An older adult client arrives at the outpatient eye surgery clinic for

a right cataract extraction and lens implant. During the immediate

postoperative period, which intervention should the nurse
implement?

A. Encourage deep breathing and coughing exercises.

B. Teach a family member to administer eye drops.

C. Provide an eye shield to be worn while sleeping

D.Obtain vital signs every 2 hours during hospitalization.

A client with pancreatitis is receiving 0.9% normal saline, and the

prescribed IV infusion rate was increased from 100 mL/hour to 150
mL/hour. Which assessment finding indicates to the nurse that the
prescription has a therapeutic outcome?

Reference Range:

Blood glucose (70 to 110 mg/dL (less than 6.1 mmol/L)] Amylase [60 to 120
units/dL (30 to 220 units/L)]

Blood urea nitrogen (BUN) [10 to 20 mg/dL (3.6 to 7.1 mmol/L)]

Hematocrit (HCT) [42% to 52% (0.42 to 0.52 volume fraction)]

A. An increase in the hematocrit (HCT) from 42% (0.42 volume fraction) to

52% (0.52 volume fraction).

B. An increase in the blood glucose level from 130 mg/dl. (7.22 mmol/L).

C. A decrease in blood urea nitrogen (BUN) from 36 mg/dL (12.9 mmol/L) to

23 mg/dL (8.21 mmol/L).

D. A decrease in serum amylase from 24 units/dl (240 units) to 12 units/dl.

(120 units/L);

While changing the dressing of a client who is immobile, the nurse

notices the boundary of the wound has increased. Before reporting
this finding to the healthcare provider, the nurse should evaluate
which of the client's laboratory values?

A. Neutrophil count.
B. C-reactive protein level.

C. Platelet count.

D. Serum potassium and sodium levels.

The nurse is preparing a teaching plan for a client taking a

prescribed diuretic for edema in the lower extremities. Which
instruction should the nurse include in this teaching plan?

A. Take the diuretic every day, regardless of weight loss or muscle weakness.

B. Weigh yourself daily at the same time and report excessive weight loss.

C. Limit fluid intake while taking the diuretic to reduce fluid retention.

D.Stop taking the medication when the edema in the lower extremities
subsides

The nurse is evaluating a client's symptoms, and formulates the

nursing problem, "High risk for injury due to potential urinary tract
infection." Which symptoms indicate the need for this nursing
problem?

A. Straining on urination and nocturia

B. Azotemia and anorexia.

C. Hematuria and proteinuria.

D. Fever and dysuria.

The nurse is assessing a client who is newly diagnosed with

hypothyroidism. Which assessment finding requires immediate
intervention?

A. Weight gain.

B. Hypoventilation.

C. Cold intolerance.

D. Lethargy
B

The healthcare provider prescribes cefazolin 800 mg IM every six

hours. The available vial is labeled, "Cefazolin 1 gram," and the
instructions for reconstitution state, For IM use add 2.5 mL sterile
water for Injection to provide a total volume of 3.0 mL. After
reconstitution, the solution contains how many mg/mL? Enter
numeric value only. If rounding is required, round to the nearest
whole number.)

333 mg/mL

The nurse reviews discharge instructions with a client who has

gastroesophageal reflux disease (GERD). Which instruction is most
important for the nurse to emphasize?

A. Minimize intake of spicy foods.

B. Remain upright following meals.

C. Avoid wearing tight fitting clothes.

D. Begin a smoking cessation program.

An adult client is admitted to the medical unit due to rectal bleeding

after a colonoscopy in which a polyp was biopsied and cauterized.
Which Intervention should the nurse do first?

A. Palpate all peripheral pulses in the extremities.

B. Encourage cough and deep breathing exercises.

C. Complete a focused assessment of the abdomen.

D.Initiate measurement of fluid intake and output

While assessing a client following lithotripsy with stent insertion,

which data indicates to the nurse that the procedure was
successful?

A. Stone fragments are collected when straining the client's urine.

B. Client denies urinary frequency, urgency, or dysuria.

C. Urine is pale pink with no observable blood clots.

D. Serum creatinine and blood urea nitrogen (BUN) levels are within normal
limits.

The practical nurse (PN) is assisting in a community center clinic

when four clients simultaneously arrive seeking help. In which order
should the PN prioritize care to be provided based on the client
needs? (Arrange the client with the highest priority first, on top,
and lowest priority last, on botom.)

A. A 12-year-old child with history of asthma who is wheezing and

complaining of shortness of breath.

B. A 7-year-old child who has type 1 diabetes mellitus and is experiencing

extreme hunger and shakiness

C. A 10-year-old child with bleeding lacerations on both knees after falling on

the playground

D. A 5-year-old child who is crying uncontrollably because of an incontinent

bowel episode.

A client with a fracture of the right femur has had skeletal traction
applied. Which intervention should the nurse include in the client's
nursing care plan?

A. Administer pain medication at designated Intervals around the clock.

B. Assess the pulses proximal to the fracture site.

C. Remove traction every shift and provide skin care.

D. Assess the pin sites for signs of infection.

Following a motor vehicle accident, a client with chest trauma

receives a chest tube to relieve a hemothorax. Two hours following
the chest tube insertion, the nurse observes the water level in the
water-seal chamber is rising during inspiration and falling during
expiration. Which action should the nurse implement?

A. Auscultate lungs for unequal breath sounds.

B. Continue to monitor the drainage system.

C. Lift and clear drainage from the chest tube.

D. Inspect the tube insertion site for leaking.

A client with a cervical spinal injury (C7) is experiencing autonomic

dysreflexia. The nurse should first assess the client for which
precipitating factor?

A. An acutely distended bladder.

B. Profuse forehead diaphoresis.

C. Skeletal traction misalignment.

D.A severe pounding headache

The nurse is admitting a client with possible tuberculosis (TB). The

client is placed in a private room with airborne precautions pending
diagnostic test results. Which diagnostic test should the nurse
review to confirm the diagnosis of TB?

A. Sputum culture positive for Mycobacterium tuberculosis.

B. Hemoccult test on sputum collected from hemoptysis.

C. Chest x-ray or computed tomography (CT).

D. Positive purified protein derivative (PPD) skin test.

Lactulose was prescribed two days ago for a client who was recently
diagnosed with hepatic encephalopathy. The client is confused and
experiencing frequent loose stools. Laboratory findings show an
elevated serum ammonia (NH) level of 220 μg/dL (157.1 μmol/dL).
Which action should the nurse take?

Reference Range:

Ammonia [10 to 80 μg/dL (6 to 47 μmol/L)]

A. Hold the next dose of lactulose.

B. Continue the prescribed dose of lactulose.

C. Replace total volume voided with oral or IV fluids.

D. Report the number of diarrhea stools to the healthcare provider (HCP).

The nurse is obtaining the admission history for a client with

suspected peptic ulcer disease (PUD). Which subjective data
reported by the client supports this disease process?

A. Severe abdominal cramps and diarrhea after eating spicy foods.

B. B Frequent use of chewable and liquid antacids for indigestion.

C. Upper mid abdominal pain described as gnawing and burning.

D. Marked loss of weight and appetite over the last 3 or 4 months.

A client with benign prostatic hyperplasia (BPH) is preparing for

discharge following a transurethral needle ablation (TUNA). Which
information should the nurse include in the discharge instructions?

A. Restrict physical activities.

B. Use incentive spirometer.

C. Report when hematuria becomes pink tinged.

D. Monitor urinary stream for decrease in output.

The nurse is caring for a client receiving thrombolytic therapy

following an acute myocardial infarction (MI). Which nursing
problem should the nurse identify as priority for this client?

A. Risk for injury related to effects of thrombolysis.

B. Activity intolerance related to ischemia.

C. Ineffective breathing pattern related to adverse drug effects.

D. Deficient knowledge related to a new medication regimen.

The nurse is caring for a client who had an appendectomy 4 hours

ago. Which finding requires immediate action by the nurse?

A. High-pitched sound heard upon inspiration.

B. Apical heart rate of 100 to 110 beats/minute.

C. Redness and edema noted at the incision site.

D. Pain rating of 8 on a scale of 0 to 10.

An adult client newly diagnosed with left ventricular dysfunction is

admitted to the hospital with fine rales and wheezing. When
assessing this client, which additional finding is the nurse likely to
obtain?

A. Fatigue.

B. Lower extremity edema.

C. Hepatomegaly.

D. Jugular vein distension.

While caring for a client with amyotrophic lateral sclerosis (ALS),

the nurse performs a neurological assessment every four hours.
Which assessment finding warrants immediate intervention by the
nurse?

A. Increasing anxiety.

B. Inappropriate laughter.

C. Asymmetrical weakness.

D. Weakened cough effort.

Which finding(s) in the client's health record should the nurse

recognize places the client at a greater risk of developing gout?
Select all that apply.

A. Obesity

B. Hypertension

C. Drinks beer nightly

D. Daily aspirin
E. Type 2 diabetes mellitus

F. Sleep apnea

G. Ibuprofen for pain

H. Nonsmoker

I. Osteoarthritis

A,B,C,D,E,F

Select the 3 dietary choices that are not part of the recommended
diet for a client with gout.

A. Garlic

B. Liver

C. Spinach

D. Oatmeal

E. Chicken

F. Shrimp

G. Lentil

H. Quinoa

I. Oranges

J. Sardines

B,F,J

The nurse is caring for a client with chronic pancreatitis who reports
persistent gnawing abdominal pain. To help the client manage the
pain, which assessment data is most important for the nurse to
obtain?

A. Eating patterns of dietary intake.

B. Activity level of bowel sounds.

C. Level and amount of physical activity.

D.Color and consistency of feces.

A
A client presents to the emergency department reporting chest pain
that is radiating to the left arm, shortness of breath, and
diaphoresis. Which medication should the nurse anticipate being
prescribed by the healthcare provider?

A. Fentanyl.

B. Hydromorphone

C. Morphine.

D. Oxycodone.

The nurse assists a client with Parkinson's disease to ambulate in

the hallway. The client appears to "freeze" and then carefully lifts
one leg and steps forward. The client tells the nurse of pretending
to step over a crack on the floor. How should the nurse respond?

A. Plan to assess the client's cognition after returning to the room. 6%

B. Confirm that this is an effective technique to help with ambulation. 80%

Most selected

C. Assist the client to a carpeted area to walk more easily. 2%

D. Reorient the client to the present location and circumstances. 11%

A client with a renal calculus reports severe right flank pain,

nausea, and vomiting.Which nursing problem has the highest
priority?

A. Acute pain related to renal calculus.

B. Nutritional deficit related to nausea.

C. Impaired renal function related to pain.

D. Risk for aspiration related to vomiting.

A client with a seizure disorder is seen at the clinic for a follow-up

visit and a prescription renewal for phenytoin. Which assessment
finding warrants immediate intervention by the nurse?
A. Chronic insomnia.

B. Puffy, bleeding gums.

C. Double vision.

D. Blood pressure 100/78 mm Hg.

A young adult client with osteoarthritis of both knees expresses the

desire to continue daily walks in the park with friends. How should
the nurse respond?

A. Encourage continued maintenance of the walking routine.

B. Advise less weight-bearing to prevent joint destruction.

C. Recommend walking indoors for improved stability and safety.

D.Suggest a calcium supplement along with continued walking.

The nurse is preparing a client for surgery who was admitted to the
emergency center following a motor vehicle collision.

The client has a fracture of the femur and is bleeding at the bone
protrusion site.

During the preoperative assessment, the nurse determines that the

client currently receives heparin subcutaneously daily.

Which is the priority nursing action?

A. Notify the healthcare provider of the client’s medication history.

B. Ensure that the potential for bleeding is explained to the client.

C. Have the client sign the surgical and transfusion permits.

D. Observe the heparin injection sites for signs of bruising.

A client experiences an ABO incompatibility reaction after multiple

blood transfusions. Which finding should the nurse report
immediately to the healthcare provider?

A. Lower back pain and hypotension.

B. Delayed painful rash with urticaria.

C. Acute rhinitis and nasal stuffiness.

D.Arthritic joint changes and chronic pain.

The nurse is caring for a client admitted to the hospital with a

tentative diagnosis of bacterial meningitis. Which diagnostic
procedure should the nurse prepare the client for the healthcare
provider?

A. Lumbar puncture.

B. Skull radiography.

C. Magnetic resonance imaging (MRI).

D.Computerized tomography (CT) scan.

A nurse is educating a patient with Type 2 diabetes mellitus and

peripheral neuropathy. What advice should the nurse give?

A. Shoes should be worn outside the house, but it is fine to be barefoot

inside.

B. Family members can assist with regular foot exams.

C. Heating pads are useful if used on the lowest setting.

D.Aching feet may be soaked in lukewarm water for one hour or more

An overweight young adult diagnosed with type 2 diabetes mellitus

is admitted for a hernia repair.

The patient reports feeling very weak and jittery.

What actions should the nurse take? (Select all that apply)

A. Check fingerstick glucose level.

B. Assess skin temperature and moisture.

C. Administer a PRN dose of regular insulin.

D. Document anxiety on the surgical checklist.

E. Measure pulse and blood pressure.

A,B,E

The nurse is providing discharge teaching to an older adult patient

hospitalized for treatment of venous leg ulcers. Which instructions
should the nurse include in the teaching plan? (Select all that
apply.)

A. Eat a diet that is high in protein and vitamins A and C.

B. Maintain bed rest as much as possible.

C. Keep legs elevated when sitting or lying down.

D. Inspect ankles daily for areas of darkening skin.

E. Apply intermittent cold compresses four times daily.

A,C,D

The nurse is assessing the lung sounds of a preschooler. Which

action should the nurse implement to ensure the child's
cooperation?

A. Have the child blow a cotton ball and have the parent catch it.

B. Allow the child to use a stethoscope on a stuffed animal.

C. Offer the child bubbles before the stethoscope is placed.

D. Place a toy in the child's hands while listening to the breath sounds.

A child diagnosed with Kawasaki disease is brought to the clinic.

The mother reports that her child is irritable, refuses to eat, and has
skin peeling on both hands and feet. Which intervention should the
nurse instruct the mother to implement first?

A. Encourage the parents to rest when possible.

B. Make a list of foods that the child likes.

C. Place the child in a quiet environment.

D.Apply lotion to hands and feet.

C
During a follow-up clinic visit, a mother tells the nurse that her 5-
month-old son who had surgical correction for tetralogy of Fallot
(TOF) has rapid breathing, often takes a long time to eat, and
requires frequent rest periods. The infant is not crying while being
held and his growth is in the expected range. Which intervention
should the nurse implement?

A. Obtain a 12-lead electrocardiogram.

B. Stimulate the infant to cry to produce cyanosis.

C. Auscultate heart and lungs while the infant is held.

D. Evaluate the infant for failure to thrive (FTT).

The mother of a one-month-old infant calls the clinic to report that

the back of her infant's head is flat. How should the nurse respond?

A. Position the infant on the stomach occasionally when awake and active.

B. Turn the infant on the left side braced against the crib when sleeping.

C. Place a small pillow under the infant's head while lying on the back.

D.Prop the infant in a sitting position with a cushion when not sleeping.

The nurse is caring for a one-month-old infant admitted for

suspected congenital hypothyroidism. Which diagnostic test results
should the nurse report to the healthcare provider?

A. Luteinizing hormone (LH) levels.

B. Thyroxine (T4).

C. Growth hormone (GH) levels.

D. Follicle stimulating hormone (FSH) levels.

An adolescent with a congenital heart defect is admitted for

diagnostic testing with surgery scheduled in 3 days. Which
intervention should the nurse implement to best support the client's
psychosocial needs?
A. Enable limited time for cell phone use.

B. Provide an activity room to spend time with other adolescents.

C. Deliver 3 meals and snacks each day upon request.

D. Allow family and friends to be present during assessments.

An infant who is developmentally delayed has a ventricular

peritoneal (VP) shunt for hydrocephalus. The nurse makes a
postoperative home visit to assess the child's progress. During the
visit, the mother tells the nurse, "When the shunt is removed, the
pressure in my baby's head will be gone." Which response should
the nurse provide?

A. "Many infants outgrow the need for a shunt after the neonatal period."

B. "The shunt will be replaced as your child grows to reduce pressure in the
brain."

C. "Other pathways in the brain will drain fluid after the shunt is removed."

D. "The shunt will have to be reinserted only if an infection or blockage

develops."

An infant who has a Wilms' tumor is admitted for surgery. Which

intervention should the nurse implement during the preoperative
period?

A. Careful bathing and handling that avoids abdominal manipulation.

B. Administer pain medication based on the FACES pain scale.

C. Include the prone position in the every 2 hour turning schedule.

D. Give antiemetic medications to prevent nausea and vomiting.

An infant born 2 days ago has not passed a meconium stool and
begins to vomit bilious secretions. Which action should the nurse
take first?

A. Measure abdominal circumference.

B. Gather supplies for an intravenous (IV) infusion.

C. Monitor strict urinary output.

D.Prepare for anorectal manometry.

The nurse is conducting an admission assessment of an infant with

heart failure who is scheduled for repair of restenosis of coarctation
of the aorta that was repaired 4 days after birth. Findings include
blood pressure higher in the arms than the lower extremities,
pounding brachial pulses, and slightly palpable femoral pulses.
Which pathophysiologic mechanism supports these findings?

A. The lumen of the aorta reduces the volume of blood flow to the lower
extremities.

B. The aortic semilunar valve obstructs blood flow into the systemic
circulation.

C. The pulmonic valve prevents adequate blood volume into the pulmonary
circulation.

D. An opening in the atrial septum causes a murmur due to a turbulent left to

right shunt.

While caring for a client with full-thickness burns covering 40% of

the body, the nurse observes purulent drainage from the wounds.
Before reporting this finding to the health care provider, the nurse
should evaluate which laboratory value?

A. Platelet count.

B. Serum albumin.

C. Neutrophil count.

D. Blood pH level.

To reduce the risk for pulmonary complications for a client with

Amyotrophic Lateral Sclerosis (ALS), which interventions should the
nurse implement? (Select all that apply)
A. Teach the client breathing exercises.

B. Establish a regular bladder routine.

C. Perform chest physiotherapy.

D. Encourage use of incentive spirometer.

E. Initiate passive range of motion exercises.

A,C,D,E

A client is admitted to the medical unit during an exacerbation of

systemic lupus erythematosus (SLE). It is most important to report
which assessment finding to the health care provider?

A. Joint pain.

B. Hematuria.

C. Low grade fever.

D. Muscle atrophy.

The nurse is assessing a client who has herpes zoster. Which

question will allow the nurse to gather further information about
this condition?

A. Has everyone at home already had varicella?

B. Have the antifungal creams been effective?

C. Do you have any dry patches on your feet and hands?

D. Do your family members share combs and brushes?

A client with obstructive sleep apnea (OSA) calls the clinic to report
difficulty wearing the continuous positive air pressure (CPAP) mask
because it is uncomfortable. The client asks the nurse for an
alternative way to manage sleep apnea. Which recommendation
should the nurse provide?

A. Begin a weight loss program.

B. Drink 1 to 2 glasses of wine at bedtime.

C. Take sedatives prior to sleep.

D.Sleep with the head of the bed flat.

A client with rheumatoid arthritis has an elevated serum rheumatoid

factor. Which interpretation of this finding should the nurse make?

A. Confirmation of the autoimmune disease process.

B. Evidence of spread of the disease to the kidneys.

C. Indication of the onset of joint degeneration.

D. Representative of a decline in the client’s condition.

An older client who experienced a cerebrovascular accident (CVA)

has difficulty with visual perception and eats only half of the food on
the meal tray. The client's family expresses concern about the
client's nutritional status. How should the nurse respond to the
family's concern?

A. Demonstrate the use of visual scanning during meals to the client and
family.

B. Explain that weight loss will be reversed after the acute phase of the
stroke has ended.

C. Suggest that the family bring foods from home that the client enjoys
eating.

D.Encourage the family to offer to feed the client when she does not eat her
entire meal

The nurse is teaching a client with cancer about skin care for the
portal site receiving external beam radiation. Which client action
about skin care indicates a need for further teaching?

A. Wears clothing to cover the radiation site.

B. Washes the radiation site with antibacterial soap and water.

C. Applies prescribed lotions to the radiation site.

D. Dries the area with patting motions after taking a shower.

A client admitted to the emergency department with an acute

exacerbation of peptic ulcer disease is vomiting and describing
epigastric pain and nausea. After obtaining vital sign
measurements, which prescription should the nurse implement
first?

A. Insert a nasogastric tube (NGT) and attach to low intermittent suction.

B. Give a prescribed analgesic for temperature above 101°F (38.3° C).

C. Place an indwelling urinary catheter and attach a bedside drainage unit.

D. Send the client to x-ray for a flat plate of the abdomen.

A client with benign prostatic hyperplasia (BPH) is preparing for

discharge following a transurethral needle ablation (TUNA). Which
information should the nurse include in the discharge instructions?

A. Use incentive spirometer.

B. Monitor urinary stream for decrease in output.

C. Report when hematuria becomes pink tinged.

D. Restrict physical activities.

A client with acute renal injury (AKI) weighs 110.3 pounds (50 kg)
and has a potassium level of 6.7 mEq/L (6.7 mmol/L) is admitted to
the hospital. Which prescribed medication should the nurse
administer first?

Reference Range:

Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]

A. Sodium polystyrene sulfonate 15 grams by mouth.

B. Sevelamer one tablet by mouth.

C. Calcium acetate one tablet by mouth.

D. Epoetin alfa, recombinant 2,500 units subcutaneously.

E. Calcium acetate one tablet by mouth.

The nurse is preparing an older client for a magnetic resonance

imaging (MRI) with contrast. Which laboratory value should the
nurse report to the healthcare provider before the scan is
performed?

Reference Range:

Glycosylated hemoglobin (A1C) [4% to 5.9%]

Creatinine [0.5 to 1.1 mg/dL (44 to 97 umol/L)]

Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

Blood Urea Nitrogen (BUN) [10 to 20 mg/dL (3.6 to 7.1 mmol/L)]

A. Fasting blood sugar of 200 mg/dL (11.1 mmol/L).

B. Glycosylated hemoglobin A1c of 8%.

C. Blood urea nitrogen of 22 mg/dL (7.9 mmol/L).

D. Serum creatinine of 1.9 mg/dL (169 umol/L).

A client with type 1 diabetes mellitus, hypertension, and chronic

kidney disease is to begin hemodialysis treatment. Which statement
should the nurse include in client education?

A. Prepare for an abdominal catheter.

B. Continue routine medications.

C. Expect the insulin dosage to be reduced.

D. Include potassium-rich foods in the diet.

A patient is admitted to the hospital with symptoms consistent with

a right hemisphere stroke. Which neurovascular assessment
requires immediate intervention by the nurse?

A. Pupillary changes to ipsilateral dilation.

B. Left-sided facial drooping and dysphagia.

C. Orientation to person and place only.

D. Unequal bilateral hand grip strengths.

After performing a head-to-toe assessment for a client with

Addison's disease, the nurse reports findings to the healthcare
provider. The findings include moist mucous membranes, strong
palpable peripheral pulses, and blood pressure 132/88 mm Hg. The
client verbalizes understanding of the illness and importance of
taking medications every day. Which action should the nurse
implement?

A. Make a referral for social services at home.

B. Continue to limit daily fluid intake to 500 mL.

C. Begin preparing the client for discharge home.

D. Recommend strict intake and output monitoring.

A client who had a biliopancreatic diversion procedure (BPD) 3

months ago is admitted with severe dehydration. Which assessment
finding warrants immediate intervention by the nurse?

A. Gastroccult positive emesis.

B. Strong foul smelling flatus.

C. Complaint of poor night vision.

D.Loose bowel movements.

A client with a closed head injury demonstrates signs of syndrome

of inappropriate antidiuretic hormone (SIADH). Which additional
finding should the nurse expect to obtain?

A. Weight gain of 2 pounds (0.91 kg) in one day.

B. Fremitus over the chest wall.

C. Serum sodium of 150 mEq/L (150 mmol/L).

D.Urine specific gravity of 1.004.

A

Following a motor vehicle accident, a client with chest trauma

receives a chest tube to relieve a hemothorax. Two hours following
the chest tube insertion, the nurse observes the water level in the
water-seal chamber is rising during inspiration and falling during
expiration. Which action should the nurse implement?

A. Lift and clear drainage from the chest tube.

B. Inspect the tube insertion site for leaking.

C. Continue to monitor the drainage system.

D. Auscultate lungs for unequal breath sounds.

The nurse is caring for a client who had an appendectomy 4 hours

ago. Which finding requires immediate action by the nurse?

A. Redness and edema noted at the incision site.

B. Apical heart rate of 100 to 110 beats/minute.

C. High-pitched sound heard upon inspiration.

D. Pain rating of 8 on a scale of 0 to 10.

A client who received 6 units of packed red blood cells 3 days ago
for a lower gastrointestinal (GI) bleed is now displaying signs of
shortness of breath with occasional stridor and is reporting muscle
cramping.

Reference Range:

Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]

Magnesium [Adult: 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L)]

Calcium [9 to 10.5 mg/dL (2.3 to 2.6 mmol/L)]

Sodium (136 to 145 mEq/L (136 to 145 mmol/L)]

Which serum laboratory value should the nurse immediately report

to the healthcare provider?

A. Potassium 4.7 mEq/L (4.70 mmol/L).

B. Magnesium 2.1 mEq/L (0.86 mmol/L).

C. Calcium 6.5 mg/dL (1.63 mmol/L).

D. Sodium 135 mEq/L (135 mmol/L).

A client with acute renal injury (AKI) weighs 110.3 pounds (50 kg)
and has a potassium level of 6.7 mEq/L (6.7 mmol/L) is admitted to
the hospital. Which prescribed medication should the nurse
administer first?

Reference Range:Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]

A. Sodium polystyrene sulfonate 15 grams by mouth.

B. Sevelamer one tablet by mouth.

C. Calcium acetate one tablet by mouth.

D. Epoetin alfa, recombinant 2,500 units subcutaneously.

The nurse is preparing an older client for a magnetic resonance

imaging (MRI) with contrast. Which laboratory value should the
nurse report to the healthcare provider before the scan is
performed?

Reference Range:Glycosylated hemoglobin (A1C) [4% to 5.9%]Creatinine

[0.5 to 1.1 mg/dL (44 to 97 umol/L)]Glucose [74 to 106 mg/dL (4.1 to 5.9
mmol/L)]Blood Urea Nitrogen (BUN) [10 to 20 mg/dL (3.6 to 7.1 mmol/L)]

A. Fasting blood sugar of 200 mg/dL (11.1 mmol/L).

B. Glycosylated hemoglobin A1c of 8%.

C. Blood urea nitrogen of 22 mg/dL (7.9 mmol/L).

D. Serum creatinine of 1.9 mg/dL (169 umol/L).

A patient is admitted to the hospital with symptoms consistent with

a right hemisphere stroke. Which neurovascular assessment
requires immediate intervention by the nurse?

A. Pupillary changes to ipsilateral dilation.

B. Left-sided facial drooping and dysphagia.

C. Orientation to person and place only.

D.Unequal bilateral hand grip strengths

After performing a head-to-toe assessment for a client with

Addison's disease, the nurse reports findings to the healthcare
provider. The findings include moist mucous membranes, strong
palpable peripheral pulses, and blood pressure 132/88 mm Hg. The
client verbalizes understanding of the illness and importance of
taking medications every day. Which action should the nurse
implement?

A. Make a referral for social services at home.

B. Continue to limit daily fluid intake to 500 mL.

C. Begin preparing the client for discharge home.

D.Recommend strict intake and output monitoring.

A client who had a biliopancreatic diversion procedure (BPD) 3

months ago is admitted with severe dehydration. Which assessment
finding warrants immediate intervention by the nurse?

A. Gastroccult positive emesis.

B. Strong foul smelling flatus.

C. Complaint of poor night vision.

D. Loose bowel movements.

A client with a closed head injury demonstrates signs of syndrome

of inappropriate antidiuretic hormone (SIADH). Which additional
finding should the nurse expect to obtain?

A. Weight gain of 2 pounds (0.91 kg) in one day.

B. Fremitus over the chest wall.

C. Serum sodium of 150 mEq/L (150 mmol/L).

D. Urine specific gravity of 1.004.

Following a motor vehicle accident, a client with chest trauma

receives a chest tube to relieve a hemothorax. Two hours following
the chest tube insertion, the nurse observes the water level in the
water-seal chamber is rising during inspiration and falling during
expiration. Which action should the nurse implement?

A. Lift and clear drainage from the chest tube.

B. Inspect the tube insertion site for leaking.

C. Continue to monitor the drainage system.

D.Auscultate lungs for unequal breath sounds.

The nurse is caring for a client who had an appendectomy 4 hours

ago. Which finding requires immediate action by the nurse?

A. Redness and edema noted at the incision site.

B. Apical heart rate of 100 to 110 beats/minute.

C. High-pitched sound heard upon inspiration.

D.Pain rating of 8 on a scale of 0 to 10.

A client who received 6 units of packed red blood cells 3 days ago
for a lower gastrointestinal (GI) bleed is now displaying signs of
shortness of breath with occasional stridor and is reporting muscle
cramping.

Reference Range:Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]Magnesium

[Adult: 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L)]Calcium [9 to 10.5 mg/dL (2.3
to 2.6 mmol/L)]Sodium (136 to 145 mEq/L (136 to 145 mmol/L)]

Which serum laboratory value should the nurse immediately report

to the healthcare provider?

A. Potassium 4.7 mEq/L (4.70 mmol/L).

B. Magnesium 2.1 mEq/L (0.86 mmol/L).

C. Calcium 6.5 mg/dL (1.63 mmol/L).

D. Sodium 135 mEq/L (135 mmol/L).

A healthy 70-year-old patient has low hemoglobin levels and no

signs of gastrointestinal bleeding.

The nurse recognizes which item is an effect of aging that could be

the reason for the low hemoglobin level?

A. Low level of hepcidin.

B. Increase in iron-binding capacity.

C. Decrease in intestinal absorption of iron.

D. Decrease in erythropoietin secretion from the kidneys.

A patient with thalassemia major who is receiving a blood

transfusion shows signs of hemochromatosis.

The nurse anticipates a prescription for which medication?

A. Methotrexate.

B. Deferoxamine.

C. Ferrous gluconate.

D.Iron dextran complex

Which goal is a primary objective for a patient who has chronic

heart failure (HF)?

A. Maximizing cardiac output.

B. Maintaining ideal body weight.

C. Performing daily aerobic exercises.

D.Maintaining a steady pulse oximetry reading.

A
The arterial blood gas (ABG) results for a patient who overdosed on
barbiturates are pH = 7.32, PaCO2 = 52, and HCO3 = 23. Which
interpretation would the nurse rely on when planning the patient's
care?

A. Metabolic acidosis.

B. Metabolic alkalosis.

C. Respiratory acidosis.

D. Respiratory alkalosis.

The nurse receives information about the assigned patients during

shift report.

Which patient would the nurse assess first?

A. A patient who reports dizziness with a blood pressure (BP) of 150/92 mm

Hg.

B. A patient who reports a severe headache and has begun vomiting.

C. A patient with a hip fracture who reports a pain level of 2 on a 1-to-10

scale.

D. A patient who received an angiotensin-converting enzyme (ACE) inhibitor

30 minutes previously and reports fatigue.

After noting that a patient with leukemia has thrombocytopenia,

which action will the nurse plan to take?

A. Palpate lymph nodes for swelling.

B. Check temperature for elevation.

C. Inspect skin for bruising or petechiae.

D.Examine oral mucosa for ulceration.

Which erythrocyte characteristic would the nurse expect to see in

the laboratory findings for a patient who has experienced acute
blood loss?
A. Microcytic.

B. Normocytic.

C. Hypochromic.

D. Megaloblastic.

The nurse presents information to a group of nursing students

about cultural and ethnic health disparities related to hypertension.

Which information would the nurse include about the comparison of

Mexican Americans to White and Black populations?

A. Mexican Americans have higher rates of good blood pressure control.

B. Mexican Americans are more likely to receive treatment for hypertension.

C. Mexican Americans have the highest prevalence of hypertension in the

world.

D. Mexican Americans have lower levels of awareness of hypertension and its

treatment.

A patient who smokes reports chest pain while at rest.

Which condition would the nurse suspect the patient is

experiencing?

A. Silent ischemia.

B. Angina decubitus.

C. Prinzmetal angina.

D. Chronic stable angina.

Which rationale supports the nurse's assessment of a patient's

magnesium level?

A. The electrolyte is the most abundant intracellular cation present in the

body.

B. The electrolyte may cause extracellular fluid overload.

C. Magnesium may affect neuromuscular excitability and contractility.

D.The patient is at risk for hypotension when the levels of magnesium

decrease

The nurse is preparing to administer Tylenol to a client admitted

with urination issues who also has difficulty sleeping (OSA).Which
interaction is most important for the nurse to implement before
leaving the client?

A. Elevate the head of the bed to a 45-degree angle

B. Apply the client's positive airway pressure device

C. Lift and lock the side rails in place

D.Remove dentures or other oral appliances

The nurse plans to encourage a group of young adult clients to

engage in problem-solving strategies.Which of the following is most
useful for the nurse to include?

A. Providing physical demonstration.

B. Using simulation activities.

C. Incorporating verbal analogies.

D. Offering positive reinforcement.

The nurse is providing postoperative care for a client who complains

of severe pain after receiving codeine 30 mg orally one hour
ago.Which intervention should the nurse implement next?

A. Ask the UAP to offer back rubs to the client.

B. Reassess the client and the level of pain.

C. Encourage the client to focus on taking deep breaths.

D. Tell the client the medication needs more time to work.

B
The healthcare provider prescribes ear drops to an adult client with
an ear infection.Which exacting should the nurse follow?

A. Swab and shake bottle before administering the drops.

B. Administer the drops with the head tilted upright.

C. Lower the edge of the dropper into the canal of the ear.

D. Keep the patient in supine position to administer the drops

How should the nurse document the finding of pain, numbness, and
tingling sensations in the lower legs?

A. Acute pain.

B. Neuropathic pain.

C. Visceral pain.

D.Nociceptive pain.

The nurse observes an unlicensed assistive personnel (UAP) feeding

a client who had a cerebral vascular accident (CVA) and is at risk for
aspiration.Which action by the UAP should the nurse recognize
indicates the need for additional teaching?

A. Places food on the unaffected side of the mouth.

B. Raises the head of the bed to 80 degrees.

C. Positions the head with the chin tilted slightly downward.

D. Allows 30 minutes of rest before feeding.

The nurse observes the skin over a client's greater trochanter, as

seen in the picture with pressure sores.What actions should the
nurse implement?

A. Instruct the unlicensed assistive personnel to frequently offer oral fluids.

B. Prepare to implement a pressure redistribution mattress.

C. Explain to the client that the wound needs debridement.

D. Obtain hemoglobin of the side to check for anemia and sensitivity.

A client who had emergency gallbladder surgery yesterday is

getting ready to be discharged.The nurse knows that the client
speaks very little English. When teaching wound care, which method
should the nurse use to evaluate the client's understanding of self-
care at home?

A. Have the client demonstrate prescribed wound care.

B. Provide written instructions in the client's native language.

C. After each instruction, ask the client if he/she understands.

D. Have an interpreter repeat the wound care instructions.

After a long bed rest, a client with a Foley catheter and wrist
restraints has repeatedly removed the antibiotic (G) tube and NG
tube.At checking the restraints, which action is most important for
the nurse to take?

A. Reinsert the peripheral IV catheter.

B. Verify that the restraints can be quickly released.

C. Assess capillary refill distal to the restraints.

D. Replace the nasogastric tube.

After a week of bed rest, a client is being assisted to a chair for the
first time.The nurse raises the head of the bed and moves the client
to a sitting position. What should the nurse implement next?

A. Determine how the client feels.

B. Support the client when rising.

C. Offer a pair of non-skid socks.

D. Place the chair by the bed.