Comprehensive Test

The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action?

The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse’s immediate action?

The nurse is caring for a client who was involuntarily hospitalized to a mental health unit and is scheduled for electroconvulsive therapy. The nurse notes that an informed consent has not been obtained for the procedure. Based on this information, what is the nurse’s best determination in planning care?

A client newly diagnosed with diabetes mellitus is instructed by the primary health care provider to obtain glucagon for emergency home use. The client asks a home care nurse about the purpose of the medication. What is the nurse’s best response to the client’s question?

The nurse is providing care to a Puerto Rican-American client who is terminally ill. Numerous family members are present most of the time, and many of the family members are very emotional. What is the most appropriate nursing action for this client?

A client presents to the emergency department with upper gastrointestinal bleeding and is in moderate distress. In planning care, what is the priority nursing action for this client?

The nurse is performing an assessment on a client with dementia. Which piece of data gathered during the assessment indicates a manifestation associated with dementia?

The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management?

The nurse provides instructions to a malnourished pregnant client regarding iron supplementation. Which client statement indicates an understanding of the instructions?

Levothyroxine is prescribed for a client diagnosed with hypothyroidism. Upon review of the client’s record, the nurse notes that the client is taking warfarin. Which modification to the plan of care should the nurse review with the client’s primary health care provider?

The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client that which positions alleviate dyspnea? Select all that apply.

1. Sitting up and leaning on a table
2. Standing and leaning against a wall
3. Lying supine with the feet elevated
4. Sitting up with the elbows resting on knees
5. Lying on the back in a low-Fowler’s position

A client is about to undergo a lumbar puncture. The nurse describes to the client that which position will be used during the procedure?

The nurse recognizes that which interventions are likely to facilitate effective communication between a dying client and family? Select all that apply.

1. The nurse encourages the client and family to identify and discuss feelings openly.
2. The nurse assists the client and family in carrying out spiritually meaningful practices.
3. The nurse removes autonomy from the client to alleviate any unnecessary stress for the client.
4. The nurse makes decisions for the client and family to relieve them of unnecessary demands.
5. The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger.

A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as “I’m such a failure. I can’t do anything right. “How should the nurse plan to respond to the client’s statement?

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific primary health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply.

1. Head midline
2. Neck in neutral position
3. Head of bed elevated 30 to 45 degrees
4. Head turned to the side when flat in bed
5. Neck and jaw flexed forward when opening the mouth

The nurse reviews the arterial blood gas results of a client with emphysema and notes that the laboratory report indicates a pH of 7.30, PaCO2 of 58 mm Hg, PaO2 of 80 mm Hg, and HCO3 of 27 mEq/L (27 mmol/L). The nurse interprets that the client has which acid-base disturbance?

The nurse has admitted a client to the clinical nursing unit after undergoing a right mastectomy. The nurse should plan to place the right arm in which position?

On the second postpartum day, a client complains of burning on urination, urgency, and frequency of urination. A urinalysis indicates the presence of a urinary tract infection. The nurse instructs the client regarding measures to take for the treatment of the infection. Which client statement indicates to the nurse the need for further instruction?

A client received 20 units of Humulin N insulin subcutaneously at 08:00. At what time should the nurse plan to assess the client for a hypoglycemic reaction?

The nurse is the first responder after a tornado has destroyed many homes in the community. Which victim should the nurse attend to first?

A pregnant client at 10 weeks’ gestation calls the prenatal clinic to report a recent exposure to a child with rubella. The nurse reviews the client’s chart. What is the nurse’s best response to the client? Refer to chart.

A breast-feeding mother of an infant with lactose intolerance asks the nurse about dietary measures. What foods should the nurse tell the mother are acceptable to consume while breast-feeding? Select all that apply.

1. 1%milk
2. Egg yolk
3. Dried beans
4. Hard cheeses
5. Green leafy vegetables

A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, “This is all my primary health care provider’s fault. I have done everything I’ve been asked to do!” Which nursing interpretation is best for this situation?

A client with terminal cancer arrives at the emergency department dead on arrival (DOA). After an autopsy is prescribed, the client’s family requests that no autopsy be performed. Which response to the family is most appropriate?

A client who is positive for human immunodeficiency virus (HIV) delivers a newborn infant. The nurse provides instructions to help the client with care of her infant. Which client statement indicates the need for further instruction?

An adolescent client is diagnosed with conjunctivitis, and the nurse provides information to the client about the use of contact lenses. Which client statement indicates the need for further information?

The nurse teaches a client newly diagnosed with type 1 diabetes about storing Humulin N insulin. Which statement indicates to the nurse that the client understood the discharge teaching?

The nurse is caring for a client scheduled for a transsphenoidal hypophysectomy. The preoperative teaching instructions should include which statement?

During a routine prenatal visit, a client complains of gums that bleed easily with brushing. The nurse performs an assessment and teaches the client about proper nutrition to minimize this problem. Which client statement indicates an understanding of the proper nutrition to minimize this problem?

A 6-year-old child has just been diagnosed with localized Hodgkin’s disease, and chemotherapy is planned to begin immediately. The mother of the child asks the nurse why radiation therapy was not prescribed as a part of the treatment. What is the nurse’s best response?

An infant born with an imperforate anus returns from surgery after requiring a colostomy. The nurse assesses the stoma and notes that it is red and edematous. Based on this finding, which action should the nurse take?

The nurse is performing an initial assessment on a newborn infant. When assessing the infant’s head, the nurse notes that the ears are low-set. Which nursing action is most appropriate?

The clinic nurse is assessing jaundice in a child with hepatitis. Which anatomical area would provide the best data regarding the presence of jaundice?

The nurse is assigned to care for a client in traction. The nurse creates a plan of care for the client and should include which action in the plan?

The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client’s health. Which interventions are appropriate? Select all that apply.

1. Set the room temperature at a comfortable level.
2. Remove distracting objects from the interviewing area.
3. Place a chair for the client across from the nurse’s desk.
4. Ensure comfortable seating at eye level for the client and nurse.
5. Provide seating for the client so that the client faces a strong light.
6. Ensure that the distance between the client and nurse is at least 7 feet (2.1 meters).

The nurse is caring for an older adult who has been placed in Buck’s extension traction after a hip fracture. On assessment of the client, the nurse notes that the client is disoriented. What is the best nursing action based on this information?

The nurse is creating a plan of care for a client in skin traction. The nurse should monitor for which priority finding in this client?

The home care nurse is visiting a client who is in a body cast. While performing an assessment, the nurse plans to evaluate the psychosocial adjustment of the client to the cast. What is the most appropriate assessment for this client?

What action should the nurse consider when counseling a client of the Amish tradition?

A client has refused to eat more than a few spoonsful of breakfast. The primary health care provider has prescribed that tube feedings be initiated if the client fails to eat at least half of a meal because the client has lost a significant amount of weight during the previous 2 months. The nurse enters the room, looks at the tray, and states, “If you don’t eat any more than that, I’m going to have to put a tube down your throat and get a feeding in that way. “The client begins crying and tries to eat more. Based on the nurse’s actions, the nurse may be accused of which violation?

When creating an assignment for a team consisting of a registered nurse (RN), 1 licensed practical nurse (LPN), and 2 assistive personnel (AP), which is the best client for the LPN?

To perform cardiopulmonary resuscitation (CPR), the nurse should use the method pictured to open the airway in which situation? Refer to figure.

The nurse teaches skin care to a client receiving external radiation therapy. Which client statement indicates the need for further instruction?

The primary health care provider’s prescription reads levothyroxine,150 mcg orally daily. The medication label reads levothyroxine, 0.1 mg per tablet. The nurse should administer how many tablet(s) to the client?

Metformin is prescribed for a client with type 2 diabetes mellitus. What is the most common side effect that the nurse should include in the client’s teaching plan?

Which nursing actions apply to the care of a child who is having a seizure? Select all that apply.

1. Time the seizure.
2. Restrain the child.
3. Stay with the child.
4. Insert an oral airway.
5. Loosen clothing around the child’s neck.
6. Place the child in a lateral side-lying position.

The nurse is conducting an interview of an older client and is concerned about the possibility of benign prostatic hyperplasia (BPH). Which are characteristics of this disorder? Select all that apply.

1. Nocturia
2. Incontinence
3. Enlarged prostate
4. Nocturnal emissions
5. Decreased desire for sexual intercourse

The nursing instructor asks a nursing student to identify the priorities of care for an assigned client. Which statement indicates that the student correctly identifies the priority client needs?

A client arrives at the clinic complaining of fatigue, lack of energy, constipation, and depression. Hypothyroidism is diagnosed, and levothyroxine is prescribed. What is an expected outcome of the medication?

The community health nurse is creating a poster for an educational session for a group of women and will be discussing the risk factors associated with breast cancer. Which risk factors for breast cancer should the nurse list on the poster? Select all that apply.

1. Multiparity
2. Early menarche
3. Early menopause
4. Family history of breast cancer
5. High-dose radiation exposure to chest
6. Previous cancer of the breast, uterus, or ovaries

The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which piece of assessment data should alert the nurse to this occurrence?

The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the primary health care provider (PHCP)?

The nurse is preparing to discontinue a client’s nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse should make which statement to the client?

A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder?

The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The primary health care provider has now prescribed that the nasogastric tube be removed. What is the priority nursing assessment prior to removing the tube?

The nurse has reviewed with the preoperative client the procedure for the administration of an enema. Which statement by the client would indicate the need for further instruction?

A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy?

The nurse is preparing a list of home care instructions regarding stoma and laryngectomy care for a client with laryngeal cancer who had a laryngectomy. Which instructions should be included in the list? Select all that apply.

1. Restrict fluid intake.
2. Obtain a MedicAlert bracelet.
3. Keep the humidity in the home low.
4. Prevent debris from entering the stoma.
5. Avoid exposure to people with infections.
6. Avoid swimming and use care when showering.

The primary health care provider prescribes 2000 mL of 5% dextrose and half-normal saline to infuse over 24 hours. The drop factor is 15 drops (gtt)/mL. The nurse should set the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage should the nurse expect?

A client has had radical neck dissection and begins to hemorrhage at the incision site. The nurse should take which actions in this situation? Select all that apply.

1. Monitor vital signs.
2. Monitor the client’s airway.
3. Apply manual pressure over the site.
4. Lower the head of the bed to a flat position.
5. Call the primary health care provider (PHCP) immediately.

A sexually active young adult client has developed viral hepatitis. Which client statement indicates the need for further teaching?

The nurse should include which interventions in the plan of care for a client with hypothyroidism? Select all that apply.

1. Provide a cool environment for the client.
2. Instruct the client to consume a high-fat diet.
3. Instruct the client about thyroid replacement therapy.
4. Encourage the client to consume fluids and high-fiber foods in the diet.
5. Inform the client that iodine preparations will be prescribed to treat the disorder.
6. Instruct the client to contact the primary health care provider (PHCP) if episodes of chest pain occur.

The nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. The nurse is planning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. Which nursing action is required before plugging the tube?

A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder?

A client with retinal detachment is admitted to the nursing unit in preparation for a repair procedure. Which prescription should the nurse anticipate?

The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing?

The nurse is caring for a client who is at risk for suicide. What is the priority nursing action for this client?

A client with tuberculosis whose status is being monitored in an ambulatory care clinic asks the nurse when it is permissible to return to work. What factor should the nurse include when responding to the client?

A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client?

The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis?

The nurse is creating a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concerns regarding the ability to meet role expectations and financial obligations. What is the priority nursing problem for this client?

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action?

After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse should expect to note which finding?

The primary health care provider prescribes erythromycin suspension 800 mg by mouth. After reconstitution, how many milliliters should the nurse pour into the medicine cup to deliver the prescribed dose? Refer to figure. Fill in the blank. ____mL