Which nursing instruction is the priority to give the client who is receiving a retention enema
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This chapter provides a 250 question practice NCLEX-RN exam, including both quick answers and full explanations. Show 1. A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every two hours. Which of the following outcome criteria would the nurse use?
A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is the best position for this client?
A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?
Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?
A newly admitted client has sickle cell crisis. He is complaining of pain in his feet and hands. The nurse’s assessment findings include a pulse oximetry of 92. Assuming that all the following interventions are ordered, which should be done first?
The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select?
Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?
The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which finding reinforces the diagnosis of B12 deficiency?
The body part that would most likely display jaundice in the dark-skinned individual is the:
The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?
The nurse is teaching the client with polycythemia vera about prevention of complications of the disease. Which of the following statements by the client indicates a need for further teaching?
A 33-year-old male is being evaluated for possible acute leukemia. Which of the following findings is most likely related to the diagnosis of leukemia?
Where is the best site for examining for the presence of petechiae in an African American client?
The client is being evaluated for possible acute leukemia. Which inquiry by the nurse is most important?
Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?
A 21-year-old male with Hodgkin’s lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client?
A client has autoimmune thrombocytopenic purpura. To determine the client’s response to treatment, the nurse would monitor:
The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client’s platelet count currently is 80,000. It will be most important to teach the client and family about:
The client has surgery for removal of a Prolactinoma. Which of the following interventions would be appropriate for this client?
The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is:
A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?
A client has had a unilateral adrenalectomy to remove a tumor. The most important measurement in the immediate post-operative period for the nurse to take is:
A client with Addison’s disease has been admitted with a history of nausea and vomiting for the past three days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement?
A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurses’ next action be?
A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in four months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?
The client presents to the clinic with a serum cholesterol of 275mg/dL and is placed on rosuvastatin (Crestor). Which instruction should be given to the client taking rosuvastatin (Crestor)?
The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During administration, the nurse should:
The six-month-old client with a ventral septal defect is receiving Digitalis for regulation of his heart rate. Which finding should be reported to the doctor?
The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:
The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?
The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the:
The nurse is checking the client’s central venous pressure. The nurse should place the zero of the manometer at the:
The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:
The best method of evaluating the amount of peripheral edema is:
A client with vaginal cancer is being treated with a radioactive vaginal implant. The client’s husband asks the nurse if he can spend the night with his wife. The nurse should explain that:
The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client?
The physician has prescribed Novalog insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?
The nurse is teaching basic infant care to a group of first-time parents. The nurse should explain that a sponge bath is recommended for the first two weeks of life because:
A client with leukemia is receiving Trimetrexate. After reviewing the client’s chart, the physician orders Wellcovorin (leucovorin calcium). The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to:
A four-month-old is brought to the well-baby clinic for immunization. In addition to the DPT and polio vaccines, the baby should receive:
The physician has prescribed Nexium (esomeprazole) for a client with erosive gastritis. The nurse should administer the medication:
A client on the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff. What is the most appropriate action for the nurse to take?
When the nurse checks the fundus of a client on the first postpartum day, she notes that the fundus is firm, is at the level of the umbilicus, and is displaced to the right. The next action the nurse should take is to:
A client is admitted to the hospital with a temperature of 99.8°F, complaints of blood-tinged hemoptysis, fatigue, and night sweats. The client’s symptoms are consistent with a diagnosis of:
The client is seen in the clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan succinate) is prescribed for the client. Which of the following in the client’s history should be reported to the doctor?
The client with suspected meningitis is admitted to the unit. The doctor is performing an assessment to determine meningeal irritation and spinal nerve root inflammation. A positive Kernig’s sign is charted if the nurse notes:
The client with Alzheimer’s disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting:
The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as:
The client with confusion says to the nurse, “I haven’t had anything to eat all day long. When are they going to bring breakfast?” The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Which response would be best for the nurse to make?
The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer’s disease. Which side effect is most often associated with this drug?
A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?
A client with a diagnosis of HPV is at risk for which of the following?
During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:
A client visiting a family planning clinic is suspected of having an STI. The best diagnostic test for treponema pallidum is:
A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome?
The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?
A primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor’s order should the nurse question?
A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. The nurse’s assessment of this data is:
Which observation in the newborn of a diabetic mother would require immediate nursing intervention?
The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is:
The client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension, the nurse would:
A client has cancer of the pancreas. The nurse should be most concerned about which nursing diagnosis?
The nurse is caring for a client with uremic frost. The nurse is aware that uremic frost is often seen in clients with:
The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client’s most appropriate priority nursing diagnosis?
The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:
The nurse working the organ transplant unit is caring for a client with a white blood cell count of 450. During evening visitation, a visitor brings a basket of fruit. What action should the nurse take?
The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale, with a BP of 90/40. The initial nurse’s action should be to:
The client admitted two days earlier with a lung resection accidentally pulls out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes?
A client being treated with sodium warfarin (Coumadin) has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan?
Which selection would provide the most calcium for the client who is four months pregnant?
The client with preeclampsia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates the understanding of magnesium toxicity?
The best size cathlon for administration of a blood transfusion to a six-year-old is:
A client is admitted to the unit two hours after an explosion causes burns to the face. The nurse would be most concerned with the client developing which of the following?
The client has recently been diagnosed with diabetes. Which of the following indicates understanding of the management of diabetes?
The client is admitted following cast application for a fractured ulna. Which finding should be reported to the doctor?
The client with AIDS should be taught to:
Which action by the healthcare worker indicates a need for further teaching?
The client is having electroconvulsive therapy for treatment of severe depression. Prior to the ECT the nurse should:
The five-year-old is being tested for enterobiasis (pinworms). Which symptom is associated with enterobiasis?
The nurse is teaching the mother regarding treatment for pedicalosis capitis. Which instruction should be given regarding the medication?
The registered nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?
The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?
The doctor accidentally cuts the bowel during surgery. As a result of this action, the client develops an infection and suffers brain damage. The doctor can be charged with:
Which assignment should not be performed by the nursing assistant?
The mother calls the clinic to report that her newborn has a rash on his forehead and face. Which action is most appropriate?
Which nurse should not be assigned to care for the client with a radium implant for vaginal cancer?
Which information should be reported to the state Board of Nursing?
The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should:
The home health nurse is planning for the day’s visits. Which client should be seen first?
The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster?
Before administering eardrops to a toddler, the nurse should recognize that it is essential to consider which of the following?
The nurse is discussing meal planning with the mother of a two-year-old. Which of the following statements, if made by the mother, would require a need for further instruction?
A client with AIDS has a viral load of 200 copies per ml. The nurse should interpret this finding as:
The client has an order for sliding scale insulin at 1900 hours and Lantus insulin at the same hour. The nurse should:
A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:
What would the nurse expect the admitting assessment to reveal in a client with glomerulonephritis?
Which action is contraindicated in the client with epiglottis?
A 25-year-old client with a goiter is admitted to the unit. What would the nurse expect the admitting assessment to reveal?
Which of the following foods, if selected by the mother with a child with celiac, would indicate her understanding of the dietary instructions?
The first action that the nurse should take if she finds the client has an O2 saturation of 68% is:
Which observation would the nurse expect to make after an amniotomy?
The client taking Glyburide (Diabeta) should be cautioned to:
The obstetric client’s fetal heart rate is 80–90 during the contractions. The first action the nurse should take is:
Arterial ulcers are best described as ulcers that:
A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time?
A vaginal exam reveals that the cervix is 4cm dilated, with intact membranes and a fetal heart tone rate of 160–170bpm. The nurse decides to apply an external fetal monitor. The rationale for this implementation is:
The following are all nursing diagnoses appropriate for a gravida 1 para 0 in labor. Which one would be most appropriate for the primagravida as she completes the early phase of labor?
As the client reaches 6cm dilation, the nurse notes late decelerations on the fetal monitor. What is the most likely explanation of this pattern?
The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:
Which of the following is a characteristic of an ominous periodic change in the fetal heart rate?
The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:
A client in the family planning clinic asks the nurse about the most likely time for her to conceive. The nurse explains that conception is most likely to occur when:
A client tells the nurse that she plans to use the rhythm method of birth control. The nurse is aware that the success of the rhythm method depends on the:
A client with diabetes asks the nurse for advice regarding methods of birth control. Which method of birth control is most suitable for the client with diabetes?
The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a diagnosis of a ruptured ectopic pregnancy?
The nurse is teaching a pregnant client about nutritional needs during pregnancy. Which menu selection will best meet the nutritional needs of the pregnant client?
The client with hyperemesis gravidarum is at risk for developing:
A client tells the doctor that she is about 20 weeks pregnant. The most definitive sign of pregnancy is:
The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to be:
Which of the following instructions should be included in the nurse’s teaching regarding oral contraceptives?
The nurse is discussing breastfeeding with a postpartum client. Breastfeeding is contraindicated in the postpartum client with:
A client is admitted to the labor and delivery unit complaining of vaginal bleeding with very little discomfort. The nurse’s first action should be to:
A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when:
The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development. Which characteristic is associated with babies born to mothers who smoked during pregnancy?
The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A negative but whose baby is O positive. To provide postpartum prophylaxis, RhoGam should be administered:
After the physician performs an amniotomy, the nurse’s first action should be to assess the:
A client is admitted to the labor and delivery unit. The nurse performs a vaginal exam and determines that the client’s cervix is 5cm dilated with 75% effacement. Based on the nurse’s assessment the client is in which phase of labor?
A newborn with narcotic abstinence syndrome is admitted to the nursery. Nursing care of the newborn should include:
A client elects to have epidural anesthesia to relieve the discomfort of labor. Following the initiation of epidural anesthesia, the nurse should give priority to:
The nurse is aware that the best way to prevent post-operative wound infection in the surgical client is to:
The elderly client is admitted to the emergency room. Which symptom is the client with a fractured hip most likely to exhibit?
The nurse knows that a 60-year-old female client’s susceptibility to osteoporosis is most likely related to:
A two-year-old is admitted for repair of a fractured femur and is placed in Bryant’s traction. Which finding by the nurse indicates that the traction is working properly?
Which statement is true regarding balanced skeletal traction? Balanced skeletal traction:
The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery, the nurse should give priority to assessing the:
Which statement made by the family member caring for the client with a percutaneous gastrostomy tube indicates understanding of the nurse’s teaching?
The nurse is assessing the client with a total knee replacement two hours post-operative. Which information requires notification of the doctor?
The nurse is caring for the client with a five-year-old diagnosis of plumbism. Which information in the health history is most likely related to the development of plumbism?
A client with a total hip replacement requires special equipment. Which equipment would assist the client with a total hip replacement with activities of daily living?
An elderly client with an abdominal surgery is admitted to the unit following surgery. In anticipation of complications of anesthesia and narcotic administration, the nurse should:
Which roommate would be most suitable for the six-year-old male with a fractured femur in Russell’s traction?
A client with osteoarthritis has a prescription for Celebrex (celecoxib). Which instruction should be included in the discharge teaching?
A client with a fractured tibia has a plaster-of-Paris cast applied to immobilize the fracture. Which action by the nurse indicates understanding of a plaster-of-Paris cast? The nurse:
The teenager with a fiberglass cast asks the nurse if it will be okay to allow his friends to autograph his cast. Which response would be best?
The nurse is assigned to care for the client with a Steinman pin. During pin care, she notes that the LPN uses sterile gloves and Q-tips to clean the pin. Which action should the nurse take at this time?
A child with scoliosis has a spica cast applied. Which action specific to the spica cast should be taken?
The client with a cervical fracture is placed in traction. Which type of traction will be utilized at the time of discharge?
A client with a total knee replacement has a CPM (continuous passive motion device) applied during the post-operative period. Which statement made by the nurse indicates understanding of the CPM machine?
A client with a fractured hip is being taught correct use of the walker. The nurse is aware that the correct use of the walker is achieved if the:
When assessing a laboring client, the nurse finds a prolapsed cord. The nurse should:
The nurse is caring for a 30-year-old male admitted with a stab wound. While in the emergency room, a chest tube is inserted. Which of the following explains the primary rationale for insertion of chest tubes?
A client who delivered this morning tells the nurse that she plans to breastfeed her baby. The nurse is aware that successful breastfeeding is most dependent on the:
The nurse is monitoring the progress of a client in labor. Which finding should be reported to the physician immediately?
The nurse is measuring the duration of the client’s contractions. Which statement is true regarding the measurement of the duration of contractions?
The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin, the nurse should monitor for:
A client with diabetes visits the prenatal clinic at 28 weeks gestation. Which statement is true regarding insulin needs during pregnancy?
A client in the prenatal clinic is assessed to have a blood pressure of 180/96. The nurse should give priority to:
A primigravida, age 42, is six weeks pregnant. Based on the client’s age, her infant is at risk for:
A client with a missed abortion at 29 weeks gestation is admitted to the hospital. The client will most likely be treated with:
A client with preeclampsia has been receiving an infusion containing magnesium sulfate for a blood pressure that is 160/80; deep tendon reflexes are 1 plus, and the urinary output for the past hour is 100mL. The nurse should:
Which statement made by the nurse describes the inheritance pattern of autosomal recessive disorders?
A pregnant client, age 32, asks the nurse why her doctor has recommended a serum alpha fetoprotein. The nurse should explain that the doctor has recommended the test:
A client with hypothyroidism asks the nurse if she will still need to take thyroid medication during the pregnancy. The nurse’s response is based on the knowledge that:
The nurse is responsible for performing a neonatal assessment on a full-term infant. At one minute, the nurse could expect to find:
A client with sickle cell anemia is admitted to the labor and delivery unit during the first phase of labor. The nurse should anticipate the client’s need for:
A client with diabetes has an order for ultrasonography. Preparation for an ultrasound includes:
An infant who weighs 8 pounds at birth would be expected to weigh how many pounds at one year?
A pregnant client with a history of alcohol addiction is scheduled for a nonstress test. The nonstress test:
A full-term male has hypospadias. Which statement describes hypospadias?
A gravida III para II is admitted to the labor unit. Vaginal exam reveals that the client’s cervix is 8cm dilated, with complete effacement. The priority nursing diagnosis at this time is:
The client with varicella will most likely have an order for which category of medication?
A client is admitted complaining of chest pain. Which of the following drug orders should the nurse question?
Which of the following instructions should be included in the teaching for the client with rheumatoid arthritis?
A client with acute pancreatitis is experiencing severe abdominal pain. Which of the following orders should be questioned by the nurse?
The client is admitted to the chemical dependence unit with an order for continuous observation. The nurse is aware that the doctor has ordered continuous observation because:
A client with a history of abusing barbiturates abruptly stops taking the medication. The nurse should give priority to assessing the client for:
During the assessment of a laboring client, the nurse notes that the FHT are loudest in the upper-right quadrant. The infant is most likely in which position?
The primary physiological alteration in the development of asthma is:
A client with mania is unable to finish her dinner. To help her maintain sufficient nourishment, the nurse should:
To maintain Bryant’s traction, the nurse must make certain that the child’s:
Which action by the nurse indicates understanding of herpes zoster?
There is an order for a trough to be drawn on the client receiving Vancomycin. The nurse is aware that he should contact the lab for them to collect the blood:
The client using a diaphragm should be instructed to:
The nurse is providing postpartum teaching for a mother planning to breastfeed her infant. Which of the client’s statements indicates the need for additional teaching?
Damage to the VII cranial nerve results in:
A client is receiving Pyridium (phenazopyridine hydrochloride) for a urinary tract infection. The client should be taught that the medication may:
Which of the following tests should be performed before beginning a prescription of Accutane?
A client with AIDS is taking Zovirax (acyclovir). Which nursing intervention is most critical during the administration of acyclovir?
A client is admitted for an CAT scan. The nurse should question the client regarding:
The nurse is caring for the client receiving Amphotericin B. Which of the following indicates that the client has experienced toxicity to this drug?
The nurse should visit which of the following clients first?
A client with cystic fibrosis is taking pancreatic enzymes. The nurse should administer this medication:
Cataracts result in opacity of the crystalline lens. Which of the following best explains the functions of the lens?
A client who has glaucoma is to have miotic eyedrops instilled in both eyes. The nurse knows that the purpose of the medication is to:
A client with a severe corneal ulcer has an order for Gentamicin gtt. q 4 hours and Neomycin 1 gtt q 4 hours. Which of the following schedules should be used when administering the drops?
The client with color blindness will most likely have problems distinguishing which of the following colors?
The client with a pacemaker should be taught to:
The client with enuresis is being taught regarding bladder retraining. The nurse should advise the client to refrain from drinking after:
Which of the following diet instructions should be given to the client with recurring urinary tract infections?
The physician has prescribed NPH insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?
A client with pneumacystis carinii pneumonia is receiving Methotrexate. The rationale for administering leucovorin calcium to a client receiving Methotrexate is to:
A client tells the nurse that she is allergic to eggs, dogs, rabbits, and chicken feathers. Which order should the nurse question?
The physician has prescribed ranitidine (Zantac) for a client with erosive gastritis. The nurse should administer the medication:
A temporary colostomy is performed on the client with colon cancer. The nurse is aware that the proximal end of a double barrel colostomy:
While assessing the postpartal client, the nurse notes that the fundus is displaced to the right. Based on this finding, the nurse should:
The physician has ordered an MRI for a client with an orthopedic ailment. An MRI should not be done if the client has:
A six-month-old client is placed on strict bed rest following a hernia repair. Which toy is best suited to the client?
The nurse is preparing to discharge a client with a long history of polio. The nurse should tell the client that:
A client on the postpartum unit has a proctoepisiotomy. The nurse should anticipate administering which medication?
A client with pancreatic cancer has an infusion of TPN (Total Parenteral Nutrition). The doctor has ordered for sliding-scale insulin. The most likely explanation for this order is:
An adolescent primigravida who is 10 weeks pregnant attends the antepartal clinic for a first check-up. To develop a teaching plan, the nurse should initially assess:
An obstetric client is admitted with dehydration. Which IV fluid would be most appropriate for the client?
The physician has ordered a thyroid scan to confirm the diagnosis of a goiter. Before the procedure, the nurse should:
The physician has ordered an injection of RhoGam for a client with blood type A negative. The nurse understands that RhoGam is given to:
The nurse is caring for a client admitted to the emergency room after a fall. X-rays reveal that the client has several fractured bones in the foot. Which treatment should the nurse anticipate for the fractured foot?
A client with bladder cancer is being treated with iridium seed implants. The nurse’s discharge teaching should include telling the client to:
Following a heart transplant, a client is started on medication to prevent organ rejection. Which category of medication prevents the formation of antibodies against the new organ?
The nurse is preparing a client for cataract surgery. The nurse is aware that the procedure will use:
A client with Alzheimer’s disease is awaiting placement in a skilled nursing facility. Which long-term plans would be most therapeutic for the client?
A client with an abdominal cholecystectomy returns from surgery with a Jackson-Pratt drain. The chief purpose of the Jackson-Pratt drain is to:
The nurse is performing an initial assessment of a newborn Caucasian male delivered at 32 weeks gestation. The nurse can expect to find the presence of:
The nurse is caring for a client admitted with multiple trauma. Fractures include the pelvis, femur, and ulna. Which finding should be reported to the physician immediately?
A client is brought to the emergency room by the police. He is combative and yells, “I have to get out of here. They are trying to kill me.” Which assessment is most likely correct in relation to this statement?
The nurse is preparing to suction the client with a tracheotomy. The nurse notes a previously used bottle of normal saline on the client’s bedside table. There is no label to indicate the date or time of initial use. The nurse should:
An infant’s Apgar score is 9 at five minutes. The nurse is aware that the most likely cause for the deduction of one point is:
The primary reason for rapid continuous rewarming of the area affected by frostbite is to:
A client recently started on hemodialysis wants to know how the dialysis will take the place of his kidneys. The nurse’s response is based on the knowledge that hemodialysis works by:
During a home visit, a client with AIDS tells the nurse that he has been exposed to measles. Which action by the nurse is most appropriate?
A client hospitalized with MRSA is placed on contact precautions. Which statement is true regarding precautions for infections spread by contact?
A client who is admitted with an above-the-knee amputation tells the nurse that his foot hurts and itches. Which response by the nurse indicates understanding of phantom limb pain?
A client with cancer of the pancreas has undergone a Whipple procedure. The nurse is aware that during the Whipple procedure, the doctor will remove the:
The physician has ordered a minimal-bacteria diet for a client with neutropenia. The client should be taught to avoid eating:
A client is discharged home with a prescription for Coumadin (sodium warfarin). The client should be instructed to:
The nurse is assisting the physician with removal of a central venous catheter. To facilitate removal, the nurse should instruct the client to:
A client has an order for streptokinase. Before administering the medication, the nurse should assess the client for:
The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid:
The nurse is changing the ties of the client with a tracheotomy. The safest method of changing the tracheotomy ties is to:
The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was 300mL. The nurse should give priority to:
The infant is admitted to the unit with tetralogy of Fallot. The nurse would anticipate an order for which medication?
The nurse is educating the lady’s club in self-breast exam. The nurse is aware that most malignant breast masses occur in the Tail of Spence. On the diagram, place an X on the Tail of Spence. 241.The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will:
The nurse is monitoring a client with a history of stillborn infants. The nurse is aware that a nonstress test can be ordered for this client to:
The nurse is evaluating the client who was admitted eight hours ago for induction of labor. The following graph is noted on the monitor. Which action should be taken first by the nurse?
The nurse notes the following on the ECG monitor. The nurse would evaluate the cardiac arrhythmia as:
A client with clotting disorder has an order to continue Lovenox (enoxaparin) injections after discharge. The nurse should teach the client that Lovenox injections should:
The nurse has a preop order to administer Valium (diazepam) 10mg and Phenergan (promethazine) 25mg. The correct method of administering these medications is to:
A client with frequent urinary tract infections asks the nurse how she can prevent the reoccurrence. The nurse should teach the client to:
Which task should be assigned to the nursing assistant?
The client has recently returned from having a thyroidectomy. The nurse should keep which of the following at the bedside?
The physician has ordered a histoplasmosis test for the elderly client. The nurse is aware that histoplasmosis is transmitted to humans by:
Which nursing assessment takes priority when administering an enema?Which nursing assessment takes priority when administering an enema to a client? When administering an enema to a client, the nurse would assess the client for cramping, dizziness, or pain. The enema may stimulate a vagal response, which increases parasympathetic stimulation. This causes a decrease in the heart rate.
What should be the nurse's first action before administering an enema?Which action should the nurse take prior to the procedure? Lubricate the tip of the rectal tube for easy insertion. A nurse is preparing to administer an enema to a client.
Which client situation would necessitate the nurse stopping the administration of an enema quizlet?If the client experiences severe pain and bloating during enema administration, the nurse should stop the enema and instruct the client to take short, panting breaths. This helps to relieve the pain and bloating sensation.
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