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A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

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250 questions, answers, and explanations are offered in this sample exam from the 2013 edition of NCLEX-RN Exam Cram.

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  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Body temperature of 99°F or less

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Toes moved in active range of motion

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Sensation reported when soles of feet are touched

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Capillary refill of < 3 seconds

    Quick Answer: 223

    Detailed Answer: 225

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Side-lying with knees flexed

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Knee-chest

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    High Fowler’s with knees flexed

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Semi-Fowler’s with legs extended on the bed

    Quick Answer: 223

    Detailed Answer: 225

  • A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Taking hourly blood pressures with mechanical cuff

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Encouraging fluid intake of at least 200mL per hour

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Position in high Fowler’s with knee gatch raised

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Administering Tylenol as ordered

    Quick Answer: 223

    Detailed Answer: 225

  • Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Steak

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Cottage cheese

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Popsicle

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Lima beans

    Quick Answer: 223

    Detailed Answer: 225

  • 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?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Adjust the room temperature

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Give a bolus of IV fluids

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Start O2

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Administer meperidine (Demerol) 75mg IV push

    Quick Answer: 223

    Detailed Answer: 225

  • The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Roast beef, gelatin salad, green beans, and peach pie

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Chicken salad sandwich, coleslaw, French fries, ice cream

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Pork chop, creamed potatoes, corn, and coconut cake

    Quick Answer: 223

    Detailed Answer: 225

  • Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    A family vacation in the Rocky Mountains

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Chaperoning the local boys club on a snow-skiing trip

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Traveling by airplane for business trips

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    A bus trip to the Museum of Natural History

    Quick Answer: 223

    Detailed Answer: 225

  • The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which finding reinforces the diagnosis of B12 deficiency?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Enlarged spleen

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Elevated blood pressure

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Bradycardia

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Beefy tongue

    Quick Answer: 223

    Detailed Answer: 225

  • The body part that would most likely display jaundice in the dark-skinned individual is the:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Conjunctiva of the eye

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Soles of the feet

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Roof of the mouth

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Shins

    Quick Answer: 223

    Detailed Answer: 225

  • 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?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    BP 146/88

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Respirations 28 shallow

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Weight gain of 10 pounds in six months

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Pink complexion

    Quick Answer: 223

    Detailed Answer: 226

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    “I will drink 500mL of fluid or less each day.”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    “I will wear support hose.”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    “I will check my blood pressure regularly.”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    “I will report ankle edema.”

    Quick Answer: 223

    Detailed Answer: 226

  • 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?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    The client collects stamps as a hobby.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    The client recently lost his job as a postal worker.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    The client had radiation for treatment of Hodgkin’s disease as a teenager.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    The client’s brother had leukemia as a child.

    Quick Answer: 223

    Detailed Answer: 226

  • Where is the best site for examining for the presence of petechiae in an African American client?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    The abdomen

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    The thorax

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    The earlobes

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    The soles of the feet

    Quick Answer: 223

    Detailed Answer: 226

  • The client is being evaluated for possible acute leukemia. Which inquiry by the nurse is most important?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    “Have you noticed a change in sleeping habits recently?”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    “Have you had a respiratory infection in the last six months?”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    “Have you lost weight recently?”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    “Have you noticed changes in your alertness?”

    Quick Answer: 223

    Detailed Answer: 226

  • Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Oral mucous membrane, altered related to chemo-therapy

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Risk for injury related to thrombocytopenia

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Fatigue related to the disease process

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Interrupted family processes related to life-threatening illness of a family member

    Quick Answer: 223

    Detailed Answer: 226

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Sexual dysfunction related to radiation therapy

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Anticipatory grieving related to terminal illness

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Tissue integrity related to prolonged bed rest

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Fatigue related to chemotherapy

    Quick Answer: 223

    Detailed Answer: 226

  • A client has autoimmune thrombocytopenic purpura. To determine the client’s response to treatment, the nurse would monitor:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Platelet count

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    White blood cell count

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Potassium levels

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Partial prothrombin time (PTT)

    Quick Answer: 223

    Detailed Answer: 226

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Bleeding precautions

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Prevention of falls

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Oxygen therapy

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Conservation of energy

    Quick Answer: 223

    Detailed Answer: 226

  • The client has surgery for removal of a Prolactinoma. Which of the following interventions would be appropriate for this client?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Place the client in Trendelenburg position for postural drainage.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Encourage coughing and deep breathing every two hours.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Elevate the head of the bed 30°.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Encourage the Valsalva maneuver for bowel movements.

    Quick Answer: 223

    Detailed Answer: 226

  • The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Measure the urinary output.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Check the vital signs.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Encourage increased fluid intake.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Weigh the client.

    Quick Answer: 223

    Detailed Answer: 227

  • A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Place the client in a sitting position.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Administer acetaminophen (Tylenol).

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Pinch the soft lower part of the nose.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Apply ice packs to the forehead.

    Quick Answer: 223

    Detailed Answer: 227

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    The blood pressure

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    The temperature

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    The urinary output

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    The specific gravity of the urine

    Quick Answer: 223

    Detailed Answer: 227

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Glucometer readings as ordered

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Intake/output measurements

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Evaluating the sodium and potassium levels

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Daily weights

    Quick Answer: 223

    Detailed Answer: 227

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Obtain a crash cart.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Check the calcium level.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Assess the dressing for drainage.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Assess the blood pressure for hypertension.

    Quick Answer: 223

    Detailed Answer: 227

  • 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?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Impaired physical mobility related to decreased endurance

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Hypothermia r/t decreased metabolic rate

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Disturbed thought processes r/t interstitial edema

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Decreased cardiac output r/t bradycardia

    Quick Answer: 223

    Detailed Answer: 227

  • 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)?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Report muscle weakness to the physician.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Allow six months for the drug to take effect.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Take the medication with fruit juice.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Report difficulty sleeping.

    Quick Answer: 223

    Detailed Answer: 227

  • The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During administration, the nurse should:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Utilize an infusion pump.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Check the blood glucose level.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Place the client in Trendelenburg position.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Cover the solution with foil.

    Quick Answer: 223

    Detailed Answer: 227

  • 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?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Blood pressure of 126/80

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Blood glucose of 110mg/dL

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Heart rate of 60bpm

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Respiratory rate of 30 per minute

    Quick Answer: 223

    Detailed Answer: 227

  • The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Replenish his supply every three months.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Take one every 15 minutes if pain occurs.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Leave the medication in the brown bottle.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Crush the medication and take with water.

    Quick Answer: 223

    Detailed Answer: 228

  • The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Macaroni and cheese

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Shrimp with rice

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Turkey breast

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Spaghetti with meat sauce

    Quick Answer: 223

    Detailed Answer: 228

  • The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Feet

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Neck

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Hands

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Sacrum

    Quick Answer: 223

    Detailed Answer: 228

  • The nurse is checking the client’s central venous pressure. The nurse should place the zero of the manometer at the:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Phlebostatic axis

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    PMI

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Erb’s point

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Tail of Spence

    Quick Answer: 223

    Detailed Answer: 228

  • The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Question the order.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Administer the medications.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Administer separately.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Contact the pharmacy.

    Quick Answer: 223

    Detailed Answer: 228

  • The best method of evaluating the amount of peripheral edema is:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Weighing the client daily

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Measuring the extremity

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Measuring the intake and output

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Checking for pitting

    Quick Answer: 223

    Detailed Answer: 228

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Overnight stays by family members is against hospital policy.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    There is no need for him to stay because staffing is adequate.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    His wife will rest much better knowing that he is at home.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Visitation is limited to 30 minutes when the implant is in place.

    Quick Answer: 223

    Detailed Answer: 228

  • The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Roast beef sandwich, potato chips, pickle spear, iced tea

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Split pea soup, mashed potatoes, pudding, milk

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Tomato soup, cheese toast, Jello, coffee

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Hamburger, baked beans, fruit cup, iced tea

    Quick Answer: 223

    Detailed Answer: 228

  • 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?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    “I will make sure I eat breakfast within 10 minutes of taking my insulin.”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    “I will need to carry candy or some form of sugar with me all the time.”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    “I will eat a snack around three o’clock each afternoon.”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    “I can save my dessert from supper for a bedtime snack.”

    Quick Answer: 223

    Detailed Answer: 229

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    New parents need time to learn how to hold the baby.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    The umbilical cord needs time to separate.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Newborn skin is easily traumatized by washing.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    The chance of chilling the baby outweighs the benefits of bathing.

    Quick Answer: 223

    Detailed Answer: 229

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Treat iron-deficiency anemia caused by chemotherapeutic agents

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Create a synergistic effect that shortens treatment time

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Increase the number of circulating neutrophils

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Reverse drug toxicity and prevent tissue damage

    Quick Answer: 223

    Detailed Answer: 229

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Hib titer

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Mumps vaccine

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Hepatitis B vaccine

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    MMR

    Quick Answer: 223

    Detailed Answer: 229

  • The physician has prescribed Nexium (esomeprazole) for a client with erosive gastritis. The nurse should administer the medication:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    30 minutes before a meal

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    With each meal

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    In a single dose at bedtime

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    30 minutes after meals

    Quick Answer: 223

    Detailed Answer: 229

  • 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?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Call security for assistance and prepare to sedate the client.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Tell the client to calm down and ask him if he would like to play cards.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Tell the client that if he continues his behavior he will be punished.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Leave the client alone until he calms down.

    Quick Answer: 223

    Detailed Answer: 229

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Check the client for bladder distention.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Assess the blood pressure for hypotension.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Determine whether an oxytocic drug was given.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Check for the expulsion of small clots.

    Quick Answer: 223

    Detailed Answer: 229

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Pneumonia

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Reaction to antiviral medication

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Tuberculosis

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Superinfection due to low CD4 count

    Quick Answer: 223

    Detailed Answer: 229

  • 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?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Diabetes

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Prinzmetal’s angina

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Cancer

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Cluster headaches

    Quick Answer: 223

    Detailed Answer: 229

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Pain on flexion of the hip and knee

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Nuchal rigidity on flexion of the neck

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Pain when the head is turned to the left side

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Dizziness when changing positions

    Quick Answer: 223

    Detailed Answer: 229

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Agnosia

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Apraxia

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Anomia

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Aphasia

    Quick Answer: 223

    Detailed Answer: 229

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Chronic fatigue syndrome

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Normal aging

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Sundowning

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Delusions

    Quick Answer: 223

    Detailed Answer: 230

  • 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?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    “You know you had breakfast 30 minutes ago.”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    “I am so sorry that they didn’t get you breakfast. I’ll report it to the charge nurse.”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    “I’ll get you some juice and toast. Would you like something else?”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    “You will have to wait a while; lunch will be here in a little while.”

    Quick Answer: 223

    Detailed Answer: 230

  • The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer’s disease. Which side effect is most often associated with this drug?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Urinary incontinence

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Headaches

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Confusion

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Nausea

    Quick Answer: 223

    Detailed Answer: 230

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Document the finding.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Report the finding to the doctor.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Prepare the client for a C-section.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Continue primary care as prescribed.

    Quick Answer: 223

    Detailed Answer: 230

  • A client with a diagnosis of HPV is at risk for which of the following?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Hodgkin’s lymphoma

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Cervical cancer

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Multiple myeloma

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Ovarian cancer

    Quick Answer: 223

    Detailed Answer: 230

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Syphilis

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Herpes

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Gonorrhea

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Condylomata

    Quick Answer: 223

    Detailed Answer: 230

  • A client visiting a family planning clinic is suspected of having an STI. The best diagnostic test for treponema pallidum is:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Venereal Disease Research Lab (VDRL)

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Rapid plasma reagin (RPR)

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Fluorescent treponemal antibody (FTA)

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Thayer-Martin culture (TMC)

    Quick Answer: 223

    Detailed Answer: 230

  • A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Elevated blood glucose

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Elevated platelet count

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Elevated creatinine clearance

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Elevated hepatic enzymes

    Quick Answer: 223

    Detailed Answer: 230

  • The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    The nurse loosely suspends the client’s arm in an open hand while tapping the back of the client’s elbow.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist.

    Quick Answer: 223

    Detailed Answer: 230

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Magnesium sulfate 4gm (25%) IV

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Brethine 10mcg IV

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Stadol 1mg IV push every 4 hours as needed prn for pain

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Ancef 2gm IVPB every 6 hours

    Quick Answer: 223

    Detailed Answer: 230

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    The infant is at low risk for congenital anomalies.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    The infant is at high risk for intrauterine growth retardation.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    The infant is at high risk for respiratory distress syndrome.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    The infant is at high risk for birth trauma.

    Quick Answer: 223

    Detailed Answer: 231

  • Which observation in the newborn of a diabetic mother would require immediate nursing intervention?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Crying

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Wakefulness

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Jitteriness

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Yawning

    Quick Answer: 223

    Detailed Answer: 231

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Decreased urinary output

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Hypersomnolence

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Absence of knee jerk reflex

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Decreased respiratory rate

    Quick Answer: 223

    Detailed Answer: 231

  • The client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension, the nurse would:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Place her in Trendelenburg position.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Decrease the rate of IV infusion.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Administer oxygen per nasal cannula.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Increase the rate of the IV infusion.

    Quick Answer: 223

    Detailed Answer: 231

  • A client has cancer of the pancreas. The nurse should be most concerned about which nursing diagnosis?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Alteration in nutrition

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Alteration in bowel elimination

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Alteration in skin integrity

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Ineffective individual coping

    Quick Answer: 223

    Detailed Answer: 231

  • The nurse is caring for a client with uremic frost. The nurse is aware that uremic frost is often seen in clients with:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Severe anemia

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Arteriosclerosis

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Liver failure

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Parathyroid disorder

    Quick Answer: 223

    Detailed Answer: 231

  • 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?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Alteration in cerebral tissue perfusion

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Fluid volume deficit

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Ineffective airway clearance

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Alteration in sensory perception

    Quick Answer: 223

    Detailed Answer: 231

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Likes to play football

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Drinks carbonated drinks

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Has two sisters

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Is taking acetaminophen for pain

    Quick Answer: 223

    Detailed Answer: 231

  • 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?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Allow the client to keep the fruit.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Place the fruit next to the bed for easy access by the client.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Offer to wash the fruit for the client.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Ask the family members to take the fruit home.

    Quick Answer: 223

    Detailed Answer: 231

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Place the client in Trendelenburg position.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Increase the infusion of normal saline.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Administer atropine intravenously.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Move the emergency cart to the bedside.

    Quick Answer: 223

    Detailed Answer: 231

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Order a chest x-ray.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Reinsert the tube.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Cover the insertion site with a Vaseline gauze.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Call the doctor.

    Quick Answer: 223

    Detailed Answer: 231

  • 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?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Assess for signs of abnormal bleeding.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Anticipate an increase in the Coumadin dosage.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Instruct the client regarding the drug therapy.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Increase the frequency of neurological assessments.

    Quick Answer: 223

    Detailed Answer: 231

  • Which selection would provide the most calcium for the client who is four months pregnant?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    A granola bar

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    A bran muffin

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    A cup of yogurt

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    A glass of fruit juice

    Quick Answer: 223

    Detailed Answer: 232

  • 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?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    The nurse performs a vaginal exam every 30 minutes.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    The nurse places a padded tongue blade at the bedside.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    The nurse inserts a Foley catheter.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    The nurse darkens the room.

    Quick Answer: 223

    Detailed Answer: 232

  • The best size cathlon for administration of a blood transfusion to a six-year-old is:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    18 gauge

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    19 gauge

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    22 gauge

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    20 gauge

    Quick Answer: 223

    Detailed Answer: 232

  • 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?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Hypovolemia

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Laryngeal edema

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Hypernatremia

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Hyperkalemia

    Quick Answer: 223

    Detailed Answer: 232

  • The client has recently been diagnosed with diabetes. Which of the following indicates understanding of the management of diabetes?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    The client selects a balanced diet from the menu.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    The client can tell the nurse the normal blood glucose level.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    The client asks for brochures on the subject of diabetes.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    The client demonstrates correct insulin injection technique.

    Quick Answer: 223

    Detailed Answer: 232

  • The client is admitted following cast application for a fractured ulna. Which finding should be reported to the doctor?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Pain at the site

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Warm fingers

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Pulses rapid

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Paresthesia of the fingers

    Quick Answer: 223

    Detailed Answer: 232

  • The client with AIDS should be taught to:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Avoid warm climates.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Refrain from taking herbals.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Avoid exercising.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Report any changes in skin color.

    Quick Answer: 223

    Detailed Answer: 232

  • Which action by the healthcare worker indicates a need for further teaching?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    The nursing assistant ambulates the elderly client using a gait belt.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    The nurse wears goggles while performing a veno-puncture.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    The nurse washes his hands after changing a dressing.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    The nurse wears gloves to monitor the IV infusion rate.

    Quick Answer: 223

    Detailed Answer: 232

  • The client is having electroconvulsive therapy for treatment of severe depression. Prior to the ECT, the nurse should:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Apply a tourniquet to the client’s arm.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Administer an anticonvulsant medication.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Ask the client if he is allergic to shellfish.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Apply a blood pressure cuff to the arm.

    Quick Answer: 223

    Detailed Answer: 232

  • The five-year-old is being tested for enterobiasis (pinworms). Which symptom is associated with enterobiasis?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Rectal itching

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Nausea

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Oral ulcerations

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Scalp itching

    Quick Answer: 223

    Detailed Answer: 232

  • The nurse is teaching the mother regarding treatment for pedicalosis capitis. Which instruction should be given regarding the medication?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Treatment is not recommended for children less than 10 years of age.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Bed linens should be washed in hot water.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Medication therapy will continue for one year.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Intravenous antibiotic therapy will be ordered.

    Quick Answer: 223

    Detailed Answer: 232

  • The registered nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    The client with HIV

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    The client with a radium implant for cervical cancer

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    The client with RSV (respiratory synctial virus)

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    The client with cytomegalovirus

    Quick Answer: 223

    Detailed Answer: 232

  • The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    The client with methicillin resistant-staphylococcus aureas (MRSA)

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    The client with diabetes

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    The client with pancreatitis

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    The client with Addison’s disease

    Quick Answer: 223

    Detailed Answer: 232

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Negligence

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Tort

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Assault

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Malpractice

    Quick Answer: 223

    Detailed Answer: 233

  • Which assignment should not be performed by the nursing assistant?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Feeding the client

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Bathing the client

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Obtaining a stool

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Administering a fleet enema

    Quick Answer: 223

    Detailed Answer: 233

  • The mother calls the clinic to report that her newborn has a rash on his forehead and face. Which action is most appropriate?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Tell the mother to wash the face with soap and apply powder.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Tell her that 30% of newborns have a rash that will go away by one month of life.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Report the rash to the doctor immediately.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Ask the mother if anyone else in the family has had a rash in the last six months.

    Quick Answer: 223

    Detailed Answer: 233

  • Which nurse should not be assigned to care for the client with a radium implant for vaginal cancer?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    The LPN who is six months postpartum

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    The RN who is pregnant

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    The RN who is allergic to iodine

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    The RN with a three-year-old at home

    Quick Answer: 223

    Detailed Answer: 233

  • Which information should be reported to the state Board of Nursing?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    The facility fails to provide literature in both Spanish and English.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    The narcotic count has been incorrect on the unit for the past three days.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    The client fails to receive an itemized account of his bills and services received during his hospital stay.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath.

    Quick Answer: 223

    Detailed Answer: 233

  • The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Call the Board of Nursing.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    File a formal reprimand.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Terminate the nurse.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Charge the nurse with a tort.

    Quick Answer: 223

    Detailed Answer: 233

  • The home health nurse is planning for the day’s visits. Which client should be seen first?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    The 78-year-old who had a gastrectomy three weeks ago and has a PEG tube

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    The five-month-old discharged one week ago with pneumonia who is being treated with amoxicillin liquid suspension

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    The 50-year-old with MRSA being treated with Vancomycin via a PICC line

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter

    Quick Answer: 223

    Detailed Answer: 233

  • 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?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    A client having auditory hallucinations and the client with ulcerative colitis

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    The client who is pregnant and the client with a broken arm

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    A child who is cyanotic with severe dypsnea and a client with a frontal head injury

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    The client who arrives with a large puncture wound to the abdomen and the client with chest pain

    Quick Answer: 223

    Detailed Answer: 233

  • Before administering eardrops to a toddler, the nurse should recognize that it is essential to consider which of the following?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    The age of the child

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    The child’s weight

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    The developmental level of the child

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    The IQ of the child

    Quick Answer: 223

    Detailed Answer: 233

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    “It is okay to give my child white grape juice for breakfast.”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    “My child can have a grilled cheese sandwich for lunch.”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    “We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch.”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    “For a snack, my child can have ice cream.”

    Quick Answer: 223

    Detailed Answer: 233

  • A client with AIDS has a viral load of 200 copies per ml. The nurse should interpret this finding as:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    The client is at risk for opportunistic diseases.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    The client is no longer communicable.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    The client’s viral load is extremely low so he is relatively free of circulating virus.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    The client’s T-cell count is extremely low.

    Quick Answer: 223

    Detailed Answer: 233

  • The client has an order for sliding scale insulin at 1900 hours and Lantus insulin at the same hour. The nurse should:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Administer the two medications together.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Administer the medications in two injections.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Draw up the Lantus insulin and then the regular insulin and administer them together.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Contact the doctor because these medications should not be given to the same client.

    Quick Answer: 223

    Detailed Answer: 234

  • A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Altered nutrition

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Impaired communication

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Risk for injury/aspiration

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Altered urinary elimination

    Quick Answer: 223

    Detailed Answer: 234

  • What would the nurse expect the admitting assessment to reveal in a client with glomerulonephritis?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Hypertension

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Lassitude

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Fatigue

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Vomiting and diarrhea

    Quick Answer: 223

    Detailed Answer: 234

  • Which action is contraindicated in the client with epiglottis?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Ambulation

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Oral airway assessment using a tongue blade

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Placing a blood pressure cuff on the arm

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Checking the deep tendon reflexes.

    Quick Answer: 223

    Detailed Answer: 234

  • A 25-year-old client with a goiter is admitted to the unit. What would the nurse expect the admitting assessment to reveal?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Slow pulse

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Anorexia

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Bulging eyes

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Weight gain

    Quick Answer: 223

    Detailed Answer: 234

  • Which of the following foods, if selected by the mother with a child with celiac, would indicate her understanding of the dietary instructions?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Whole-wheat toast

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Angel hair pasta

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Reuben on rye

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Rice cereal

    Quick Answer: 223

    Detailed Answer: 234

  • The first action that the nurse should take if she finds the client has an O2 saturation of 68% is:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Elevate the head.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Recheck the O2 saturation in 30 minutes.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Apply oxygen by mask.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Assess the heart rate.

    Quick Answer: 223

    Detailed Answer: 234

  • Which observation would the nurse expect to make after an amniotomy?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Dark yellow amniotic fluid

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Clear amniotic fluid

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Greenish amniotic fluid

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Red amniotic fluid

    Quick Answer: 223

    Detailed Answer: 234

  • The client taking Glyburide (Diabeta) should be cautioned to:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Avoid eating sweets.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Report changes in urinary pattern.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Allow three hours for onset.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Check the glucose daily.

    Quick Answer: 223

    Detailed Answer: 234

  • The obstetric client’s fetal heart rate is 80–90 during the contractions. The first action the nurse should take is:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Reposition the monitor.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Turn the client to her left side.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Ask the client to ambulate.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Prepare the client for delivery.

    Quick Answer: 223

    Detailed Answer: 234

  • Arterial ulcers are best described as ulcers that:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Are smooth in texture

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Have irregular borders

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Are cool to touch

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Are painful to touch

    Quick Answer: 223

    Detailed Answer: 234

  • A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Anticipate the need for a Caesarean section.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Apply an internal fetal monitor.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Place the client in Genu Pectoral position.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Perform an ultrasound.

    Quick Answer: 223

    Detailed Answer: 234

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    The cervix is closed.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    The membranes are still intact.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    The fetal heart tones are within normal limits.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    The contractions are intense enough for insertion of an internal monitor.

    Quick Answer: 223

    Detailed Answer: 234

  • 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?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Impaired gas exchange related to hyperventilation

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Alteration in placental perfusion related to maternal position

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Impaired physical mobility related to fetal-monitoring equipment

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Potential fluid volume deficit related to decreased fluid intake

    Quick Answer: 223

    Detailed Answer: 235

  • As the client reaches 6cm dilation, the nurse notes late decelerations on the fetal monitor. What is the most likely explanation of this pattern?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    The baby is sleeping.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    The umbilical cord is compressed.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    There is head compression.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    There is uteroplacental insufficiency.

    Quick Answer: 223

    Detailed Answer: 235

  • The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Notify her doctor.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Start an IV.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Reposition the client.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Readjust the monitor.

    Quick Answer: 223

    Detailed Answer: 235

  • Which of the following is a characteristic of an ominous periodic change in the fetal heart rate?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    A fetal heart rate of 120–130bpm

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    A baseline variability of 6–10bpm

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Accelerations in FHR with fetal movement

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    A recurrent rate of 90–100bpm at the end of the contractions

    Quick Answer: 223

    Detailed Answer: 235

  • The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    The bladder fills more rapidly because of the medication used for the epidural.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Her level of consciousness is such that she is in a trancelike state.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    The sensation of the bladder filling is diminished or lost.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    She is embarrassed to ask for the bedpan that frequently.

    Quick Answer: 223

    Detailed Answer: 235

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Estrogen levels are low

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Lutenizing hormone is high

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    The endometrial lining is thin

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    The progesterone level is low

    Quick Answer: 223

    Detailed Answer: 235

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Age of the client

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Frequency of intercourse

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Regularity of the menses

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Range of the client’s temperature

    Quick Answer: 223

    Detailed Answer: 235

  • 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?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Intrauterine device

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Oral contraceptives

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Diaphragm

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Contraceptive sponge

    Quick Answer: 223

    Detailed Answer: 235

  • The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a diagnosis of a ruptured ectopic pregnancy?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Painless vaginal bleeding

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Abdominal cramping

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Throbbing pain in the upper quadrant

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Sudden, stabbing pain in the lower quadrant

    Quick Answer: 223

    Detailed Answer: 235

  • 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?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Hamburger patty, green beans, French fries, and iced tea

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Roast beef sandwich, potato chips, baked beans, and cola

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Baked chicken, fruit cup, potato salad, coleslaw, yogurt, and iced tea

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Fish sandwich, gelatin with fruit, and coffee

    Quick Answer: 223

    Detailed Answer: 236

  • The client with hyperemesis gravidarum is at risk for developing:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Respiratory alkalosis without dehydration

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Metabolic acidosis with dehydration

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Respiratory acidosis without dehydration

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Metabolic alkalosis with dehydration

    Quick Answer: 223

    Detailed Answer: 236

  • A client tells the doctor that she is about 20 weeks pregnant. The most definitive sign of pregnancy is:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Elevated human chorionic gonadatropin

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    The presence of fetal heart tones

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Uterine enlargement

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Breast enlargement and tenderness

    Quick Answer: 223

    Detailed Answer: 236

  • The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to be:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Hypoglycemic, small for gestational age

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Hyperglycemic, large for gestational age

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Hypoglycemic, large for gestational age

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Hyperglycemic, small for gestational age

    Quick Answer: 223

    Detailed Answer: 236

  • Which of the following instructions should be included in the nurse’s teaching regarding oral contraceptives?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Weight gain should be reported to the physician.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    An alternate method of birth control is needed when taking antibiotics.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    If the client misses one or more pills, two pills should be taken per day for one week.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Changes in the menstrual flow should be reported to the physician.

    Quick Answer: 223

    Detailed Answer: 236

  • The nurse is discussing breastfeeding with a postpartum client. Breastfeeding is contraindicated in the postpartum client with:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Diabetes

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    HIV

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Hypertension

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Thyroid disease

    Quick Answer: 224

    Detailed Answer: 236

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Assess the fetal heart tones.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Check for cervical dilation.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Check for firmness of the uterus.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Obtain a detailed history.

    Quick Answer: 224

    Detailed Answer: 236

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Her contractions are two minutes apart.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    She has back pain and a bloody discharge.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    She experiences abdominal pain and frequent urination.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Her contractions are five minutes apart.

    Quick Answer: 224

    Detailed Answer: 236

  • 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?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Low birth weight

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Large for gestational age

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Preterm birth, but appropriate size for gestation

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Growth retardation in weight and length

    Quick Answer: 224

    Detailed Answer: 237

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Within 72 hours of delivery

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Within one week of delivery

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Within two weeks of delivery

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Within one month of delivery

    Quick Answer: 224

    Detailed Answer: 237

  • After the physician performs an amniotomy, the nurse’s first action should be to assess the:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Degree of cervical dilation

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Fetal heart tones

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Client’s vital signs

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Client’s level of discomfort

    Quick Answer: 224

    Detailed Answer: 237

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Active

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Latent

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Transition

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Early

    Quick Answer: 224

    Detailed Answer: 237

  • A newborn with narcotic abstinence syndrome is admitted to the nursery. Nursing care of the newborn should include:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Teaching the mother to provide tactile stimulation

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Wrapping the newborn snugly in a blanket

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Placing the newborn in the infant seat

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Initiating an early infant-stimulation program

    Quick Answer: 224

    Detailed Answer: 237

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Checking for cervical dilation

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Placing the client in a supine position

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Checking the client’s blood pressure

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Obtaining a fetal heart rate

    Quick Answer: 224

    Detailed Answer: 237

  • The nurse is aware that the best way to prevent post-operative wound infection in the surgical client is to:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Administer a prescribed antibiotic.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Wash her hands for two minutes before care.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Wear a mask when providing care.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Ask the client to cover her mouth when she coughs.

    Quick Answer: 224

    Detailed Answer: 237

  • The elderly client is admitted to the emergency room. Which symptom is the client with a fractured hip most likely to exhibit?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Pain

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Disalignment

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Cool extremity

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Absence of pedal pulses

    Quick Answer: 224

    Detailed Answer: 237

  • The nurse knows that a 60-year-old female client’s susceptibility to osteoporosis is most likely related to:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Lack of exercise

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Hormonal disturbances

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Lack of calcium

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Genetic predisposition

    Quick Answer: 224

    Detailed Answer: 237

  • 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?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    The infant no longer complains of pain.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    The buttocks are 15° off the bed.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    The legs are suspended in the traction.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    The pins are secured within the pulley.

    Quick Answer: 224

    Detailed Answer: 238

  • Which statement is true regarding balanced skeletal traction? Balanced skeletal traction:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Uses a Steinman pin

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Requires that both legs be secured

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Utilizes Kirschner wires

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Is used primarily to heal the fractured hips

    Quick Answer: 224

    Detailed Answer: 238

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Serum collection (Davol) drain

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Client’s pain

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Nutritional status

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Immobilizer

    Quick Answer: 224

    Detailed Answer: 238

  • Which statement made by the family member caring for the client with a percutaneous gastrostomy tube indicates understanding of the nurse’s teaching?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    “I must flush the tube with water after feedings and clamp the tube.”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    “I must check placement four times per day.”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    “I will report to the doctor any signs of indigestion.”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    “If my father is unable to swallow, I will discontinue the feeding and call the clinic.”

    Quick Answer: 224

    Detailed Answer: 238

  • The nurse is assessing the client with a total knee replacement two hours post-operative. Which information requires notification of the doctor?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Scant bleeding on the dressing

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Low-grade temperature

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Hemoglobin of 7gm

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    The urinary output has been 120ml during the last hour

    Quick Answer: 224

    Detailed Answer: 238

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    The client has traveled out of the country in the last six months.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    The client’s parents are skilled stained-glass artists.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    The client lives in a house built in 1990.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    The client has several brothers and sisters.

    Quick Answer: 224

    Detailed Answer: 238

  • 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?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    High-seat commode

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Recliner

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    TENS unit

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Abduction pillow

    Quick Answer: 224

    Detailed Answer: 238

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Administer oxygen via nasal cannula.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Have narcan (naloxane) available.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Prepare to administer blood products.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Prepare to do cardioresuscitation.

    Quick Answer: 224

    Detailed Answer: 238

  • Which roommate would be most suitable for the six-year-old male with a fractured femur in Russell’s traction?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    16-year-old female with scoliosis

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    12-year-old male with a fractured femur

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    10-year-old male with sarcoma

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    6-year-old male with osteomylitis

    Quick Answer: 224

    Detailed Answer: 239

  • A client with osteoarthritis has a prescription for Celebrex (celecoxib). Which instruction should be included in the discharge teaching?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Take the medication with milk.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Report chest pain.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Remain upright after taking for 30 minutes.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Allow six weeks for optimal effects.

    Quick Answer: 224

    Detailed Answer: 239

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Handles the cast with the fingertips

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Petals the cast

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Dries the cast with a hair dryer

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Allows 24 hours before bearing weight

    Quick Answer: 224

    Detailed Answer: 239

  • 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?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    “It will be alright for your friends to autograph the cast.”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    “Because the cast is made of plaster, autographing can weaken the cast.”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    “If they don’t use chalk to autograph, it is okay.”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    “Autographing or writing on the cast in any form will harm the cast.”

    Quick Answer: 224

    Detailed Answer: 239

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Assisting the LPN with opening sterile packages and peroxide

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Telling the LPN that clean gloves are allowed

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Telling the LPN that the registered nurse should perform pin care

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Asking the LPN to clean the weights and pulleys with peroxide

    Quick Answer: 224

    Detailed Answer: 239

  • A child with scoliosis has a spica cast applied. Which action specific to the spica cast should be taken?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Check the bowel sounds.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Assess the blood pressure.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Offer pain medication.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Check for swelling.

    Quick Answer: 224

    Detailed Answer: 239

  • The client with a cervical fracture is placed in traction. Which type of traction will be utilized at the time of discharge?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Russell’s traction

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Buck’s traction

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Halo traction

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Crutchfield tong traction

    Quick Answer: 224

    Detailed Answer: 239

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    “Use of the CPM will permit the client to ambulate during the therapy.”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    “The CPM machine controls should be positioned distal to the site.”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    “If the client complains of pain during the therapy, I will turn off the machine and call the doctor.”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    “Use of the CPM machine will alleviate the need for physical therapy after the client is discharged.”

    Quick Answer: 224

    Detailed Answer: 239

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Palms rest lightly on the handles

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Elbows are flexed 0°

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Client walks to the front of the walker

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Client carries the walker

    Quick Answer: 224

    Detailed Answer: 240

  • When assessing a laboring client, the nurse finds a prolapsed cord. The nurse should:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Attempt to replace the cord.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Place the client on her left side.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Elevate the client’s hips.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Cover the cord with a dry, sterile gauze.

    Quick Answer: 224

    Detailed Answer: 240

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    The tube will allow for equalization of the lung expansion.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Chest tubes serve as a method of draining blood and serous fluid and assist in reinflating the lungs.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Chest tubes relieve pain associated with a collapsed lung.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Chest tubes assist with cardiac function by stabilizing lung expansion.

    Quick Answer: 224

    Detailed Answer: 240

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Mother’s educational level

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Infant’s birth weight

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Size of the mother’s breast

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Mother’s desire to breastfeed

    Quick Answer: 224

    Detailed Answer: 240

  • The nurse is monitoring the progress of a client in labor. Which finding should be reported to the physician immediately?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    The presence of scant bloody discharge

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Frequent urination

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    The presence of green-tinged amniotic fluid

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Moderate uterine contractions

    Quick Answer: 224

    Detailed Answer: 240

  • The nurse is measuring the duration of the client’s contractions. Which statement is true regarding the measurement of the duration of contractions?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Duration is measured by timing from the beginning of one contraction to the beginning of the next contraction.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Duration is measured by timing from the end of one contraction to the beginning of the next contraction.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Duration is measured by timing from the beginning of one contraction to the end of the same contraction.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Duration is measured by timing from the peak of one contraction to the end of the same contraction.

    Quick Answer: 224

    Detailed Answer: 240

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Maternal hypoglycemia

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Fetal bradycardia

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Maternal hyperreflexia

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Fetal movement

    Quick Answer: 224

    Detailed Answer: 240

  • A client with diabetes visits the prenatal clinic at 28 weeks gestation. Which statement is true regarding insulin needs during pregnancy?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Insulin requirements moderate as the pregnancy progresses.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    A decreased need for insulin occurs during the second trimester.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Elevations in human chorionic gonadotrophin decrease the need for insulin.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Fetal development depends on adequate insulin regulation.

    Quick Answer: 224

    Detailed Answer: 240

  • A client in the prenatal clinic is assessed to have a blood pressure of 180/96. The nurse should give priority to:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Providing a calm environment

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Obtaining a diet history

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Administering an analgesic

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Assessing fetal heart tones

    Quick Answer: 224

    Detailed Answer: 240

  • A primigravida, age 42, is six weeks pregnant. Based on the client’s age, her infant is at risk for:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Down syndrome

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Respiratory distress syndrome

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Turner’s syndrome

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Pathological jaundice

    Quick Answer: 224

    Detailed Answer: 241

  • A client with a missed abortion at 29 weeks gestation is admitted to the hospital. The client will most likely be treated with:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Magnesium sulfate

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Calcium gluconate

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Dinoprostone (Prostin E.)

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Bromocrystine (Parlodel)

    Quick Answer: 224

    Detailed Answer: 241

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Continue the infusion of magnesium sulfate while monitoring the client’s blood pressure.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Stop the infusion of magnesium sulfate and contact the physician.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Slow the infusion rate and turn the client on her left side.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Administer calcium gluconate IV push and continue to monitor the blood pressure.

    Quick Answer: 224

    Detailed Answer: 241

  • Which statement made by the nurse describes the inheritance pattern of autosomal recessive disorders?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    An affected newborn has unaffected parents.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    An affected newborn has one affected parent.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Affected parents have a one in four chance of passing on the defective gene.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Affected parents have unaffected children who are carriers.

    Quick Answer: 224

    Detailed Answer: 241

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Because it is a state law

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    To detect cardiovascular defects

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Because of her age

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    To detect neurological defects

    Quick Answer: 224

    Detailed Answer: 241

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    There is no need to take thyroid medication because the fetus’s thyroid produces a thyroid-stimulating hormone.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Regulation of thyroid medication is more difficult because the thyroid gland increases in size during pregnancy.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    It is more difficult to maintain thyroid regulation during pregnancy due to a slowing of metabolism.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Fetal growth is arrested if thyroid medication is continued during pregnancy.

    Quick Answer: 224

    Detailed Answer: 241

  • The nurse is responsible for performing a neonatal assessment on a full-term infant. At one minute, the nurse could expect to find:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    An apical pulse of 100

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    An absence of tonus

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Cyanosis of the feet and hands

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Jaundice of the skin and sclera

    Quick Answer: 224

    Detailed Answer: 241

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Supplemental oxygen

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Fluid restriction

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Blood transfusion

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Delivery by Caesarean section

    Quick Answer: 224

    Detailed Answer: 241

  • A client with diabetes has an order for ultrasonography. Preparation for an ultrasound includes:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Increasing fluid intake

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Limiting ambulation

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Administering an enema

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Withholding food for eight hours

    Quick Answer: 224

    Detailed Answer: 241

  • An infant who weighs 8 pounds at birth would be expected to weigh how many pounds at one year?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    14 pounds

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    16 pounds

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    18 pounds

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    24 pounds

    Quick Answer: 224

    Detailed Answer: 241

  • A pregnant client with a history of alcohol addiction is scheduled for a nonstress test. The nonstress test:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Determines the lung maturity of the fetus

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Measures the activity of the fetus

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Shows the effect of contractions on the fetal heart rate

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Measures the neurological well-being of the fetus

    Quick Answer: 224

    Detailed Answer: 242

  • A full-term male has hypospadias. Which statement describes hypospadias?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    The urethral opening is absent

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    The urethra opens on the top side of the penis

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    The urethral opening is enlarged

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    The urethra opens on the under side of the penis

    Quick Answer: 224

    Detailed Answer: 242

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Alteration in coping related to pain

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Potential for injury related to precipitate delivery

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Alteration in elimination related to anesthesia

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Potential for fluid volume deficit related to NPO status

    Quick Answer: 224

    Detailed Answer: 242

  • The client with varicella will most likely have an order for which category of medication?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Antibiotics

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Antipyretics

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Antivirals

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Anticoagulants

    Quick Answer: 224

    Detailed Answer: 242

  • A client is admitted complaining of chest pain. Which of the following drug orders should the nurse question?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Nitroglycerin

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Ampicillin

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Propranolol

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Verapamil

    Quick Answer: 224

    Detailed Answer: 242

  • Which of the following instructions should be included in the teaching for the client with rheumatoid arthritis?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Avoid exercise because it fatigues the joints.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Take prescribed anti-inflammatory medications with meals.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Alternate hot and cold packs to affected joints.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Avoid weight-bearing activity.

    Quick Answer: 224

    Detailed Answer: 242

  • A client with acute pancreatitis is experiencing severe abdominal pain. Which of the following orders should be questioned by the nurse?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Meperidine 100mg IM m 4 hours PRN pain

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Mylanta 30 ccs m 4 hours via NG

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Cimetadine 300mg PO m.i.d.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Morphine 8mg IM m 4 hours PRN pain

    Quick Answer: 224

    Detailed Answer: 242

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Hallucinogenic drugs create both stimulant and depressant effects.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Hallucinogenic drugs induce a state of altered perception.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Hallucinogenic drugs produce severe respiratory depression.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Hallucinogenic drugs induce rapid physical dependence.

    Quick Answer: 224

    Detailed Answer: 242

  • A client with a history of abusing barbiturates abruptly stops taking the medication. The nurse should give priority to assessing the client for:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Depression and suicidal ideation

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Tachycardia and diarrhea

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Muscle cramping and abdominal pain

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Tachycardia and euphoric mood

    Quick Answer: 224

    Detailed Answer: 242

  • 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?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Right breech presentation

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Right occipital anterior presentation

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Left sacral anterior presentation

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Left occipital transverse presentation

    Quick Answer: 224

    Detailed Answer: 243

  • The primary physiological alteration in the development of asthma is:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Bronchiolar inflammation and dyspnea

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Hypersecretion of abnormally viscous mucus

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Infectious processes causing mucosal edema

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Spasm of bronchiolar smooth muscle

    Quick Answer: 224

    Detailed Answer: 243

  • A client with mania is unable to finish her dinner. To help her maintain sufficient nourishment, the nurse should:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Serve high-calorie foods she can carry with her.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Encourage her appetite by sending out for her favorite foods.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Serve her small, attractively arranged portions.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Allow her in the unit kitchen for extra food whenever she pleases.

    Quick Answer: 224

    Detailed Answer: 243

  • To maintain Bryant’s traction, the nurse must make certain that the child’s:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Hips are resting on the bed, with the legs suspended at a right angle to the bed

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Hips are slightly elevated above the bed and the legs are suspended at a right angle to the bed

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Hips are elevated above the level of the body on a pillow and the legs are suspended parallel to the bed

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Hips and legs are flat on the bed, with the traction positioned at the foot of the bed

    Quick Answer: 224

    Detailed Answer: 243

  • Which action by the nurse indicates understanding of herpes zoster?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    The nurse covers the lesions with a sterile dressing.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    The nurse wears gloves when providing care.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    The nurse administers a prescribed antibiotic.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    The nurse administers oxygen.

    Quick Answer: 224

    Detailed Answer: 243

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    15 minutes after the infusion

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    30 minutes before the fourth infusion

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    One hour after the infusion

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Two hours after the infusion

    Quick Answer: 224

    Detailed Answer: 243

  • The client using a diaphragm should be instructed to:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Refrain from keeping the diaphragm in longer than four hours

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Keep the diaphragm in a cool location

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Have the diaphragm resized if she gains five pounds

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Have the diaphragm resized if she has any surgery

    Quick Answer: 224

    Detailed Answer: 243

  • 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?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    “I’m wearing a support bra.”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    “I’m expressing milk from my breast.”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    “I’m drinking four glasses of fluid during a 24-hour period.”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    “While I’m in the shower, I’ll allow the water to run over my breasts.”

    Quick Answer: 224

    Detailed Answer: 243

  • Damage to the VII cranial nerve results in:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Facial pain

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Absence of ability to smell

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Absence of eye movement

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Tinnitus

    Quick Answer: 224

    Detailed Answer: 243

  • A client is receiving Pyridium (phenazopyridine hydrochloride) for a urinary tract infection. The client should be taught that the medication may:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Cause diarrhea

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Change the color of her urine

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Cause mental confusion

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Cause changes in taste

    Quick Answer: 224

    Detailed Answer: 244

  • Which of the following tests should be performed before beginning a prescription of Accutane?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Check the calcium level.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Perform a pregnancy test.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Monitor apical pulse.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Obtain a creatinine level.

    Quick Answer: 224

    Detailed Answer: 244

  • A client with AIDS is taking Zovirax (acyclovir). Which nursing intervention is most critical during the administration of acyclovir?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Limit the client’s activity.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Encourage a high-carbohydrate diet.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Use an incentive spirometer to improve respiratory function.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Encourage fluids.

    Quick Answer: 224

    Detailed Answer: 244

  • A client is admitted for an CAT scan. The nurse should question the client regarding:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Pregnancy

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    A titanium hip replacement

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Allergies to antibiotics

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Inability to move his feet

    Quick Answer: 224

    Detailed Answer: 244

  • The nurse is caring for the client receiving Amphotericin B. Which of the following indicates that the client has experienced toxicity to this drug?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Changes in vision

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Nausea

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Urinary frequency

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Changes in skin color

    Quick Answer: 224

    Detailed Answer: 244

  • The nurse should visit which of the following clients first?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    The client with diabetes with a blood glucose of 95mg/dL

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    The client with hypertension being maintained on Lisinopril

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    The client with chest pain and a history of angina

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    The client with Raynaud’s disease

    Quick Answer: 224

    Detailed Answer: 244

  • A client with cystic fibrosis is taking pancreatic enzymes. The nurse should administer this medication:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Once per day in the morning

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Three times per day with meals

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Once per day at bedtime

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Four times per day

    Quick Answer: 224

    Detailed Answer: 244

  • Cataracts result in opacity of the crystalline lens. Which of the following best explains the functions of the lens?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    The lens controls stimulation of the retina.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    The lens orchestrates eye movement.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    The lens focuses light rays on the retina.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    The lens magnifies small objects.

    Quick Answer: 224

    Detailed Answer: 244

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Anesthetize the cornea

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Dilate the pupils

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Constrict the pupils

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Paralyze the muscles of accommodation

    Quick Answer: 224

    Detailed Answer: 244

  • 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?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Allow five minutes between the two medications.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    The medications may be used together.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    The medications should be separated by a cycloplegic drug.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    The medications should not be used in the same client.

    Quick Answer: 224

    Detailed Answer: 244

  • The client with color blindness will most likely have problems distinguishing which of the following colors?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Orange

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Violet

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Red

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    White

    Quick Answer: 224

    Detailed Answer: 244

  • The client with a pacemaker should be taught to:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Report ankle edema

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Check his blood pressure daily

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Refrain from using a microwave oven

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Monitor his pulse rate

    Quick Answer: 224

    Detailed Answer: 245

  • The client with enuresis is being taught regarding bladder retraining. The nurse should advise the client to refrain from drinking after:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    1900

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    1200

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    1000

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    0700

    Quick Answer: 224

    Detailed Answer: 245

  • Which of the following diet instructions should be given to the client with recurring urinary tract infections?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Increase intake of meats.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Avoid citrus fruits.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Perform pericare with hydrogen peroxide.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Drink a glass of cranberry juice every day.

    Quick Answer: 224

    Detailed Answer: 245

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    “I will make sure I eat breakfast within two hours of taking my insulin.”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    “I will need to carry candy or some form of sugar with me all the time.”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    “I will eat a snack around three o’clock each afternoon.”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    “I can save my dessert from supper for a bedtime snack.”

    Quick Answer: 224

    Detailed Answer: 245

  • A client with pneumacystis carinii pneumonia is receiving Methotrexate. The rationale for administering leucovorin calcium to a client receiving Methotrexate is to:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Treat anemia

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Create a synergistic effect

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Increase the number of white blood cells

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Reverse drug toxicity

    Quick Answer: 224

    Detailed Answer: 245

  • A client tells the nurse that she is allergic to eggs, dogs, rabbits, and chicken feathers. Which order should the nurse question?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    TB skin test

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Rubella vaccine

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    ELISA test

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Chest x-ray

    Quick Answer: 224

    Detailed Answer: 245

  • The physician has prescribed ranitidine (Zantac) for a client with erosive gastritis. The nurse should administer the medication:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    30 minutes before meals

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    With each meal

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    In a single dose at bedtime

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    60 minutes after meals

    Quick Answer: 224

    Detailed Answer: 245

  • A temporary colostomy is performed on the client with colon cancer. The nurse is aware that the proximal end of a double barrel colostomy:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Is the opening on the client’s left side

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Is the opening on the distal end on the client’s left side

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Is the opening on the client’s right side

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Is the opening on the distal right side

    Quick Answer: 224

    Detailed Answer: 245

  • While assessing the postpartal client, the nurse notes that the fundus is displaced to the right. Based on this finding, the nurse should:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Ask the client to void.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Assess the blood pressure for hypotension.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Administer oxytocin.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Check for vaginal bleeding.

    Quick Answer: 224

    Detailed Answer: 245

  • The physician has ordered an MRI for a client with an orthopedic ailment. An MRI should not be done if the client has:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    The need for oxygen therapy

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    A history of claustrophobia

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    A permanent pacemaker

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Sensory deafness

    Quick Answer: 224

    Detailed Answer: 246

  • A six-month-old client is placed on strict bed rest following a hernia repair. Which toy is best suited to the client?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Colorful crib mobile

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Hand-held electronic games

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Cars in a plastic container

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    30-piece jigsaw puzzle

    Quick Answer: 224

    Detailed Answer: 246

  • The nurse is preparing to discharge a client with a long history of polio. The nurse should tell the client that:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Taking a hot bath will decrease stiffness and spasticity.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    A schedule of strenuous exercise will improve muscle strength.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Rest periods should be scheduled throughout the day.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Visual disturbances can be corrected with prescription glasses.

    Quick Answer: 224

    Detailed Answer: 246

  • A client on the postpartum unit has a proctoepisiotomy. The nurse should anticipate administering which medication?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Dulcolax suppository

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Docusate sodium (Colace)

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Methyergonovine maleate (Methergine)

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Bromocriptine sulfate (Parlodel)

    Quick Answer: 224

    Detailed Answer: 246

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Total Parenteral Nutrition leads to negative nitrogen balance and elevated glucose levels.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Total Parenteral Nutrition cannot be managed with oral hypoglycemics.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Total Parenteral Nutrition is a high-glucose solution that often elevates the blood glucose levels.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Total Parenteral Nutrition leads to further pancreatic disease.

    Quick Answer: 224

    Detailed Answer: 246

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    The client’s knowledge of the signs of preterm labor

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    The client’s feelings about the pregnancy

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Whether the client was using a method of birth control

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    The client’s thought about future children

    Quick Answer: 224

    Detailed Answer: 246

  • An obstetric client is admitted with dehydration. Which IV fluid would be most appropriate for the client?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    .45 normal saline

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Dextrose 1% in water

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Lactated Ringer’s

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Dextrose 5% in .45 normal saline

    Quick Answer: 224

    Detailed Answer: 246

  • The physician has ordered a thyroid scan to confirm the diagnosis of a goiter. Before the procedure, the nurse should:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Assess the client for allergies.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Bolus the client with IV fluid.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Tell the client he will be asleep.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Insert a urinary catheter.

    Quick Answer: 224

    Detailed Answer: 246

  • The physician has ordered an injection of RhoGam for a client with blood type A negative. The nurse understands that RhoGam is given to:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Provide immunity against Rh isoenzymes

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Prevent the formation of Rh antibodies

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Eliminate circulating Rh antibodies

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Convert the Rh factor from negative to positive

    Quick Answer: 224

    Detailed Answer: 246

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Application of a short inclusive spica cast

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Stabilization with a plaster-of-Paris cast

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Surgery with Kirschner wire implantation

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    A gauze dressing only

    Quick Answer: 224

    Detailed Answer: 246

  • A client with bladder cancer is being treated with iridium seed implants. The nurse’s discharge teaching should include telling the client to:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Strain his urine

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Increase his fluid intake

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Report urinary frequency

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Avoid prolonged sitting

    Quick Answer: 224

    Detailed Answer: 247

  • 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?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Antivirals

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Antibiotics

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Immunosuppressants

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Analgesics

    Quick Answer: 224

    Detailed Answer: 247

  • The nurse is preparing a client for cataract surgery. The nurse is aware that the procedure will use:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Mydriatics to facilitate removal

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Miotic medications such as Timoptic

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    A laser to smooth and reshape the lens

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Silicone oil injections into the eyeball

    Quick Answer: 224

    Detailed Answer: 247

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Placing mirrors in several locations in the home

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Placing a picture of herself in her bedroom

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Placing simple signs to indicate the location of the bedroom, bathroom, and so on

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Alternating healthcare workers to prevent boredom

    Quick Answer: 224

    Detailed Answer: 247

  • A client with an abdominal cholecystectomy returns from surgery with a Jackson-Pratt drain. The chief purpose of the Jackson-Pratt drain is to:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Prevent the need for dressing changes

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Reduce edema at the incision

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Provide for wound drainage

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Keep the common bile duct open

    Quick Answer: 224

    Detailed Answer: 247

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Mongolian spots

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Scrotal rugae

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Head lag

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Polyhydramnios

    Quick Answer: 224

    Detailed Answer: 247

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Hematuria

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Muscle spasms

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Dizziness

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Nausea

    Quick Answer: 224

    Detailed Answer: 247

  • 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?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    The client is experiencing an auditory hallucination.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    The client is having a delusion of grandeur.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    The client is experiencing paranoid delusions.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    The client is intoxicated.

    Quick Answer: 224

    Detailed Answer: 247

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Lip the bottle and use a pack of sterile 4×4 for the dressing.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Obtain a new bottle and label it with the date and time of first use.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Ask the ward secretary when the solution was requested.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Label the existing bottle with the current date and time.

    Quick Answer: 224

    Detailed Answer: 247

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    The baby is hypothermic.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    The baby is experiencing bradycardia.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    The baby’s hands and feet are blue.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    The baby is lethargic.

    Quick Answer: 224

    Detailed Answer: 247

  • The primary reason for rapid continuous rewarming of the area affected by frostbite is to:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Lessen the amount of cellular damage

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Prevent the formation of blisters

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Promote movement

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Prevent pain and discomfort

    Quick Answer: 224

    Detailed Answer: 248

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Passing water through a dialyzing membrane

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Eliminating plasma proteins from the blood

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Lowering the pH by removing nonvolatile acids

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Filtering waste through a dialyzing membrane

    Quick Answer: 224

    Detailed Answer: 248

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Administer an antibiotic.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Contact the physician for an order for immune globulin.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Administer an antiviral.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Tell the client that he should remain in isolation for two weeks.

    Quick Answer: 224

    Detailed Answer: 248

  • A client hospitalized with MRSA is placed on contact precautions. Which statement is true regarding precautions for infections spread by contact?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    The client should be placed in a room with negative pressure.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Infection requires close contact; therefore, the door may remain open.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Transmission is highly likely, so the client should wear a mask at all times.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Infection requires skin-to-skin contact and is prevented by hand washing, gloves, and a gown.

    Quick Answer: 224

    Detailed Answer: 248

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    “The pain will go away in a few days.”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    “The pain is due to peripheral nervous system interruptions. I will get you some pain medication.”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    “The pain is psychological because your foot is no longer there.”

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    “The pain and itching are due to the infection you had before the surgery.”

    Quick Answer: 224

    Detailed Answer: 248

    Quick Answer: 224

    Detailed Answer: 248

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Head of the pancreas

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Proximal third section of the small intestines

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Stomach and duodenum

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Esophagus and jejunum

    Quick Answer: 224

    Detailed Answer: 248

  • The physician has ordered a minimal-bacteria diet for a client with neutropenia. The client should be taught to avoid eating:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Fruits

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Salt

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Pepper

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Ketchup

    Quick Answer: 224

    Detailed Answer: 248

  • A client is discharged home with a prescription for Coumadin (sodium warfarin). The client should be instructed to:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Have a Protime done monthly.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Eat more fruits and vegetables.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Drink more liquids.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Avoid crowds.

    Quick Answer: 224

    Detailed Answer: 248

  • The nurse is assisting the physician with removal of a central venous catheter. To facilitate removal, the nurse should instruct the client to:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Perform the Valsalva maneuver as the catheter is advanced

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Turn his head to the left side and hyperextend the neck

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Take slow, deep breaths as the catheter is removed

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Turn his head to the right while maintaining a sniffing position

    Quick Answer: 224

    Detailed Answer: 248

  • A client has an order for streptokinase. Before administering the medication, the nurse should assess the client for:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Allergies to pineapples and bananas

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    A history of streptococcal infections

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Prior therapy with phenytoin

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    A history of alcohol abuse

    Quick Answer: 224

    Detailed Answer: 249

  • The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Using oil- or cream-based soaps

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Flossing between the teeth

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    The intake of salt

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Using an electric razor

    Quick Answer: 224

    Detailed Answer: 249

  • The nurse is changing the ties of the client with a tracheotomy. The safest method of changing the tracheotomy ties is to:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Apply the new tie before removing the old one.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Have a helper present.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Hold the tracheotomy with the nondominant hand while removing the old tie.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Ask the doctor to suture the tracheostomy in place.

    Quick Answer: 224

    Detailed Answer: 249

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Turning the client to the left side

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Milking the tube to ensure patency

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Slowing the intravenous infusion

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Notifying the physician

    Quick Answer: 224

    Detailed Answer: 249

  • The infant is admitted to the unit with tetralogy of Fallot. The nurse would anticipate an order for which medication?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Digoxin

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Epinephrine

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Aminophyline

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Atropine

    Quick Answer: 224

    Detailed Answer: 249

  • 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.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    Quick Answer: 224

    Detailed Answer: 249

  • The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Tire easily

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Grow normally

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Need more calories

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Be more susceptible to viral infections

    Quick Answer: 224

    Detailed Answer: 249

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Determine lung maturity

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Measure the fetal activity

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Show the effect of contractions on fetal heart rate

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Measure the well-being of the fetus

    Quick Answer: 224

    Detailed Answer: 250

  • 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?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Instruct the client to push.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Perform a vaginal exam.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Turn off the Pitocin infusion.

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Place the client in a semi-Fowler’s position.

    Quick Answer: 224

    Detailed Answer: 250

  • The nurse notes the following on the ECG monitor. The nurse would evaluate the cardiac arrhythmia as:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Atrial flutter

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    A sinus rhythm

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Ventricular tachycardia

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Atrial fibrillation

    Quick Answer: 224

    Detailed Answer: 250

  • 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:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Be injected into the deltoid muscle

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Be injected into the abdomen

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Aspirate after the injection

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Clear the air from the syringe before injections

    Quick Answer: 224

    Detailed Answer: 250

  • 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 nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Administer the medications together in one syringe

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Administer the medication separately

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Administer the Valium, wait five minutes, and then inject the Phenergan

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Question the order because they cannot be given at the same time

    Quick Answer: 224

    Detailed Answer: 250

  • A client with frequent urinary tract infections asks the nurse how she can prevent the reoccurrence. The nurse should teach the client to:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Douche after intercourse

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Void every three hours

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Obtain a urinalysis monthly

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Wipe from back to front after voiding

    Quick Answer: 224

    Detailed Answer: 250

  • Which task should be assigned to the nursing assistant?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Placing the client in seclusion

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Emptying the Foley catheter of the preeclamptic client

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Feeding the client with dementia

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Ambulating the client with a fractured hip

    Quick Answer: 224

    Detailed Answer: 250

  • The client has recently returned from having a thyroidectomy. The nurse should keep which of the following at the bedside?

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    A tracheotomy set

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    A padded tongue blade

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    An endotracheal tube

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    An airway

    Quick Answer: 224

    Detailed Answer: 250

  • The physician has ordered a histoplasmosis test for the elderly client. The nurse is aware that histoplasmosis is transmitted to humans by:

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    A.

    Cats

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    B.

    Dogs

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    C.

    Turtles

    A nurse is preparing to conduct an initial survey and assessment on a newly admitted client

    D.

    Birds

    Quick Answer: 224

    Detailed Answer: 250

    • What should the nurse do prior to performing an initial assessment on a newly admitted client?

    Before conducting a health assessment on a client, what should the nurse do first? Introduce herself to the client. The night shift RN is caring for a hospitalized adult client who reports being unable to sleep.

    When the nurse first enters the client's room they perform a general survey what information will the nurse gather during this assessment?

    Rationale 1: During a general survey, the nurse observes the client performing routine activities, such as walking and sitting. This allows the nurse to begin to gather data about the client's mobility. These data will then be incorporated into the remainder of exam and history.

    Which of the following is the first action during the physical assessment of the client ATI?

    The first action the nurse should take using the nursing process is to assess the client. The nurse should begin a complete physical examination by inspecting the client's body systematically, observing for both expected and unexpected physical findings.

    Which of the following elements should a nurse assess during a general survey quizlet?

    The four areas of the general survey are physical appearance, body structure, mobility, and behavior. A general survey does not include assessment of mental status and physical condition.

    nurse preparing conduct initial survey assessment newly admitted client

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