A nurse is assessing a patient that has undergone a recent CABG. The nurse notices a mole with irregular edges with a bluish color. The nurse should:
The nurse observes a staff member not following the plan of care for a client with an antisocial personality disorder. The nurse should:
A client receives a cervical intracavity radium implant as part of her therapy. A common side effect of a cervical implant is:
Which of the following lab values would indicate symptomatic AIDS in the medical chart? (T4 cell count per deciliter)
Which of the following is responsible for laws mandating the reporting of certain infections and diseases?
Which of the following symptoms is not indicative of autonomic dysreflexia in the client with a spinal cord injury?
A patient has recently been prescribed Albuterol. Which of the following changes are not associated with Albuterol?
A mother that has never breast-feed a child before is having trouble getting the baby to latch on to the breast. The baby has lost 3% of its’ birth weight within the first 2 days of life. The best statement is:
Tricyclics (Antidepressants) sometimes have which of the following adverse affects on patients that have a diagnosis of depression?
The PN is caring for a client with diabetes insipidus. The nurse can expect the lab work to show:
After securing the client’s safety from a faulty electric bed, the nurse should take which action?
The nurse is assessing an elder who the nurse suspects is being physically abused. The most important question for nurse to ask is:
The nurse assesses a client for physiological risk factors for falls. The nurse should conclude that the client is not at risk if which of the following is discovered?
A primigravida begins labor when her family is unavailable and she is alone. She is very upset that her family is not with her. Which approach can the nurse take to meet the client’s needs at this time?
A nurse is assessing a 18 year-old female who has recently suffered a TBI. The nurse notes a slower pulse and impaired respiration. The nurse should report these findings immediately to the physician, due to the possibility the patient is experiencing which of the following conditions?
A client was involved in a motor vehicle accident in which the seat belt was not worn. The client is exhibiting crepitus, decreased breath sounds on the left, complains of shortness of breath, and has a respiratory rate of 34/min. Which of the following assessment findings should concern the nurse the most?
A 14 year-old boy has been admitted to a mental health unit for observation and treatment. The boy becomes agitated and starts yelling at nursing staff members. What should the nurse first response be?
A client who has a known history of cardiac problems and is still smoking enters the clinic complaining of sudden onset of sharp, stabbing pain that intensifies with a deep breath. The pain is occurring on only one side and can be isolated upon general assessment. The nurse concludes that this description is most likely caused by:
The nurse is caring for a client who is dying. While assessing the client for signs of impending death, the nurse observes the client for:
Common problems for supervisors include all of the following except:
A hospitalized client has just been informed that he has terminal cancer. He says to the nurse, “There must be some mistake in the diagnosis.” The nurse determines that the client is demonstrating which of the following?
Someone who has received a recent tattoo should be screened for:
Which of the following observations is most important when assessing a client’s breathing?
At what point in the nurse-client relationship should termination first be addressed?
The 24-hour day-night cycle is known as:
In conducting a health screening for 12-month-old children, the nurse expects them to have been immunized against which of the following diseases?
Using clichés in therapeutic communication leads the client toward:
A 45-year-old client with type I diabetes is in need of support services upon discharge from a skilled rehabilitation unit. Which of the following services is an example of a skilled support service?
Legal protection of confidentiality:
Client self-determination is the primary focus of:
A client can receive the mumps, measles, rubella (MMR) vaccine if he or she:
A nurse is planning a brief treatment program for a client who was raped. A realistic, short-term goal is to:
According to the ANA Code of Ethics for Nurses, professional nurses have an ethical obligation to:
The drug of choice to decrease uric acid levels is:
An assessment of the skull of a normal 10-monthold baby should identify which of the following?
The focus of a nurse case manager is:
Which of the following is the primary force in sex education in a child’s life?
Which of the following conditions is mammography used to detect?
A client with an ileus is placed on intestinal tube suction. Which of the following electrolytes is lost with intestinal suction?
When helping a client gain insight into anxiety, the nurse should:
What do the following ABG values indicate: pH 7.38, PO2 78 mmHg, PCO2 36mmHg, and HCO3 24 mEq/L?
When obtaining a health history on a menopausal woman, which information should a nurse recognize as a contraindication for hormone replacement therapy?
For which of the following conditions might blood be drawn for uric acid level?
A client who is immobilized secondary to traction is complaining of constipation. Which of the following medications should the nurse expect to be ordered?
The nurse is assessing the dental status of an 18-month-old child. How many teeth should the nurse expect to examine?
Which of the following lab values is associated with a decreased risk of cardiovascular disease?
Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma?
Which of the following diseases or conditions is least likely to be associated with increased potential for bleeding?
Ashley and her boyfriend Chris, both 19 years old, are transported to the Emergency Department after being involved in a motorcycle accident. Chris is badly hurt, but Ashley has no apparent injuries, though she appears confused and has trouble focusing on what is going on around her. She complains of dizziness and nausea. Her pulse is rapid, and she is hyperventilating. The nurse should assess Ashley’s level of anxiety as:
To remove hard contact lenses from an unresponsive client, the nurse should:
Which fetal heart monitor pattern can indicate cord compression?
A health care worker is concerned about a new mother being overwhelmed by caring for her infant. The health care worker should:
Which of the following foods should be avoided by clients who are prone to develop heartburn as a result of gastroesophgeal reflux disease (GERD)?
All of the following should be performed when fetal heart monitoring indicates fetal distress except:
Physical examination of a client regarding mobility status should:
In alcoholics with anemia:
Client room environments should include:
Safety measures for using crutches must be taught to clients. Safety measures for the use of crutches include:
When discussing possible complications of pregnancy with a client, the nurse should explain that all of the following are symptoms of urinary tract infection (UTI). Which of the following is least indicative of UTI during pregnancy?
Which of the following statements by a client indicates adequate preparation for magnetic resonance imaging?
With a breech presentation, the nurse must be particularly alert for which of the following?
One of the major functions of the kidneys in maintaining normal fluid balance is:
A spinal change occurring with pregnancy that alters mobility is:
Which of the following actions should a nurse take first for a client who has just vomited 300 cc of bright red blood?
Which of the following nursing diagnoses is most appropriate for a client with a new colostomy?
A successful resolution of the nursing diagnosis Negative Self-Concept (related to unrealistic selfexpectations) is when the client can:
Which of the following blood pressure parameters indicates PIH? Elevation over a baseline of:
Which of the following should be included in a diet rich in iron?
Which type of diet should the nurse provide to help a client who has major burns maintain a positive nitrogen balance?
The teaching plan for a postpartum client who is about to be discharged should include which of the following instructions?
Which of the following represents a normal serum potassium level?
The NSAID that is comparable to morphine in efficacy is:
A client with major head trauma is receiving bolus enteral feeding. The most important nursing order for this client is:
Which of the following statements by an adult child of a client with late-stage Alzheimer’s disease indicates a need for further teaching by the nurse?
Which instruction should be given in a health education class regarding testicular cancer?
When caring for a client with a possible diagnosis of placenta previa, which of the following admission procedures should the nurse omit?
When teaching parents how their children learn sex role identification, the nurse should include which of the following statements?
Incidences of child abuse apperar to be higher in the African-American community and might be explained by:
An 8-year-old Asian child is being examined during a school screening. The nurse notices small bruises on the anterior and posterior ribs. The nurse should ask the child:
The nurse is transferring a client from a wheelchair to the bed. Which is the correct procedure?
The nurse has completed client teaching about introducing solid foods to an infant. To evaluate teaching, the nurse asks the mother to identify an appropriate first solid food. Which of the following is an appropriate response?
Which of the following instructions should a nurse give a client who is about to undergo pelvic ultrasonography?
An Asian family has an elderly member with latestage Alzheimer’s disease. The physician has recommended placement in a long-term care facility, but the family refuses. Which of the following is an appropriate response to the family by the nurse?
A Roman Catholic client is preparing to have magnetic resonance imaging. He wants to wear his metal crucifix pendant while he is receiving the test. Which of the following is an appropriate response by the nurse?
A client who is newly diagnosed with Parkinson’s disease and beginning medication therapy asks the nurse, “How soon will I see improvement ?” The nurse’s best response is:
A client with jaundice has which skin color?
Which of the following statements is correct regarding rape?
A man reports his wife is constantly cleaning. The activity has interfered with the family life. Friends have stopped visiting because she makes them uncomfortable. He states he has awakened in the middle of the night and found her cleaning. The nurse should consult with the couple and recommend the husband help with therapy by:
A client has a nasogastric (NG) tube in place following abdominal surgery. The purpose of this tube immediately following surgery is to:
A client had a colostomy done one day ago. Which of the following is an abnormal finding when assessing the stoma?
Activities of effective supervisors can be taskrelated or people-related activities. An example of a task-related supervisory activity is:
A woman is in the active phase of labor. An external monitor has been applied, and a fetal heart deceleration of uniform shape is observed, beginning just as the contraction is under way and returning to the baseline at the end of the contraction. Which of the following nursing actions is most appropriate?
The nurse is preparing to administer IV Vancomycin to a client. Which of the following nursing actions
should be taken first?
The nurse’s first action upon discovery of an electrical fire should be which of the following?
A client is having psychological counseling for problems communicating with his mother. Which model of stress is the most useful in reference to this stressor?
An example of an extended care facility is a:
An adolescent female reports being raped at a party where alcohol was served. The client admits to drinking alcohol before being raped by an acquaintance. The nurse should:
The emergency triage nurse should perform which action upon receiving the history that a client has a severe cough, fever, night sweats, and body wasting?
The primary organ for drug elimination is the:
Mrs. Peterson complains of difficulty falling asleep, awakening earlier than desired, and not feeling rested. She attributes these problems to leg pain that is secondary to her arthritis. What is the most appropriate nursing diagnosis for her?
A neighbor telephones the nurse to tell her that her child has erythema infectiosum and asks for information. The nurse knows that another name for the disorder is:
How many temporary teeth should the nurse expect to find in a 5-year-old client’s mouth?
Acute hyphema is associated with what type of injury?
When questioning an elder about suspected abuse, the nurse should keep the questions:
While walking in the hallway of an acute care unit of the hospital, the nurse overhears the change of shift report. The nurse should:
During a routine health screening, the nurse should talk to the parents of a 1-year-old child about which of the following?
Delegation of tasks to appropriate personnel allows the nurse to:
The nurse uses prioritization to determine all the following except: