in bed 3Place the call bell within reach 4Have the client empty the bladder - answers>4 The parents of a school-age child are providing information to the nurse about their child. Which of these health issues should the nurse recognize as a finding that could suggest type 1 diabetes? 1Being a picky eater 2Weight gain 3Bedwetting 4Oily and acne-prone skin - answers>3 An adolescent client arrives at a clinic three weeks after the birth of her first baby. She tells the nurse she is very worried about not returning to her pre-pregnancy weight. Which approach should the nurse take first? 1Review the client's pattern of weight gain over the past year 2Encourage her to talk about her self-image 3Give her several pamphlets on postpartum nutrition 4Ask the mother to record her diet for the next few weeks - answers>2 A nurse is caring for a client admitted with the diagnosis of suspected Legionnaire's disease. Which finding would require the nurse's immediate attention? 1Dry mouth with frequent requests for water 2Abdominal gas pains that are severe and disappear suddenly 3 Increased use of accessory muscles of breathing 4Difficulty sleeping due to leg cramps - answers>3 2Achievement or status of progress related to prior goals 3Identification of any findings of physical and psychosocial stressors 4Establishment of goals to ensure continuity of care - answers>2 A nurse is named in a lawsuit. Which of these factors will offer the best protection for that nurse in a court of law? 1Clinical specialty certification by an accredited organization 2Complete and accurate documentation of assessments and interventions 3Sworn statement that health care provider orders were followed 4Above-average performance reviews prepared by nurse manager - answers>2 The nurse is assigned to care for several clients on the day shift. Which client should the nurse see first after receiving shift report? 1The client with asthma who is scheduled for a chest X-ray prior to discharge 2The client with peptic ulcer disease who has been vomiting most of the night 3The client with chronic kidney disease who completed peritoneal dialysis two hours ago 4The client with pancreatitis who reports pain at a level of eight out of 10 - answers>2 The nurse hears a health care provider (HCP) loudly criticizing one of the unlicensed assistive persons (UAP) within the earshot of others. The UAP does not react or respond to the HCP's complaints. What is the best action by the nurse? 1Notify the chief of the medical staff about the HCP's breach of professional conduct. 2Encourage the UAP to directly confront the HCP about the unprofessional behavior. 3Complete an incident report describing the HCP's unprofessional behavior. 4Walk up to the HCP and quietly state, "This unacceptable behavior has to stop." - answers>2 Information about case management and the role of the case management nurse is presented during an orientation session for new nurses. Which statement correctly describes an important fact about case management? 1Case management strategies focus mainly on the client's needs after discharge. 2Case management is a collaborative process designed to meet complex client needs. 3Physicians are responsible and accountable for client outcomes. 4The interdisciplinary team makes all the decisions for the client and family. - answers>2 During the management of a client's pain, the nurse should adhere to the code of ethics for nurses. Which of these actions should the nurse consider first when treating the client's pain? 1Cultural sensitivity is fundamental to client-centered pain management. 2Clients have the right to have their pain managed promptly. 3Nurses should not judge a client's pain based on the nurse's values. 4The client's self-report of pain is the most important consideration. - answers>4 A client with a musculoskeletal disorder has been newly fitted with a lower limb orthotic. Which activity can the nurse delegate to the certified nursing assistant (CNA)? 1Provide instruction to the client for ambulation with the orthotic. 2Monitor the client's response to moving with the orthotic. 3Check the client's skin for any redness or irritation from the orthotic. 4Assist with transferring the client from the bed to the chair. - answers>4 Upon completing a review of a 27-year-old client's admission documents, the nurse identifies that the client does not have an advance directives. What action should the nurse take? 1Lecture the client on the importance of having advance directives. 2Inform the charge nurse to offer information about advance directives. 3Advance directives are not appropriate for this client due to the client's age. 4Refer this issue to the client's health care provider. - answers>2 The home health nurse is visiting a client diagnosed with type 1 diabetes and osteoarthritis. The client has difficulty holding and using the prescribed insulin pen. The nurse should refer the client to which community resource person? 1Physical therapist 2Pharmacist 3Physical therapist 4Occupational therapist - answers>4 Holding and using an insulin pen requires fine motor skills and good vision. A client with osteoarthritis (OA) might experience limited movement and pain in the joints of the fingers and hand. An occupational therapist can help a client improve the fine motor skills needed to prepare an insulin injection. An occupational therapist works with clients to perform tasks that are needed for smaller movements to maintain activities of daily living or for work. A client diagnosed with schizophrenia insists that the nurse explain the use and side effects of the medications prescribed for the client. What should the nurse understand before responding to the client? 1The psychiatrist will need to grant permission to discuss the client's medications. 2All clients have a right to be informed about their prescribed medications 3A decision to reinforce or not reinforce information about medications should be made by the nurse alone. 4It is too dangerous for clients who are diagnosed with schizophrenia to know about their medications. - answers>2 The nurse asks another staff nurse to sign for wasting a partial-dose opioid injection, although the wasting was not witnessed by anyone. This type of request seems to be a pattern of behavior for this nurse. What is the most appropriate action for the second staff nurse to take? 1Report this request immediately to the nurse manager. 2Review the client's medication administration record (MAR) for past wastes. 3Ask the nurse's client if they witnessed the waste of the partial dose. 4Confront the nurse about suspected narcotics diversion. - answers>1 A client diagnosed with bipolar disorder has been referred to social services for possible placement in a community halfway house after discharge. The social worker telephones the 2The client diagnosed with peripheral artery disease (PAD) who reports cramp-like pains in both calf muscles following physical therapy 3The client with a history of heart failure (HF) who reports going to the bathroom "too much" after taking a diuretic 4The client diagnosed with hypertension whose last recorded blood pressure (BP) was 180/90 after returning from the radiology department - answers>1 The licensed practical nurse (LPN) is reassigned to work on an acute care unit. Which of these clients would be most appropriate for the LPN to accept? 1A trauma victim with multiple lacerations requiring complex dressings 2An older adult client diagnosed with cystitis who has an indwelling urethral catheter 3A confused client whose family complains about the nursing care given after the client's surgery 4A client, admitted for a possible stroke, with unstable neurological findings - answers>2 A nurse must use an interpreter to collect data from a client. Which action should the nurse take to help communicate with the client? 1Include a family member and direct comments to that person 2Talk to the interpreter in advance and leave the client and interpreter alone for discussion 3Speak directly to the interpreter while asking questions 4Face the client while asking questions as the interpreter translates the information - answers>4 The 4-year-old child is newly diagnosed with hepatitis A. Which instructions should the nurse reinforce with the child's parents? 1Use gentle cleansers to protect jaundiced child's skin from breakdown. 2Child can return to daycare two days after starting antibiotic treatment. 3Keep child on bedrest for several weeks before gradually resuming activity. 4Wash hands thoroughly with soap and warm water after contact with the child. - answers>4 The hepatitis A virus spreads through contaminated food or water, as well as unsanitary conditions in childcare facilities or schools. The infection resolves spontaneously and symptom relief is usually the only treatment. A client has been placed in physical restraints due to aggressive behavior. Which of the following demonstrates that the nurse has appropriately implemented the restraints? (Select all that apply.) - answers>To avoid injury, restraints should never be fastened to a moving part of a bed or stretcher. A physical restraint order is never "as needed." An order must be written by a provider for each restraint episode. Documentation must be done every 15 minutes on the restraint flow sheet, which is part of the client's permanent medical record. It is a legal requirement to notify the client's advocate or a relative if requested by the client. The nurse is reinforcing education to a group of parents on how to treat accidental poisoning of children in the home. What information should the nurse include? 1Empty the child's mouth of any poisonous substance still present. 2Give the child a glass of milk to drink to neutralize the poisonous substance. 3Induce vomiting if the child is suspected of swallowing something poisonous. 4Start treatment before calling the Poison Control Center - answers>1 The nurse is stuck in the hand by an exposed needle that was accidentally left in the client's bed. What action should the nurse take first? 1Contact employee or occupational health services. 2Look up the policy and procedure on needlestick injury. 3Immediately wash hands vigorously with soap and warm water. 4Notify the nursing supervisor and complete an incident report. - answers>3 The nurse is reviewing the documentation of a client's care in their electronic health record and realizes that one of the entries was completed on the wrong client. Which of the following actions are appropriate for the nurse to take? - answers>Mark the entry as "mistaken entry-wrong patient." Enter the time the error was discovered. The nurse is preparing a client for a colonoscopy and notes that the consent form has not been signed. Which of the following statements by the nurse are appropriate to make to the client? - answers>"Please tell me your full name and date of birth." "Do you have any questions about the colonoscopy?" "Describe what the health care provider told you about a colonoscopy." An outpatient client is scheduled to receive an oral solution of radioactive iodine. In order to reduce radiation exposure to others, which information should the nurse reinforce? 1No solid food may be eaten for six hours after ingestion. 2Urine and saliva will be radioactive for 24 hours after ingestion. 3Wash laundry separately and rinse twice in hot water. 4Wait for 48 hours to have grandchildren visit at home. - answers>2 The client is diagnosed with active tuberculosis (TB) and the case has been reported to the local health department. The nurse understands that the most important reason for notifying the health department is: 1To ensure that treatment compliance will be monitored 2To trace and screen recent contacts the client had 3To maintain important disease outbreak statistics 4To track the incidence of tuberculosis cases - answers>2 The parent of a toddler who is being treated for suspected poisoning asks, "Why is activated charcoal used?" What is the best response by the nurse? 1"When the poison is absorbed into the blood stream, the activated charcoal will neutralize it." 2"Activated charcoal binds with the poison to limit absorption in the digestive tract." 3"Activated charcoal causes vomiting, which will eliminate the poison from the body." 4"The activated charcoal will protect the kidneys from any long-lasting damage." - answers>2 The age at which a child typically develops the ability to sit steadily without support is around 7 to 8 months. Saying several words, drinking from a cup and using a neat pincer grasp are developmental milestones that most children do not reach until age 11 to 12 months. A client is forgetful and experiencing short-term memory loss. While collecting data about short-term memory loss, which action should the nurse take first? 1Ask the client to state his date of birth. 2Confirm that the client's hearing is intact. 3Observe the client while performing an activity. 4Ask the client to name the current U.S. president. - answers>2 During the physical inspection of a client, the nurse notes a pulsating mass in the client's periumbilical area. Which action should the nurse take next? 1Measure the length of the mass. 2Auscultate the area. 3Palpate the area. 4Percuss the area. - answers>2 A client has a family history of coronary artery disease (CAD). Which of the following findings should be of concern to the nurse? 1Low density lipoprotein (LDL) cholesterol level of 80 mg/dL 2Blood pressure of 154/78 3Serum creatinine of 0.4 mg/dL 4A glycosylated hemoglobin (Hb A1C) level of 4.8% - answers>2 Which of the following actions performed by the nurse indicates that additional education on ergonomic principles is needed to reduce the risk of injury? 1Flex the knees and knee close to an object, before lifting it from the floor. 2Use arm and leg strength to assist in repositioning a client in bed. 3Push a bed down the hall, instead of pulling it during transport. 4Bend and twist at the waist when assisting a client in transferring to the chair. - answers>4 A client with a back injury asks the nurse how chiropractic manipulation works. What is the nurse's best response? 1Electrical energy fields 2Spinal column manipulation 3Mind-body balance 4Exercise of joints - answers>2 The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) and a significant family history of coronary artery disease. Which of the following prescriptions by the health care provider would treat a major modifiable risk factor of coronary artery disease? 1Atorvastatin 2Prednisone 3Albuterol 4Fluticasone/salmeterol - answers>1 Atorvastatin is an HMG-CoA reductase inhibitor, more widely known as a statin, and it is a medication used to treat hyperlipidemia. Statins reduce LDL levels, reduce triglycerides and increase HDL levels. Hyperlipidemia is a major modifiable risk factor of coronary artery disease. A 20-year-old male client who has a profuse, purulent urethral discharge with painful urination is seen at a community health clinic. Which information will be most important for the nurse to obtain? 1Sexual orientation 2Recent sexual contacts 3Immunization history 4Contraceptive preference - answers>2 The nurse recognizes that which finding indicates a child has attained the developmental stage of concrete operations, according to Piaget? 1The child makes the moral judgment that "stealing is wrong." 2The child explores the environment with the use of sight and movement. 3The child thinks in mental images or word pictures. 4The child reasons that homework is time-consuming but necessary. - answers>1 After the death of a client, the family approaches the nurse and requests that a family member be allowed to perform a ritual bath on the deceased client prior to moving the body. What would be the most appropriate response by the nurse? 1"I will have to check on hospital regulations and policies." 2"These procedures have to be carried out by our staff." 3"Is there anything you need from me to perform the bath?" 4"A ritual bath will have to wait until after postmortem care." - answers>3 A nurse is working to establish a therapeutic relationship with a client. Which action would support the nurse's goal? 1Establish trust and rapport with the client. 2Identify with what the client is feeling. 3Praise the client for appropriate behavior. 4Advise the client on problem-solving techniques. - answers>1 The client diagnosed with paranoid-type schizophrenia is sitting alone, intently staring at and watching other clients and staff members. The client becomes hostile when approached with medication and claims that the medication controls the mind. What type of symptom(s) does the nurse recognize that this client is exhibiting? 1Antisocial behavior 2Negative symptoms pulse and blood pressure are elevated. The client states to the nurse, "I have to get out of here." What is the most likely cause for the client's symptoms and behavior? 1Dissatisfaction with hospital care 2Anxiety related to being hospitalized 33hock related to the injuries 4Early stage of alcohol withdrawal - answers>4 signs and symptoms of alcohol withdrawal, such as sweating, tremors, hyperactivity, hypertension and tachycardia. The client most likely wants to leave the hospital to obtain alcohol. The client must be monitored very closely for progression to more severe alcohol withdrawal symptoms, including seizures and delirium tremens (DTs). A client who is taking duloxetine asks the nurse if the medication treats depression or diabetes. What is the best response from the nurse? 1"Duloxetine is used to treat depression but can also be used to lower blood sugar levels." 2"Duloxetine is used to treat depression but can be used to treat pain that can occur in people with diabetes." 3"Duloxetine is not prescribed for either depression or diabetes." 4"Duloxetine is used to treat diabetes but can also be used to treat depression." - answers>2 Duloxetine is a selective serotonin and norepinephrine reuptake inhibitor (SNRI) that can be used to treat depression but also can be used to treat pain associated with diabetic neuropathy. The nurse is caring for a female client with a body mass index (BMI) of 45. Which conditions should the nurse plan to discuss with the client due to the risks associated with her weight? (Select all that apply.) - answers>obstructive sleep apnea gallstones coronary artery disease breast cancer HYPERTHYROIDISM IS NOT ASSOCIATED WITH BEING OVERWEIGHT OR BMI The nurse is caring for a client diagnosed with substance use disorder (SUD). The client states, "I just drink occasionally. I don't know why my wife and the judge think that I need to be in an alcohol treatment program." Which of the following behaviors are consistent with SUD? (Select all that apply.) - answers>Prone to act impulsively Insecurity in relationships Craving and inability to abstain from alcohol The nurse is caring for a client who has a history of heavy alcohol use. Which findings would indicate that the client is probably experiencing delirium tremens (DTs)? 1Chest pain, nausea, diaphoresis and tachycardia 2Nausea, vomiting, bloody stools and hypotension 3Headache, blurred vision, garbled speech and hypertension 4Excitability, disorientation, tremors and tachycardia - answers>4 A couple that recently immigrated to the United States tells the nurse about their concern that hospital staff is giving their child the "evil eye." What should the nurse communicate to the other personnel who are involved in the care of this family? 1Touch the child after or while looking at the child. 2Avoid touching or looking at the child. 3Look only at the parents and not the child. 4Instruct the parents to remain outside of the room. - answers>1 an "evil eye" is cast by looking at a person without touching them or while the person is unaware. The evil eye is believed to cause misfortune or injury. The spell is broken by touching the child while looking at them or assessing them. The nurse is caring for a client diagnosed with end-stage heart failure (HF). The family members are distressed about the client's impending death. Which action should the nurse take initially? 1Explain the stages of death and dying to the family. 2Recommend an easy-to-read book on grief. 3Ask about the family's religious affiliation and practices. 4Explore the family's past patterns for dealing with death. - answers>4 A nurse is caring for a client who is being treated for major depression. During which time period is the client most likely to be at the highest risk for attempting suicide? 1 1 to 2 weeks after initiating antidepressant medication. 26 to 12 months after discharge from the hospital. 3Around the time of the client's birthday. 4While under one-on-one observation in the hospital. - answers>1 A client diagnosed with schizophrenia first speaks animatedly to another client, with exaggerated clarity of pronunciation. The nurse then observes the client turning abruptly away, mumbling to themselves and speaking to the wall. Which priority goal/outcome should the nurse select for the client's plan of care? 1Client will express feelings appropriately through verbal interactions. 2Client will accurately interpret events and other's behaviors. 3Client will engage in meaningful and understandable verbal communication. 4Client will demonstrate improved social relationships. - answers>3 The nurse is working in an inpatient psychiatric setting and understands that touching clients should be limited to a quick handshake for which reason? 1Touching a client, other than a handshake, can set off a violent episode. 2Refraining from touching signals the termination of the nurse-client relationship. 3A handshake allows the use of therapeutic touch while maintaining boundaries. 4A handshake will not be misinterpreted as an invitation to more sexual behavior. - answers>3 A client is on NPO status and has a nasogastric (NG) tube in place, connected to low- intermittent suction, to help resolve a small bowel obstruction. Which nursing intervention should the nurse implement for this client? 1Allow the client to melt ice chips in their mouth. 2Provide oral care at least every 2 to 4 hours. 3Swab the client's mouth, using glycerin swabs. 4Provide the client mints to freshen their breath. - answers>2 The nurse is caring for an adult client who suffered second degree burns over 25% of their body in a house fire. Which observation best indicates that fluid resuscitation has been effective? 1Elastic, nontenting skin turgor 2Moist oral mucus membranes 3Urine output of 35 mL per hour 4No reports of thirst - answers>3 The goal is to maintain an hourly urine output of 0.5 mL/hour (about 30 mL/hour) for the average adult. Which of the following actions by the nurse indicates a need for additional education on the prevention of health care-associated infections (HAIs)? 1The nurse uses their own stethoscope to assess the lung sounds of a client placed on contact precautions for Methicillin-resistant Staphylococcus aureus (MRSA) infection. 2The nurse calls the health care provider (HCP) to request the removal of the indwelling urinary catheter for a two days postoperative client. 3The nurse cleanses hands with soap and water for 60 seconds after caring for a client with Clostridium difficile (C. difficile) infection. 4The nurse wears a gown and gloves when providing perineal care to a client with Vancomycin-resistant Enterococci (VRE) infection. - answers>1 A client has been diagnosed with dysphagia due to a stroke. What nursing intervention should the nurse implement for this client? 1Instruct the client to tilt their head back while swallowing. 2Position the client in an upright position while they are eating. 3Assist the client to drink through a straw. 4Instruct the client to use sips of water to help wash down food. - answers>2 A client is transferred from the postanesthesia care unit (PACU) to the medical-surgical unit after an appendectomy. Which action should the nurse on the medical-surgical unit perform first? 1Ask the client about pain. 2Orient the client to the unit. 3Review the postoperative orders. 4Take the client's vital signs. - answers>4 The nurse is evaluating the effectiveness of a bowel training program for a client with chronic constipation. Which statements made by the client should the LPN/VN report to the RN for additional teaching? - answers>Bowel training programs are designed to return defecation to normal. Fluid intake should be 2.5 to 3 liters per day. The client should increase fiber in their diet, and intake hot drinks just prior to their normal bowel elimination time to facilitate normal bowel function. A suppository treatment should be administered about half an hour before the client's normal bowel elimination time—inserting it just prior to bedtime will disturb the client's sleep pattern. The client should be provided with privacy for about 30 to 40 minutes and should sit on a commode or bedpan whenever they have the urge to defecate. An obese client tells the nurse, "I just started a diet and I am eating no more than 800 calories a day." What information should the nurse reinforce with the client? 1Very low-calorie diets often have severe and irreversible side effects. 2Very low-calorie diets are adequate if balanced with fruits and vegetables. 3Very low-calorie diets are intended for short-term use only. 4Very low-calorie diets are appropriate for long-term weight management. - answers>3 A 2-year-old child is brought to the pediatrician's office by the parents, who report that the child has been having diarrhea for two days. What nutritional information should the nurse provide to the parents? 1Keep the child fasting, give them nothing to eat, and return the next day. 2Give the child only clear liquids and gelatin for 24 hours. 3Continue a regular diet and add electrolyte replacement drinks. 4Give the child bananas, apples, rice and toast as tolerated. - answers>3 The nurse is providing care to an older adult client diagnosed with bilateral pneumonia. Which intervention should the nurse implement to best promote the client's comfort? 1Encourage visits from family and friends. 2Keep conversations short. 3Increase the client's oral fluid intake. 4Monitor vital signs frequently. - answers>2 An 82-year-old male client is admitted with benign prostatic hyperplasia (BPH). Which finding by the nurse will require immediate action? 1Severe abdominal pain 2A bladder ultrasound value of 900 mL 3A heart rate of 110 bpm 4A blood pressure of 180/105 - answers>2 The nurse is reviewing the laboratory results for a client diagnosed with dehydration. Which result is most important to communicate to the health care provider? 1Serum creatinine level of 2.8 mg/dL 2Blood glucose level of 146 mg/dL 3Serum potassium level of 5.0 mEq/L 4Serum hemoglobin level of 15.7 g/dL - answers>1 4The client has a history of urinary retention. - answers>2 they are excreted by glomerular filtration. Aminoglycosides are nephrotoxic and requires close monitoring of renal function. A client with chronic kidney disease should not receive this medication. The nurse in a long-term care facility is preparing to administer medications. Which physiological changes does the nurse know will affect medication pharmaco*kinetics in older adults? 1Due to an increase in glomerular filtration rates, medications are excreted more rapidly. 2Due to a decrease in gastric emptying, higher medication doses are prescribed. 3Due to a decrease in renal drug excretion, a greater risk for adverse medication effects exist. 4Due to an increase in metabolism, medications are prescribed more frequently. - answers>3 The nurse prepares to administer a liquid medication to an infant. At the bedside, the parent states that the infant does not like to take medications. Which action should the nurse perform to ease the medication administration? 1Use an oral syringe to administer the medication, alternating with a pacifier. 2Mix the liquid medication with a full bottle of formula. 3Give half the dose now and the remaining amount in an hour. 4Ask the health care provider (HCP) to switch the medication to an injection. - answers>1 A client is admitted with deep vein thrombosis (DVT). The health care provider (HCP) orders the immediate administration of an intravenous bolus of heparin sodium 200 units/kg . The client weighs 187 lbs. How many mL should the nurse draw up from the supplied 10 mL vial that contains 5,000 units per mL? Do not round. - answers>3.4 The nurse has given discharge instructions to a client who suffers from sensory neuropathy due to diabetes. The client was prescribed gabapentin. Which of the following statements indicates that the client understands the nurse's instructions regarding the medication? 1"I can stop taking the medication at any time." 2"It is safe to take extra doses if my pain becomes worse." 3"The medication might cause me to have insomnia." 4"My doctor prescribed it for the pain in my legs." - answers>4 The nurse is reviewing medication orders for a client who has requested something for pain. In the process, the nurse finds a new written order for a pain medication. The health care provider (HCP) wrote, "Give APAP every six hours as needed for pain." Which parts of the medication order should the nurse clarify before administering the medication? - answers>route drug name dosage The nurse administers a medication to the wrong client. Which action(s) should the nurse take when the medication error is identified? (Select all that apply.) - answers>Notify health care provider Complete an incident report Monitor the client for adverse effects Document the error in the medical record A client recovering from hip replacement surgery is taking acetaminophen with codeine every three hours for pain. For which side effect should the nurse monitor the client? 1Diffuse rash 2Constipation 3Wheezing 4Hyperglycemia - answers>2 A client is prescribed trimethoprim/sulfamethoxazole for recurrent urinary tract infections. Which statement by the nurse about this medication is correct? 1"You can stop the medication after five days." 2"Be sure to take the medication with food." 3"Drink at least eight glasses of water a day." 4"It is safe to take with oral contraceptives." - answers>3 Unlike many other antibiotics, trimethoprim/sulfamethoxazole does not seem to affect hormonal birth control such as the pill, the patch or ring. The hospice nurse is visiting a client diagnosed with end-stage lung cancer and metastases to the bone. What should the nurse keep in mind when planning for effective pain management? 1Relief of pain will be achieved quickly. 2Pain therapy is based on the client's report of pain. 3High doses of opioid analgesics will be required. 4The client will most likely become addicted. - answers>2 The nurse is discharging a client who is at risk for venous thromboembolism (VTE). The client is prescribed enoxaparin. Which instruction should the nurse provide to this client? 1"Notify your health care provider if your stools appear tarry or black." 2"You should massage the injection site for better absorption." 3"An intravenous (IV) catheter will be placed to administer the medication." 4"You must have your partial thromboplastin time (PTT) checked weekly." - answers>1 As with any anticoagulant, enoxaparin carries the risk of bleeding. Clients should be instructed to report the presence of tarry stools, bleeding gums, hematuria, ecchymosis or petechiae to their HCP A client who has been diagnosed with Raynaud's disease and hypertension is prescribed nifedipine. For which side effect should the nurse monitor the client? 1Decreased urine output 2Facial flushing 3Cyanosis of the lips 4Increased pain in fingers - answers>2 3Muscle cramps 4Constipation - answers>3 Furosemide is a loop (potassium-wasting) diuretic. It can cause dehydration and hypokalemia, which can result in muscle cramps. This is the most important finding. The nurse is reviewing prescribed medications with a client. Which information should the nurse reinforce about captopril? 1Avoid using salt substitutes. 2Avoid green leafy vegetables. 3Restrict fluids to 1000 mL/day. 4Take the medication with meals. - answers>1 Captopril is an angiotensin converting enzyme (ACE) inhibitor. It reduces aldosterone secretion, thereby reducing sodium and water retention. Captopril is used to treat hypertension and heart failure. Because it can cause an accumulation of serum potassium (i.e., hyperkalemia), clients should avoid the use of salt substitutes, which often contain potassium instead of sodium chloride. A nurse administers cimetidine to a 75-year-old client diagnosed with a gastric ulcer. The nurse should monitor the client for which adverse reaction? 1Hearing loss 2Mental status change 3Constipation 4Increased liver enzymes - answers>2 Cimetidine is a histamine H2-receptor antagonist used to treat gastric ulcers. It has been found to cause confusion in susceptible clients, such as the elderly and debilitated clients. Clients over age 50 or who are severely ill may become temporarily confused while taking H2 blockers, especially cimetidine. A client at risk for a stroke has been prescribed clopidogrel. Which information is most important for the nurse to reinforce with the client? 1"You must take the medication on an empty stomach." 2"If you miss a dose, take a double dose the next day." 3"You must have your lab tests checked weekly." 4"You must stop the medication a week before your surgery." - answers>4 Clopidogrel is an oral antiplatelet drug with similar effects to aspirin. The drug is taken for secondary prevention of myocardial infarction, ischemic stroke and other vascular events. Clopidogrel prevents platelet aggregation. Like all other antiplatelet drugs, clopidogrel poses a risk of serious bleeding. Clopidogrel should be discontinued 5 to 7 days before elective surgery. The nurse is reinforcing the correct use of a metered-dose inhaler (MDI) for a client newly- diagnosed with asthma. The client asks, "how will I know the canister is empty?" What is the best response by the nurse? 1"Drop the canister in water to observe if it floats." 2"Contact your pharmacy to find out when to obtain a refill." 3"Count the number of doses as the inhaler is used." 4"Shake the canister and listen for any fluid movement." - answers>3 A client is prescribed furosemide and digoxin for heart failure. The nurse should monitor the client for which potential adverse drug effect? 1Pulmonary hypertension 2Acute arterial occlusion 3Cardiac dysrhythmias 4Acute kidney injury - answers>3 Digoxin is a cardiac glycoside, or positive inotrope that increases myocardial contractility. By increasing contractile force, digoxin can increase cardiac output in clients with heart failure (HF). Furosemide is a potassium-wasting (loop) diuretic, prescribed to prevent fluid overload in clients with HF. Clients who take furosemide are at risk for developing hypokalemia. Potassium ions compete with digoxin and a low potassium level can cause digoxin toxicity, leading to lethal cardiac dysrhythmias. Therefore, it is imperative that potassium levels be kept within normal range (3.5 to 5 mEq/L) while taking digoxin. The nurse in an ambulatory clinic is speaking with the parents of a 2-year-old child diagnosed with acute otitis media. Which information is most important for the nurse to include in the instructions to the parents? 1The child must complete the entire course of the prescribed antibiotic. 2The child may be given a decongestant to relieve pressure on the tympanic membrane. 3The child should return to the clinic to evaluate effectiveness of the treatment. 4The child may be given acetaminophen or ibuprofen drops for pain. - answers>1 The nurse is reinforcing teaching about levothyroxine for a client newly-diagnosed with hypothyroidism. Which information should the nurse make sure to reinforce about this medication? 1The medication may decrease the client's energy level. 2The medication will decrease the client's heart rate. 3The medication should be taken in the morning. 4The medication must be stored in a dark container. - answers>3 A thyroid supplement, such as levothyroxine, should be taken on an empty stomach in the morning. Morning dosing minimizes the side effect of insomnia and an empty stomach facilitates absorption. Levothyroxine will cause an increase in the client's energy level and heart rate. A client received hydromorphone orally one hour ago. When the nurse enters the client's room, the client is unresponsive to verbal stimuli and has a respiratory rate of six. Which action should the nurse take next? 1Prepare for endotracheal intubation. 2Administer supplemental oxygen. 3Begin cardiopulmonary resuscitation. 4Prepare to administer naloxone. - answers>4 A client has been prescribed alendronate for osteoporosis. Which of the following statements indicate the client understands how to safely take this medication? (Select all that apply.) - answers>Alendronate is a bisphosphonate used to treat osteoporosis. It can cause esophagitis 3Estrogen replacement therapy for the past three years 4History of acute hepatitis A - answers>3 The estrogen in hormone replacement therapy (and in birth control pills) can increase clotting factors in the blood, increasing the risk for development of a DVT. The nurse is caring for a client receiving mechanical ventilation. The nurse understands which are the possible causes for a high-pressure alarm? (Select all that apply.) - answers>Kinked tubing, secretions and/or bronchospasms cause obstruction to airflow from the ventilator, creating high pressure in the ventilator circuit and setting off the high-pressure alarm. The nurse is reviewing the medical record of a client on the medical surgical unit and notes a positive result of the stool for occult blood (OB) test. The nurse recognizes which risk factors for this result? (Select all that apply.) - answers>Drugs that can cause GI bleeding include NSAIDs such as ibuprofen and naproxen (Aleve). Corticosteroids can cause gastric irritation, including peptic ulcers that can also lead to GI bleeding. Factors that may cause a false positive result include bleeding gums following a dental procedure and the ingestion of red meats within three days before testing because red meats contain animal hemoglobin. A client is scheduled for a computerized tomography (CT) scan of the abdomen with contrast. What action should the nurse take before sending the client to the imaging department? 1Insert a temporary urinary catheter. 2Confirm that a signed consent is in the chart. 3Keep the client on bedrest. 4Hold all of the client's medications. - answers>2 An 80-year-old client with type 2 diabetes mellitus is admitted to the emergency department with worsening confusion and decreased level of consciousness. Which of these findings is most important for the nurse to report to the health care provider? 1Blood glucose of 380 mg/dL 2Arterial blood pH of 7.36 3Urine output greater than 100 mL/hour 4Serum osmolarity of 355 mOsm/L - answers>4 The nurse is monitoring a 45-year-old client who just underwent a cardioversion for dysrhythmias. The client's respirations are 12 per minute. Which action should the nurse take next? 1Measure the client's oxygen saturation. 2Ask another nurse to verify the respiratory rate. 3Notify the health care provider (HCP). 4Continue to monitor the client. - answers>4 Normal respirations range from 12 to 20 per minute; respirations of eight or less per minute would be a cause for concern. The nurse is preparing a client for an intravenous pyelogram (IVP) test. Which intervention should the nurse plan to implement? 1Limit client's fluid intake to 400 mL prior to the test. 2Inform client that no special preparation is necessary. 3Instruct client to maintain a regular diet until the test. 4Administer a laxative the evening before the test. - answers>4 It is important for the large intestine to be clear of stool to allow full visualization of the kidney, bladder and ureters. The nurse is preparing to suction a client's tracheostomy. What action should the nurse take to prevent hypoxia during the procedure? 1Explain procedure to client. 2Monitor heart rate during suctioning. 3Use sterile technique. 4Provide preoxygenation to the client. - answers>4 The nurse is caring for a comatose client. To prevent keratitis, moisturizing ointment should be prescribed for which body site? 1Lower eyelids 2External ear canal 3Fingernails and toenails 4Perianal area - answers>1 Unconscious or comatose clients are often unable to close their eyes or do not have a functioning blink reflex. When the eye remains open for a prolonged time, the cornea will dry out, causing irritation or ulceration. The nurse is in the process of inserting a urinary catheter in an adult female client. The nurse advances the catheter approximately 2 to 3 inches (5 to 7 cm), but no urine return is seen. What should the nurse do next? 1Inflate the catheter balloon. 2Advance the catheter a few more inches. 3Withdraw the catheter and try again. 4Notify the health care provider (HCP). - answers>2 A child diagnosed with thalassemia has received several blood transfusions during the past three days. What lab value is the priority for the nurse to monitor with this client? 1Hemoglobin level 2Platelet count 3Blood urea nitrogen level 4Neutrophil percentage - answers>1 A normal hemoglobin range for children is approximately 11 to 13 gm/dL. Thalassemia, also called Cooley's anemia, is a genetic defect that causes anemia, i.e., a condition in which the blood contains below-normal hemoglobin levels. Hemoglobin is the oxygen-carrying protein component of the red blood cell (RBC). A client is admitted to the hospital with endocarditis. The nurse understands that which risk factors can lead to the development of endocarditis? (Select all that apply.) - answers>Oral abscess with tooth extraction History of aortic valve replacement Placement of an arteriovenous fistula for hemodialysis Placement of a central venous access device The nurse is reviewing the chart of a client who was recently diagnosed with coronary artery disease due to atherosclerosis. Which factors most likely contributed to the development of this disease? (Select all that apply.) - answers>Mother died of a myocardial infarction Low-density lipoprotein (LDL) level of 149 mg/dL History of diabetes mellitus Used to smoke 40 packs per year until one year ago The target LDL level for a client is less than 100 mg/dL. The nurse is evaluating a client who was admitted for a small bowel obstruction and dehydration. Which observation by the nurse would indicate that the dehydration is improving? 1The client has normoactive bowel sounds. 2The client voided 300 mL of urine in the past two hours. 3The client denies any nausea or vomiting. 4The client reports the passing of flatus. - answers>2 A client is admitted to the telemetry unit with syncope due to sinus bradycardia. Which intervention should the nurse include in the client's plan of care? 1Maintain the client on bedrest. 2Administer a stool softener daily. 3Implement seizure precautions. 4Discuss the client's wishes for organ donation. - answers> A client is admitted to the telemetry unit with syncope due to sinus bradycardia. Which intervention should the nurse include in the client's plan of care? 1Maintain the client on bedrest. 2Administer a stool softener daily. 3Implement seizure precautions. 4Discuss the client's wishes for organ donation. - answers>2 To avoid a vasovagal response (i.e., the slowing of the heart rate caused by bearing down when trying to defecate) and the risk for another syncopal episode, it is important to ensure that the client's bowel movements are soft and easily expelled. The client should also be instructed to avoid holding their breath or bearing down (Valsalva maneuver). A client diagnosed with iron deficiency anemia is prescribed ferrous sulfate suspension orally. Which instruction would be most appropriate for the nurse to give to the client regarding this medication? 1"You should use a straw when taking this medication." 2'Taking this medication will turn your urine dark orange in color." 3"Diarrhea is a common side effect when taking this medication." 4"You should take the medication with food to enhance absorption." - answers>1 Because liquid iron can stain the teeth, the most appropriate instruction is to use a straw The nurse is caring for a client with severe iron deficiency anemia. Which interventions should the nurse include in the client's plan of care? (Select all that apply.) - answers>Instruct assistive personnel to allow the client to rest during care activities. Monitor the client for palpitations and orthostatic hypotension. Review the client's medical record for NSAID use. Encourage the client to eat more green leafy vegetables and beans. Monitor the client's stool for color, consistency and frequency. The nurse is caring for a client with a diagnosis of pericarditis. The unlicensed assistive person reports to the nurse that the client's last set of vital signs were blood pressure of 84/40 mm Hg, respiratory rate of 28 breaths/minute, heart rate of 112 and the client seemed short of breath. The nurse examines the client and also notes the presence of jugular vein distention. What should the nurse do next? 1Administer the prescribed metoprolol. 2Notify the health care provider. 3Place the client on nothing by mouth status. 4Obtain a 12-lead electrocardiogram. - answers>2 risk for cardiac tamponade due to jugular vein distention The nurse in the outpatient clinic is reviewing the medical record of a client diagnosed with Raynaud's disease. What information from the client's health history would support this diagnosis? (Select all that apply.) - answers>The client works in an office setting as a typist. The client smokes two packs of cigarettes per day. Warfarin is listed on the medication reconciliation form. The client complains of brittle fingernails that break easily. Fingers become cyanotic when exposed to cold objects. A client is admitted to the cardiology unit for treatment for recurrent supraventricular tachycardia. Which observation by the nurse would best indicate that the client's condition can be considered hemodynamically stable? 1The client denies any chest pain and capillary refill is less than three seconds. 2The client's blood pressure is 88/40 mm Hg. 3The client's pulse oximeter reads 91% on three liters nasal cannula. 4The client's cardiac monitor shows a heart rate of 170 beats per minute. - answers>1 A client with a history of chronic alcohol use disorder is admitted to the inpatient unit with a serum magnesium level of 1.0 mEq/L. Which intervention should the nurse implement first? 1Assess the client's deep tendon reflexes. histamine, prostaglandins, eosinophils and cytokines. This leads to sneezing, runny nose with clear discharge, nasal congestion and an increased eosinophil counts. Symptoms may appear similar to a cold. Due to drainage, the client's sense of smell can be altered. The nurse is caring for a client with a dry chest tube drainage system due to a left tension pneumothorax. Two hours ago, the health care provider (HCP) changed the chest tube prescription to water seal only. When entering the client's room, the nurse finds the client to be short of breath, tachypneic and with an oxygen saturation (SpO2) of 84%. On auscultation, the nurse notes absent breath sounds to the left upper lobe. What action should the nurse take first? 1Apply oxygen via nasal cannula 2Document all interventions in the client's medical record 3Notify the appropriate HCP 4Request a chest X-ray - answers>1 The nurse is planning care for a client admitted to the hospital with influenza. Which interventions should the nurse include in the client's plan of care? (Select all that apply.) - answers>Antiviral agents, such as oseltamivir, are used to shorten the course and reduce symptoms of the flu. Droplet transmission-based precautions are indicated to prevent the spread of the flu. To avoid further transmission of the illness, visitors with signs/symptoms of a respiratory illness should not be permitted on the unit. It is important to ensure that clients understand how to prevent transmission of infections such as the flu through proper hand hygiene and cough etiquette. A client has been diagnosed with emphysema. Which intervention should the nurse implement when caring for this client? 1Inquire if the client has a power of attorney for health care. 2Reassure the client that the lung damage is usually reversible. 3Schedule a lung cancer screening for the client. 4Assist the client with enrolling in a smoking cessation program. - answers>4 A nurse is administering the influenza vaccine in an occupational health clinic. Within 10 minutes of giving the vaccine to a middle-aged adult male, the man reports having itchy and watery eyes, feeling anxious and short of breath. What should the nurse do first? 1Administer SQ epinephrine. 2Maintain the airway. 3Take the client's vital signs. 4Apply oxygen. - answers>1 The nurse is evaluating whether teaching a client with dysphagia about preventing aspiration was effective. Which action by the client indicates that additional teaching is required? 1The client is sitting in a chair during meals. 2The client uses a straw to drink. 3The client tucks in the chin while swallowing. 4The client alternates solids with liquids. - answers>2 The nurse is assisting with discharging a client from the hospital who was admitted for acute exacerbation of chronic obstructive pulmonary disease. Which statement by the client indicates that teaching was effective? 1"I will make sure to get the pneumonia vaccine every October." 2"I will eat foods low in calories and protein." 3"I will switch from regular to electronic cigarettes." 4"I will use my spacer each time I use my inhaler." - answers>4 The home health nurse is reviewing information with a client who is being treated for pulmonary tuberculosis. Which statement by the nurse is correct? 1"You should not leave your home until your cough is completely gone." 2"Your family members should get the tuberculosis vaccine." 3"You can stop the medications once your symptoms have resolved." 4"You should avoid public transportation and crowds in enclosed areas." - answers>4 The nurse is caring for a client newly diagnosed with chronic obstructive pulmonary disease (COPD). The nurse reviews the client's medical record and notes which risk factors? (Select all that apply.) - answers>It is primarily caused by cigarette smoking. Other risk factors include genetics, asthma and exposure to occupational chemicals and air pollution. ALL HISTORY OF The nurse in the pediatric clinic is caring for an acutely ill, 10-year-old child. Which assessment finding would require immediate intervention by the nurse? 1Slow, irregular respirations 2Temperature of 101.3° F (38.5° C) 3Rapid, bounding pulse 4Profuse diaphoresis - answers>1 The nurse is preparing a client for a pulmonary CT angiogram with contrast to rule out a pulmonary embolism. For which laboratory result should the nurse notify the health care provider immediately? 1D-dimer level of 1.2 mcg/mL 2Serum creatinine level of 2.8 mg/dL 3Arterial blood gas PaO2 level of 80 mm Hg 4Serum troponin level of 0.1 mg/mL - answers>2 The client's creatinine level is significantly elevated (normal creatinine level is 0.8 to 1.2 mg/dL), placing the client at risk for dye-induced renal failure and the nurse should notify the health care provider of this lab result immediately. The nurse in the primary health care provider's office is reviewing the medical record of a client with idiopathic pulmonary arterial hypertension. The nurse should expect which potential clinical manifestations with this disease? (Select all that apply.) - answers>Classic symptoms include: exertional dyspnea and chest pain, fatigue, right-sided heart failure (cor pulmonale) due to the increased workload of the right ventricle and abnormal heart sounds, such as an S3. 4Implementation of airborne precautions - answers>3 Intravenous immunoglobulins (IV Ig) are used to treat Guillain-Barré in the early phase. They are believed to interfere with antigen presentation and help to modulate the body's immune response. The nurse in the neurology office is reviewing information about levetiracetam with a 30-year- old female client with a history of seizures. Which instruction about the medication should the nurse make sure to include? 1"You might experience irregular menses and intermittent bleeding." 2"Call the office immediately if you feel like hurting or killing yourself." 3"You should stay away from large crowds and sick children." 4"You should avoid becoming pregnant while taking this medication." - answers>2 Levetiracetam is an anti-convulsant medication used to prevent seizures. One of the significant side effects is behavioral changes and suicidal ideations. The nurse is performing a home visit for an older adult client with Alzheimer's disease. Which of the following observations should be a priority for the nurse to address? 1Good lighting in the stairwell 2Throw rugs on the kitchen floor 3Lamps plugged directly into wall outlets 4Handrails in the bathtub - answers>2 The nurse is collecting data from a college student who comes to the health clinic with symptoms of meningitis. The student resides in the school dormitory. What is the priority action the nurse should take? 1Perform a focused neurological assessment. 2Administer acetaminophen for the headache. 3Alert the college's administration and dormitory staff. 4Obtain the client's immunization history. - answers>3 The clinic nurse is following up with a client who was seen a few days ago for trigeminal neuralgia. Which action by the client indicates an understanding of how to manage the condition? 1Takes an analgesic after performing household chores. 2Keeps the environment at a moderate temperature and free from drafts. 3Eats a bowl of hot, steaming soup every day for lunch. 4Performs vigorous brushing of teeth twice per day. - answers>2 Trigeminal neuralgia is a disruption in the cranial nerve and causes sudden, severe, brief stabbing pain. Keeping the environment at a moderate temperature and free from drafts can reduce the risk of triggering an acute attack. The nurse in the long-term care facility is reviewing the plan of care for a client with Parkinson's disease. Which interventions should the nurse make sure to include for this client? (Select all that apply.) - answers>Set-up a bladder training program for the client. Encourage participation in speech therapy. Use cognitive strategies to enhance the client's memory. Provide assistance with ambulation. The nurse is reviewing the plan of care for a 30-year-old client newly diagnosed with multiple sclerosis. Which interventions should the nurse include for this client? (Select all that apply.) Instruct the client on how to self-catheterize as needed. Review methods to prevent and treat constipation. Encourage participation in physical and occupational therapy. Encourage participation in vocational rehabilitation. Encourage independence in personal care and bathing. - answers>Review methods to prevent and treat constipation. Encourage participation in physical and occupational therapy. Encourage participation in vocational rehabilitation. Encourage independence in personal care and bathing. The nurse is caring for a client who has a history of peptic ulcer disease. The nurse notes the abdomen is rigid and the client complains of severe pain with palpation. What is the priority action by the nurse? 1Record the findings in the client's record. 2Ask the client about dietary habits. 3Notify the health care provider of the findings. 4Review the client's record for NSAID use. - answers>3 The nurse is caring for a client who is suffering from an exacerbation of ulcerative colitis. Which manifestations would the nurse expect to see with this client? (Select all that apply.) Fever of 104° F (40° C) Crackles in the lower lung fields Mucous noted in the stool "You should only consume clear liquids for the next 12 to 24 hours." "Remember to stop eating any food six hours before you come to the center." "Make sure to drink the entire bowel preparation liquid." A client is being admitted to the hospital with complaints of bloody stools for several days. Which interventions should the nurse expect to be prescribed for this client? (Select all that apply.) - answers>Administration of pantoprazole Collection of a stool sample for occult blood testing Discontinuation of all NSAID medications The nurse is reinforcing teaching with a client regarding their diagnosis of hepatic encephalopathy. Which statement by the client indicates that additional teaching is needed? 1"I will brush my teeth with a soft toothbrush to avoid bleeding gums." 2"I will eat enough protein and calories to stay healthy." 3"I will stop taking ibuprofen for my knee and back pain." 4"I will stop taking my lactulose when I have more than one loose stool." - answers>4 The nurse is assisting with meal planning for a client with cholelithiasis. Which food items would be most appropriate for this client? (Select all that apply.) - answers>The most common cause of gallbladder disease is from stones that block the biliary ducts. Other causes are due to inflammation, infection, tumors or decreased blood flow due to damaged vessels. Intake of high cholesterol or fatty foods can increase the risk of gallbladder inflammation. To avoid inflammation, the client should follow a low cholesterol, low-fat diet and limit their intake of fried and processed foods such as breakfast cereals, lunch meats and microwavable meals. The nurse is assigned to care for a client with end-stage liver failure and portal hypertension. Which clinical manifestations would the nurse expect to see with these conditions? (Select all that apply.) Diminished pedal pulses Shortness of breath Increased weight gain Increased abdominal girth Elevated serum albumin level - answers>Shortness of breath Increased weight gain Increased abdominal girth Which discharge instruction should the nurse make sure to include for a client with chronic pancreatitis? 1"Make sure to eat a low-fat, high-fiber diet." 2"Try to reduce smoking cigarettes to half a pack per day." 3"Limit alcohol intake to one drink a day." 4"Take the prescribed pancreatic enzymes on an empty stomach." - answers>1 The nurse is assisting in developing as plan of care for a postoperative client following a radical left mastectomy. Which nursing problem should be the priority for this client? 1Risk of infection of the surgical site 2Anxiety related to the cancer diagnosis 3Acute pain related to the surgery 4Impaired left arm circulation (lymphedema) - answers>3 The nurse is evaluating a client's understanding of appropriate dietary choices with chronic kidney disease. Which food choices by the client indicate an understanding of the teaching? (Select all that apply.) Fresh apples Baked chicken Unsalted pretzels Slice of cheese Orange juice Baked potato - answers>Fresh apples Baked chicken Unsalted pretzels A client with chronic kidney disease (CKD) must limit intake of potassium, sodium, phosphorus and protein. In CKD, the kidneys are unable to adequately excrete these components. Foods low in potassium include: apples, grapes, lettuce and cauliflower. Foods high in potassium include: bananas, oranges, potatoes and spinach. Foods low in phosphorus include: chicken, shrimp, crab and rice. Foods high in phosphorus include: organ meats, salmon, scallops, nuts and cheese. A client comes to the community health clinic with symptoms of gonorrhea. Which intervention should the nurse implement first? 1Discuss the risk of infertility with the client. 2Collect a urethral swab from the client. 3Instruct the client to notify past sexual partners. 4Obtain information about the client's recent sexual encounters. - answers>4 The nurse is assisting with developing a plan of care for a client with benign prostatic hyperplasia. Which nursing interventions should the nurse include for this client? (Select all that apply.)