Question 3    See full question

20s

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The mother of a 3-day-old, breast-fed infant expresses concern that her infant has had two recent diapers that contained a lot of loose, yellowish stool. Which explanation by the nurse is best?

You Selected:

•  “Please save the next diaper so the nurses can examine the stools.”

Correct response:

•  “It’s normal for breast-fed infants to pass three or more loose, yellow stools per day.”

  Explanation:

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Question 18    See full question

37s

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A client with borderline personality disorder becomes angry when he is told that today’s psychotherapy session with the nurse will be delayed 30 minutes because of an emergency. When the session finally begins, the client expresses anger. Which response by the nurse would be helpful in dealing with the client’s anger?

You Selected:

•  “I know it’s frustrating to wait. I’m sorry this happened.”

Correct response:

•  “Can we talk about how this is making you feel right now?”

  Explanation:

  Remediation:

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Question 23    See full question

18s

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A client is admitted with retinal detachment. Which sign or symptom would the nurse anticipate during data collection?

You Selected:

•  drooping of the eyelids

Correct response:

•  flashing lights and floaters

  Explanation:

  Remediation:

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Question 24  See full question

2m 22s

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A client is ordered to receive 1 g of neomycin sulfate orally every hour × 4 doses followed by 1 g orally every 4 hours for the remaining balance of the 24 days. Neomycin sulfate tablets are available in 500 mg per tablet. How many tablets should the nurse administer for each dose? Record your answer using a whole number.

Your response:

•  1

Correct response:

•  2

  Explanation:

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Question 31    See full question

19s

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Which statement by a client undergoing external radiation therapy indicates the need for further teaching?

You Selected:

•  “I will not use my heating pad during my treatment.”

Correct response:

•  “I’m afraid I’ll expose my family members to radiation.”

  Explanation:

  Remediation:

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Question 36    See full question

21s

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A toddler is diagnosed with iron deficiency anemia. When teaching the parents about using supplemental iron elixir, the nurse should provide which instruction?

You Selected:

•  “Give the iron preparation before meals.”

Correct response:

•  “Give the elixir with water or juice.”

  Explanation:

  Remediation:

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Question 38    See full question

55s

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A nurse is caring for a 17-year-old brought to the mental health facility by a family member who is concerned about the client’s recent 20-lb (9 kg) weight loss, and weight loss total of 50 lb (22.7 kg) in the last year. What interventions are essential in the treatment of an adolescent diagnosed with an eating disorder? Select all that apply.

•  

 Provide a highly structured environment.

•  

 Monitor the clients’ weight, vitals, intake and output, caloric intake, and exercise.

•  

 Provide an isolation environment to monitor all activities.

•  

 Instruct the client and family that treatment for eating disorders takes a few weeks and the family is not involved in the process.

•  

 Assist the client in changing the negative perception to a positive one, and assist in setting realistic goals.

Correct response: 

Incorrect response: 

Your selection: 

  Explanation:

  Remediation:

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Question 39    See full question

38s

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A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis?

You Selected:

•  pH, 5.0; PaCO₂ 30 mm Hg

Correct response:

•  pH, 7.25; PaCO₂ 50 mm Hg

  Explanation:

  Remediation:

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Question 41    See full question

21s

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Which statement reflects appropriate documentation in the medical record of a hospitalized client?

You Selected:

•  “Small pressure injury noted on left leg.”

Correct response:

•  “Client’s skin is moist and cool.”

  Explanation:

  Remediation:

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Question 42    See full question

44s

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A nurse is collecting data on an 8-month-old for signs of neurologic deficit and increased intracranial pressure (ICP). Which finding should the nurse expect to observe?

You Selected:

•  depressed fontanel

Correct response:

•  altered level of consciousness

  Explanation:

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Question 46    See full question

21s

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The licensed practical nurse removes a client’s nasogastric (NG) tube according to the physician’s order. The nurse should watch for which complication after removing an NG tube?

You Selected:

•  Presence of bowel sounds

Correct response:

•  Abdominal distention

  Explanation:

  Remediation:

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Question 47    See full question

15s

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The nurse admits a client with Crohn’s disease who is experiencing an exacerbation. Which intervention should the nurse make a priority of care?

You Selected:

•  encouraging ambulation

Correct response:

•  promoting bowel rest

  Explanation:

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Question 54    See full question

53s

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A client experiences weight loss, abdominal distention, crampy abdominal pain, and intermittent diarrhea after the birth of her second child. Diagnostic tests reveal gluten-induced enteropathy. Which foods would the nurse instruct the client to eliminate from her diet permanently?

You Selected:

•  milk and dairy products

Correct response:

•  cereal grains (except rice and corn)

  Explanation:

  Remediation:

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Question 55    See full question

31s

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A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client’s plan of care?

You Selected:

•  Applying talcum powder to the irradiated areas daily after bathing

Correct response:

•  Avoiding using soap on the irradiated areas

  Explanation:

  Remediation:

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Question 59    See full question

17s

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A nurse is caring for a client with an ileostomy. What is the most common complication of this procedure?

You Selected:

•  Cholelithiasis

Correct response:

•  Peristomal skin irritation

  Explanation:

  Remediation:

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Question 61    See full question

51s

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One day after having a cesarean birth, a client reports incisional pain that she rates as a 3 on a 1-to-10 scale, with 10 representing the most severe pain. The physician prescribed ibuprofen (Motrin), 400 mg by mouth every 4 to 6 hours, as needed. Which intervention should the nurse take when administering this drug?

You Selected:

•  Obtain the client’s pulse rate before administering the drug.

Correct response:

•  Administer the drug with meals or milk.

  Explanation:

  Remediation:

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Question 64    See full question

19s

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The physician prescribes 20 units of U-100 regular insulin for a client. The only syringe available is a 1-ml tuberculin syringe. How many milliliters of insulin should the nurse administer?

You Selected:

•  2

Correct response:

•  0.2

  Explanation:

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Question 65    See full question

19s

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An otherwise healthy adolescent has meningitis and is receiving IV and oral fluids. The nurse should monitor this teen’s fluid balance to decrease the risk of what complication?

You Selected:

•  dehydration

Correct response:

•  cerebral edema

  Explanation:

  Remediation:

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Question 68    See full question

14s

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What medication would probably be ordered for the acutely aggressive schizophrenic client?

You Selected:

•  Amitriptyline

Correct response:

•  Haloperidol

  Explanation:

  Remediation:

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Question 69    See full question

20s

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The nurse collecting data on a client asks the client the meaning of the proverb “People in glass houses shouldn’t throw stones.” What is the nurse assessing by asking this question?

You Selected:

•  Comprehension

Correct response:

•  Concept formation

  Explanation:

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Question 72    See full question

1m 2s

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A nurse observes a medical student walk into a client’s room and begin questioning her about her current health status. The client appears reluctant to respond. How should the nurse intervene?

You Selected:

•  Encourage the client to cooperate with the medical student.

Correct response:

•  Explain to the client that she has the right to refuse to answer questions asked by the medical student.

  Explanation:

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Question 73    See full question

41s

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Propranolol 80 mg PO BID has been ordered by the health care provider. The nurse reinforces teaching of this medication. Which indicates teaching has been successful?

You Selected:

•  The client takes the medication with breakfast and dinner.

Correct response:

•  The client checks pulse for bradycardia.

  Explanation:

  Remediation:

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Question 79    See full question

46s

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A client at 42 weeks’ gestation is 3 cm dilated and 30% effaced with membranes intact and the fetus at +2 station. Fetal heart rate (FHR) is 140 to 150 beats/minute. After 2 hours, the nurse notes on the external fetal monitor that for the past 10 minutes, the FHR ranged from 160 to 190 beats/minute. The client states that her baby has been extremely active. Uterine contractions are strong, occurring every 3 to 4 minutes and lasting 40 to 60 seconds. The nurse suspects fetal hypoxia based on which finding?

You Selected:

•  excessively frequent contractions, with rapid fetal movement

Correct response:

•  excessive fetal activity and fetal ­tachy­cardia

  Explanation:

  Remediation:

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Question 82    See full question

40s

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A physician asks a nurse to witness an informed consent of a client scheduled for gastric bypass surgery. What should the nurse do?

You Selected:

•  Explain the procedure to the client before signing the consent.

Correct response:

•  Sign the consent only if she sees the client sign it.

  Explanation:

  Remediation:

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Question 83    See full question

17s

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A 12-year-old child with cystic fibrosis (CF) is prescribed pancrelipase for a trypsin deficiency. When reinforcing education with the child and parents, how does the nurse instruct them to administer the pancrelipase?

You Selected:

•  On an empty stomach

Correct response:

•  With meals and snacks

  Explanation:

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Question 86    See full question

12s

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Which intervention takes priority when caring for a neonate immediately after birth?

You Selected:

•  administering a vitamin K injection

Correct response:

•  covering the neonate’s head with a cap

  Explanation:

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Question 88    See full question

1m 2s

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A client is scheduled for an endoscopy. On admission, the nurse asks the client if he has an advance directive, and the client states, “No.” What should the nurse do next?

You Selected:

•  Advise the client that an advance directive is required before the procedure.

Correct response:

•  Provide the client with information about an advance directive.

  Explanation:

  Remediation:

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Question 90    See full question

12s

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A nurse is caring for a client with multiple myeloma. When assisting with the plan of care, which nursing intervention is most appropriate?

You Selected:

•  balancing rest and activity

Correct response:

•  preventing bone injury

  Explanation:

  Remediation:

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Question 92    See full question

19s

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A client has the following arterial blood gas values: pH, 7.30; PaO₂, 89 mm Hg; PaCO₂, 50 mm Hg; and HCO₃^–, 26 mEq/L. Which acid-base imbalance should the nurse anticipate based on these values?

You Selected:

•  Metabolic alkalosis

Correct response:

•  Respiratory acidosis

  Explanation:

  Remediation:

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Question 93    See full question

32s

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A client, age 43, has no family history of breast cancer or other risk factors for this disease. The nurse should instruct her to have a mammogram how often?

You Selected:

•  Twice per year

Correct response:

•  Once per year

  Explanation:

  Remediation:

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Question 94    See full question

15s

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A nurse is assisting with developing a care plan for a client with Hepatitis A. What is the main route of transmission of this virus?

You Selected:

•  blood

Correct response:

•  feces

  Explanation:

  Remediation:

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Question 100    See full question

18s

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The nurse is caring for a client experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. Which condition should the nurse suspect?

You Selected:

•  pulmonary embolism

Correct response:

•  heart failure

  Explanation:

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Question 102    See full question

1m 9s

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A client with diabetes who had a stroke has right-sided paralysis and incontinence and is in the rehabilitation center. Which action should be the nurse’s priority in caring for the client?

You Selected:

•  To conserve energy, maintain bed rest when the client is not in therapy.

Correct response:

•  Wash the client’s skin with soap and water, gently patting it dry.

  Explanation:

  Remediation:

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Question 103    See full question

47s

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An agitated client with left-sided heart failure reports increasing shortness of breath and coughs up pink-tinged, foamy sputum. The nurse should recognize these findings as signs and symptoms of which disorder?

You Selected:

•  right-sided heart failure

Correct response:

•  acute pulmonary edema

  Explanation:

  Remediation:

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Question 105    See full question

1m 56s

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A school-age child experiences symptoms of excessive polyphagia, polyuria, and weight loss. The physician diagnoses type I diabetes mellitus and admits the child to the facility for insulin regulation. The physician prescribes an insulin regimen of insulin (Humulin R) and isophane insulin (Humulin N) administered subcutaneously. How soon after administration can the nurse expect the regular insulin to begin to act?

You Selected:

•  1 to 2 hours

Correct response:

•  ½ to 1 hour

  Explanation:

  Remediation:

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Question 106    See full question

26s

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The nurse is observing pupillary responses from a client. Which method should the nurse use to evaluate pupil accommodation?

You Selected:

•  Have the client follow an object upward, downward, obliquely, and horizontally.

Correct response:

•  Observe for pupil constriction and convergence while focusing on an object coming toward the client.

  Explanation:

  Remediation:

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Question 107    See full question

29s

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The nurse is providing care for a child in traction. Which nursing action is a priority?

You Selected:

•  giving range of motion (ROM) to all joints, including those immediately proximal and distal to the fracture, every shift

Correct response:

•  assessing the pin sites every shift and as needed

  Explanation:

  Remediation:

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Question 108    See full question

1m 1s

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A single parent of a school-age child recently diagnosed with a growth hormone deficiency comments that the prescribed treatment plan seems very complicated. What is the best response from the nurse?

You Selected:

•  “I can teach you anything you need to know.”

Correct response:

•  “This must be a stressful time for you.”

  Explanation:

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Question 110    See full question

36s

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While examining a client’s leg, the nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressings is most appropriate for the nurse to apply?

You Selected:

•  Sterile petroleum gauze

Correct response:

•  Moist sterile saline gauze

  Explanation:

  Remediation:

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Question 112    See full question

26s

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A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. Based on this finding, the nurse would anticipate which test as the priority?

You Selected:

•  noninvasive arterial studies of the right leg

Correct response:

•  venous duplex ultrasound of the right leg

  Explanation:

  Remediation:

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Question 113    See full question

36s

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At a previous visit, the parents of an infant with cystic fibrosis received instruction in the administration of pancrelipase. At a follow-up visit, which finding suggests the need for further teaching?

You Selected:

•  Glucose in urine

Correct response:

•  Fatty stools

  Explanation:

  Remediation:

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Question 116    See full question

30s

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The nurse is caring for an 8-year old child with acute asthma. Which data collection finding should the nurse immediately report to the charge nurse?

You Selected:

•  The child’s respiratory rate is 24 breaths/minute.

Correct response:

•  During auscultation, breath sounds are diminished bilaterally and no wheezing is audible.

  Explanation:

  Remediation:

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Question 120    See full question

38s

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Which instructions should be included in the discharge teaching plan for a client after a thyroidectomy for Graves’ disease?

You Selected:

•  Keep an accurate record of intake and output.

Correct response:

•  Have regular follow-up care.

  Explanation:

  Remediation:

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Question 121    See full question

31s

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A pediatric nurse is providing discharge instructions for the family of a school-age child with idiopathic thrombocytopenia. Which activity should be restricted until further notice?

You Selected:

•  swimming

Correct response:

•  bicycle riding

  Explanation:

  Remediation:

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Question 123    See full question

22s

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An 8-year-old child is suspected of having meningitis. Signs of meningitis include:

You Selected:

•  Koplik spots.

Correct response:

•  Kernig’s sign.

  Explanation:

  Remediation:

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Question 125    See full question

18s

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The nurse advises a client recovering from a myocardial infarction to decrease fat and sodium intake. Which foods should the nurse instruct the client to avoid? Select all that apply.

•  

 pepperoni pizza

•  

 oatmeal

•  

 bacon

•  

 cheese

•  

 apple juice

•  

 soft drinks

Correct response: 

Incorrect response: 

Your selection: 

  Explanation:

  Remediation:

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Question 128    See full question

33s

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After collecting a urine specimen, which action by the nurse is most appropriate?

You Selected:

•  Keep the specimen in the refrigerator until it can be taken to the laboratory.

Correct response:

•  Take the specimen to the laboratory immediately.

  Explanation:

  Remediation:

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Question 129    See full question

29s

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The nurse just received the shift report on her group of clients. Based on the information she received, which client should she assess first?

You Selected:

•  A client with a temperature of 101° F (38.3° C)

Correct response:

•  A client who underwent a right nephrectomy yesterday and is complaining of pain

  Explanation:

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Question 131    See full question

2m 46s

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A pregnant client with diabetes is admitted to the labor unit. Which action by the nurse would be most appropriate for this situation?

You Selected:

•  Prepare the client for cesarean birth.

Correct response:

•  Ask the client about her most recent blood glucose levels.

  Explanation:

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Question 132    See full question

19s

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A preschool-age child underwent a tonsillectomy 4 hours ago. Which data collection finding would make the nurse suspect postoperative hemorrhage?

You Selected:

•  Vomiting of dark brown emesis

Correct response:

•  Frequent swallowing

  Explanation:

  Remediation:

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Question 133    See full question

32s

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A client with a history of epilepsy is admitted to the medical-surgical unit. While assisting the client from the bathroom, the nurse observes the start of a tonic-clonic seizure. Which nursing interventions are appropriate for this client? Select all that apply.

•  

 Assist the client to the floor.

•  

 Turn the client to the side.

•  

 Place a pillow under the client’s head.

•  

 Give the prescribed dose of oral phenytoin.

•  

 Insert an oral suction device to remove secretions in the mouth.

Correct response: 

Incorrect response: 

Your selection: 

  Explanation:

  Remediation:

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Question 134    See full question

30s

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Which client would be most at risk for secondary Parkinson disease caused by pharmacotherapy?

You Selected:

•  a 60-year-old client taking prednisone for chronic obstructive pulmonary disease (COPD)

Correct response:

•  a 30-year-old client with schizophrenia taking chlorpromazine

  Explanation:

  Remediation:

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Question 135    See full question

29s

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The nurse is observing a new mother interact with her baby for the first time approximately 1 hour after the baby’s birth. Upon receiving the baby, the mother begins to undress her baby. Which of the following should the nurse do?

You Selected:

•  Encourage the mother to rewrap the baby because the room is cold.

Correct response:

•  Anticipate and support the behavior as a normal part of bonding.

  Explanation:

  Remediation:

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Question 136    See full question

1m 13s

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The licensed practical nurse (LPN) is assigned to care for a 4-year-old child who had a Harrington rod inserted the day before and notices the client is receiving antibiotics by a syringe pump. The nurse is IV certified, but uncomfortable because they are unfamiliar with the equipment. What would be the best course of action?

You Selected:

•  Refuse the assignment for safety reasons.

Correct response:

•  Request in-service education for use of the ­syringe pump.

  Explanation:

  Remediation:

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Question 138  See full question

1m 55s

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The nurse is gathering vital signs on a client. Blood pressure reading is 180/100 mm Hg by electronic blood pressure cuff. Place in order the steps that should be taken.

You Selected:

•  Notify the RN.
•  Perform a manual blood pressure.
•  Wait 5 minutes.
•  Notify the health care provider.

Correct response:

•  Wait 5 minutes.
•  Perform a manual blood pressure.
•  Notify the RN.
•  Notify the health care provider.

  Explanation:

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Question 143    See full question

35s

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A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless, temporary change?

You Selected:

•  Redness of the upper part of the feet

Correct response:

•  Bluish urine

  Explanation:

  Remediation:

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Question 147    See full question

14s

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The nurse is caring for a child with symptomatic aortic stenosis. Which instruction should be provided to the child and parents.

You Selected:

•  Avoid digoxin and diuretics.

Correct response:

•  Restrict exercise.

  Explanation:

  Remediation:

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Question 148    See full question

23s

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The nurse is caring for a client who has suffered a severe stroke. During data collection, the nurse notices Cheyne-Stokes respirations. The client inquires about Cheyne-Stokes respirations. What information would the nurse include in her explanation?

You Selected:

•  “They are rapid, deep breaths with abrupt pauses between each breath.”

Correct response:

•  “They are progressively deeper breaths followed by shallower breaths with apneic periods.”

  Explanation:

  Remediation:

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Question 149    See full question

30s

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A nurse is caring for a client who underwent a nephrectomy. While gathering data about client’s response to the surgery, the nurse should stay alert for which signs and symptoms of hemorrhage?

You Selected:

•  restlessness, confusion, increased urine output, and warm, dry skin

Correct response:

•  weak, irregular pulse; cool, moist skin; and hypotension

  Explanation:

  Remediation:

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Question 150    See full question

5s

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A nurse is caring for a client who was admitted to the intensive care unit with a diagnosis of respiratory failure. Arterial blood gases are as follows: pH 7.28, PCO2 54 mm Hg, and HCO3– 25 mEq/L, PO2 55, O 2 saturation 89%. What does the nurse determine the results indicate?

You Selected:

•  respiratory alkalosis

Correct response:

•  respiratory acidosis

  Explanation:Add a Note