Worksheetsfinal
Total questions: 100
Worksheet time: 51mins
A nurse assessing a client notes that the client has a constant leakage of small amounts of urine and a bladder that is distended and palpable. The nurse should associate these findings with which of the following types of urinary incontinence?
Overflow incontinence
Reflex incontinence
Urge incontinence
Stress incontinence
A nurse is providing instructions about bowel cleansing with
polyethylene glycol-electrolyte solution (PEG) for a client who is going to have a colonoscopy. Which of the following information should the nurse include?
To prevent dehydration, drink an additional liter of fluid during preparation time
Abdominal bloating might occur.
"Drink 400 mL every hour until bowel movements are clear."
"Expect bowel movements to begin 3 hr following completion of solution."
A nurse overhears two assistive personnel (AP) from the medical-surgical unit discussing a hospitalized client while in the cafeteria. Which of the following is the priority nursing action?
Ask the nurse manager to provide an inservice program about confidentiality to the staff on the unit.
Document the occurrence in a personal log.
Quietly tell the APs that this is not appropriate.
Complete an incident report.
A nurse is providing instructions for a 52-v ear-old client who is scheduled for a colonoscoov. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate?
"know you're anxious, but this procedure is recommended for people your age."
"After you have signed the consent form, we can talk more about this.
"Before the examination, your provider will give you a sedative that will make you sleepy.
"Don't worry; most clients dislike the prep more than the procedure itselt."
A nurse is reviewing the serum laboratory findings for a client who has hypertension and is prescribed hydrochlorothiazide. Which of the following
findings should the nurse report to the provider?
Potassium 2.3 mEq/l.
Sodium 136 mEg/L
Calcium 10 mg/dL
Chloride 99 mEq/L
A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?
Fluid imbalance
Airway obstruction
Infection
Paralytic ileus
A nurse is teaching a client about how to use a patient-controlled analgesia (PCA) pump. Which of the following instructions should the nurse
include in the teaching?
"Ask a family member to push the patient-control button when the client is sleeping."
"Several bolus doses are infused if the button is pushed repeatedly within a 5 to 10 minute timeframe before lock-out."
"Use the pain scale to determine if you need to self-administer."
"There is a 30 minute lock-out limit programmed on your PCA pump."
A nurse is caring for a client following a CA and observes the client experiencing severe dysphagia. The nurse notifies the provider. Which of the following nutritional therapies will likely be prescribed?
Supplements via nasogastric tube
NPO until dysphagia subsides
Initiation of total parenteral nutrition
Soft residue diet
A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take?
Administer an analgesic PO.
Remove the catheter and insert another into a different site.
Administer a local anesthetic.
Request a prescription for placement of a central venous access device.
A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?
Loosen restrictive clothing.
Place a pillow under the child's head.
Clear the area of hazards.
Position the child side-lying.
A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect?
Allergic
Febrile
Hemolytic
Acute pain
A nurse is caring for a client who was admitted for suspected abuse. The client is quiet and withdrawn. Which of the following actions should the nurse take to promote client communication?
Provide basic wound care for obvious physical injuries.
Be direct and honest when speaking with the client.
Probe the client to offer a factual account of the abuse.
Invite a family member to be present for the nursing history.
A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse?
Clamps the NG tube during auscultation
Performs auscultation between meals
Palpates the abdomen prior to performing auscultation.
Auscultates bowel sounds for 3 to 5 min
A nurse is caring for a client who is experiencing severe nausea and vomiting after a course of chemotherapy. The nurse should monitor the client for which of the following clinical manifestations?
Respiratory acidosis
Metabolic alkalosis
Respiratory alkalosis
Metabolic acidosis
A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO, 48 mm Hg and the HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate of which of the following acid base balances?
Respiratory acidosis
Metabolic alkalosis
Respiratory alkalosis
Metabolic acidosis
A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?
Check the client's skin every 8 hr for signs of breakdown.
Request a prescription for the insertion of an indwelling urinary catheter.
Apply a moisture barrier ointment to the client's skin.
Clean the client's skin and perineum with hot water after each episode of incontinence.
A nurse is observing a client's nonverbal behavior. When evaluating this behavior, the nurse should factor in which of the following principles influencing nonverbal communication?
The client's sociocultural background influences nonverbal communication.
Nonverbal communication is a poor reflection of what the client feels.
The client enacts nonverbal communication consciously.
Nonverbal communication conveys less truth than what the client states verbally.
A nurse is caring for a client whose partner died five years ago. Which of the following findings indicates that the client is experiencing maladaptive grief!
The client exercises at a local health facility 3 days each week.
The client joined a bowling league 2 months ago.
The client meets his daughter for dinner every weeK.
The client has kept his partner's closet untouched since her death.
A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following beverages should the nurse tell the client to avoid while taking this medication?
milk
grapefruit juices
orange juice
coffee
A nurse is caring for a client who reports recurrent flank pain, 8/10 pain scale, nausea, and vomiting for 24 hr. Which of the following actions is the nurse's priority?
Strain the urine.
Monitor intake and output.
Administer an antiemetic.
Administer pain medication.
A nurse is assessing an adolescent who experienced blunt trauma to the abdomen. Which of the following findings is the nurse's priority?
Abdominal pain rated 4 on a scale of 0 to 10
Heart rate 72/min
Respiratory rate 20/min
Blood pressure 92/50 mm Hg
A nurse is providing teaching about self-administration of insulin to the parent of a school-age child who has a new of diabetes mellitus. Which of the following statements by the parent indicates a need for further teaching?
"I will be sure my child aspirates before injecting the insulin."
"The insulin can be injected anywhere there is adipose tissue."
"I will be sure my child rotates sites after 5 injections in one area."
"The insulin should be injected at a 90-degree angle."
A nurse in an outpatient clinic is assessing a middle adult client as part of a routine physical examination. The client's BP is 142/88 mm Hg, his body mass index (BMI) is 31, and he is a current smoker. The nurse should identify that this client has multiple risk factors for which of the following disorders?
Thyroid disease
Testicular cancer
Depression
Cardiovascular disease
A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following actions is the highest priority?
Protecting the client from injury
Ensuring that the client feels safe
Determining the cause of the client's anxiety
Identifying the client's coping skills
A nurse in a public clinic is planning a health fair for older adult clients in the community. In teaching medication safety, which of the following foods should the nurse advise the clients to avoid when taking their prescriptions?
Milk
Grapefruit juice
Carbonated beverage
Apple juice
A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take?
Apply the bag for 20 to 30 min at a time
Place the bag directly on the skin.
Allow room for some air inside the bag.
Reapply the bag 30 min after removing it.
A nurse is preparing an education program for a group of parents of adolescents. Which of the following should be included as indicators of nutritional risk among adolescents? (Select all that apply.)
Frequently skipping breakfast
Eating without family supervision frequently
Skipping more than three meals per week
Eating fast food once weekly
Hearty appetite
A nurse is planning care for a client who has anorexia nervosa. The nurse should make which of the following client goals the priority?
Make negative statements about improvements in body image.
Feel in control of her behavior.
Identify changes within the family unit that promote the client's autonomy.
Gain 2 pounds of weight per week.
A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies?
"These tests help determine the degree of damage to the heart tissues."
"These tests will enable the provider to determine the heart structure and mobility of the heart valves."
"Cardiac enzymes assist in diagnosing the presence of pulmonary congestion."
"Cardiac enzymes will identify the location of the MI."
A nurse on a medical-surgical unle is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP? (Select all that apply.)
Record urinary output,
Transfer a client to a stretcher.
Demonstrate the technique to Instill eye drops.
Ambulate a elient who has a cane.
Irrigate a wound,
A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first?
Determine the location of the pain.
Administer the medication.
Reposition the client.
Review the effects of the pain medication.
A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?
Evaluation
Assessment
Implementation
Planning
A nurse is caring for a client who is postoperative following abdominal surgery. The nurse discovers a loop of bowel through an opening in the surgical incision. Which of the following actions should the nurse take?
Gently reinsert the bowel back into the client's wound.
Apply moistened sterile gauze to the site.
Position the client on his left side.
Place the head of the client's bed in the flat position.
A nurse working for a home health agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address?
Swollen gums
Dysphagia
Pruritus
Urinary hesitancy
A nurse is caring for a client following an esophagogastroduodenoscopy (ED) procedure. Which of the following assessments is the nurse's priority for nutrional need ?
urine urgency
Gag reflex
Nausea
Diarrhoea
A nurse is providing care for a surgeon on a medical-surgical unit. A nurse from another unit asks the nurse about the surgeon's medical diagnosis.
The nurse responds that he is unable to provide the information requested. The nurse is displaying which of the following ethical principles?
Nonmaleficence
Paternalism
Justice
Utility
A nurse is caring for a child who ingested kerosene. Which of the following assessments is the nurse's priority?
Visual acuity
Burns of the mouth
Bowel sounds
Respiratory rate
A nurse is caring for a client who has the following arterial blood gas results: HCO; 18 mEg, PaCO 28 mm Hg and pH 7.30. The nurse recognizes the client is experiencing which of the following acid base imbalances?
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis
A nurse is preparing a teaching plan for a client who has chronic constipation secondary to irregular bowel habits. Which of the following should the nurse plan to include in the teaching?
The client should try to take in all of the required dietary fiber with the morning meal.
The client should follow a high-fiber diet to establish bowel regularity.
The client should be taught that the goal of therapy is to have a bowel movement daily.
The client should drink two to three 8 oz glasses of water each day.
A murse is caring for a dient who has diabetic ketoasidosis. Which of the following manifestations should the murse expect?
Magnant hypertension
Blood glucose level below 40 my/dl
Acetone order to Breath
Greyne-Stoles breathing
A nurse is assessing a client who is receiving one unit of packed RBs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first?
Notify the laboratory.
Obtain a urine specimen.
Inform the provider.
Stop the infusion of blood.
A nurse is caring for a client who has been diagnosed with end-stage liver cancer. Which of the following responses is an indication the client is in the denial phase of the grief process?
"The doctor says I only have a few months to live, but I know he is exaggerating to get me to take my medication."
"Even though I am not hurting right now, I don't feel like I have the energy to get out of bed."
"The doctor has been so good to me. I know he has tried everything he can. It is just my time."
" can't believe the doctor graduated from medical school. He doesn't know a thing about treating cancer!"
A nurse is educating a client who is experiencing sleep disturbances and desires to decrease caffeine intake. Which of the following beverages should the nurse recommend?
Lemon-lime soda
Chocolate milk
Brewed iced tea
Diet cola
A nurse is providing discharge teaching to a client following a mastectomy. Which of the following client statements indicates an improving body image?
"When will all this pain start to go away?"
"Do I have to go home with drains?"
"The incision looks like it is healing."
"My sister will change the dressing every day."
A nurse is assessing a client who is receiving a unit of packed RBs. The client appears flushed and reports low-back pain. Which of the following actions is the nurse's priority?
Notify the blood bank.
Collect a urine specimen.
Stop the transfusion.
Begin an infusion of 0.9% sodium chloride through new tubing.
A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility?
Stiffness in the lower extremities
Difficulty hearing some types of sounds
A reddened area over the sacrum
Difficulty moving the upper extremities
A nurse is providing anticipatory guidance about child development to the parents of a preschooler. Which of the following developmental tasks should the nurse include as being expected of a preschooler?
Controls impulsive feelings
Expresses need for privacy
Participates in imaginary play
Builds a collection of cards
A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs?
Administer medication to sedate the client.
Call the family and ask them to stay with the client.
Move the client to a room closer to the nurses' station
Apply wrist and leg restraints to the client.
A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?
Obtain a pair of slipper-socks for the client.
Increase the client's oral fluid intake.
Rub the client's feet briskly for several minutes.
Place a moist heating pad under the client's feet.
A nurse is assessing the psychosocial development of a toddler. The nurse should recognize that this stage is characterized by which of the following?
Erikson's stage of initiative versus guilt
Demonstrations of sexual curiosity
Imaginary playmates
Negative behaviors characterized by the need for autonomy
A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention?
Intake and output
Tissue turgor
Daily weight
Sodium level
A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures?
Abduction pillow
Trochanter roll
Footboard
Sheepskin heel pad
A nurse is teaching a middle-age client about hypertension. Which of the following information should the nurse include in the teaching?
"Limit your alcohol consumption to three drinks a day."
"Diuretics are the first type of medication to control hypertension."
"Plan to lower saturated fats to 10 percent of your daily calorie intake."
"Reaching your goal blood pressure will occur within 2 months."
A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort?
Stop the enema and document that the client did not tolerate the procedure.
Encourage the client to bear down.
Lower the height of the solution container.
Allow the client to expel some fluid before continuing.
A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?
Ensure four fingers fit under the restraints to prevent constriction.
Anticipate removing the restraints every 4 hr.
Secure the restraints using a quick-release tie.
Secure the restraints to the lowest bar of the side rail.
A nurse is planning nutritional teaching for a client who is experiencing fatigue due to iron deficiency anemia. Which of the following foods should the nurse recommend to the client?
Black beans
Ice cream
Black tea
Whole milk
A nurse is discussing good food choices with a client who is recovering from an exacerbation of inflammatory bowel disease and is to stal lactose diet. Which of the following foods is the best choice for the client?
Cheddar cheese
Soy milk
Low-fat yogurt
Cottage cheese
When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. Which of the following actions should the nurse take?
Inform the charge nurse and administer the dose of the medication the provider prescribed.
Contact the provider to question the dosage.
Ask another nurse to verify that the dosage is appropriate for the client
Contact the pharmacy and confirm that the dosage is safe to administer.
A nurse in a provider's office is collecting a health history from a client who is at risk for primary osteoporosis. Which of the following findings is a risk factor for the development of osteoporosis?
Sedentary lifestyle
Long-term use of diuretics
Prolonged stress
Obesity
A nurse is assisting with the admission of a client to an inpatient unit. Which of the following sources of information should the nurse rely on for accurate information about the client?
Family information
Progress note
Medical history
Client concerns
A nurse is providing nutritional teaching to a client who has osteoporosis. Which of the following foods should the nurse recommend as being the highest in calcium?
1 plain baked potato
3 oz canned salmon
1 cup chopped chicken breast
1 cup carrot strips
A nurse on an inpatient mental health unit is caring for a client who has major depressive disorder and malnutrition. Which of the following actions should the nurse take to improve the client's nutritional status?
Weigh the client at the same time every morning.
Sit with the client during meals and snacks.
Enroll the client in a nutritional class on the unit.
Ask provider to arrange a consultation with the facility chaplain.
A nurse is teaching a client who has a new prescription for ibuprofen to treat hip pain. Which of the following instructions should the nurse include in the teaching?
Store the medication in the refrigerator.
Expect ringing in your ears.
Take the medication with food.
Monitor for weight loss.
A nurse is establishing health promotion goals for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should the nurse include?
The client will increase calorie intake by 200 cal per day.
The client will walk for 30 min 5 days a week.
The client will list foods that are high in calcium, which should be avoided.
The client will replace cigarettes with smokeless tobacco products.
A nurse is caring for a client in the orientation phase of the nurse-client relationship. Which of the following communication techniques should the nurse use during this phase?
Review the client's progress toward personal objectives.
Encourage the client to use self-exploration.
Elicit information from the client.
Talk with others who have information about the client.
The nurse is practicing which of the following ethical concepts when the client refuses to drink a between meal protein and calorie supplement?
Autonomy
beneficent
A nurse is caring for a client who is undergoing a lumbar puncture. Which of the following is the priority action for the nurse take to maintain privacy for the client?
Use sterile drapes to cover the client.
Ask family members to leave the room.
Exposing the patient unnecessarily
Pull the curtains around the client's bed.
A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure?
Nurse
Anesthesiologist
Surgical suite nurse
Surgeon
A nurse in an acute care setting is serving on a committee whose charge is to use the auditing process to client care. Which of the following aspects of client care is measured by a process audit?
Length of facility stay for a cohort of clients
Quality of nursing care provided
Availability of resources, such as fire extinguishers
Nursing staff ratios
A nurse is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the nurse expect?
РасО2 50 mm Hg
Potassium 3.3 mEg/L
HCO3-30 mEQ/L
PH 7.45
A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select all that apply.)
Contractures of the extremities
Diarrhea
Polyuria
Pressure ulcers
Crackles in the lungs
A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see?
Pa02 below 70 mm Hg
pH below 7.35
HCO3 above 26 mEq/L
PaCO, above 45 mm Hg
A nurse is assessing a child and notes several bruises. Which of the following actions should the nurse take?
Report the suspected abuse to the authorities
Separate the child from the parents.
Ask a psychiatrist to talk with the parents.
Obtain a detailed history.
A nurse is reinforcing teaching about nutritional considerations with the parents of a toddler. Which of the following statements by the parents indicates an understanding of the teaching?
"The quality of food I provide him is more important than the quantity."
"His average daily intake should be about 3,000 calories."
"Because he is such a picky eater, I will give him one of my vitamins each day.
"I should expect him to have an increased appetite."
A nurse is caring for a client who has a postoperative ileus and an NG tube that has drained 2,500 ml in the past 6 hr. Which of the following electrolyte imbalances should the nurse monitor the client for?
Elevated magnesium level
Decreased potassium level
Elevated sodium level
Decreased calcium level
A nurse in a clinic is teaching a group of clients about preventing low back pain and injury. Which of the following statements should the nurse identify as an indication that the client requires further clarification?
"'lI carry heavy objects close to my body."
"I'II sit with my knees lower than my hips."
"I'II do exercises that strengthen my abdominal muscles."
"I'II wear low-heeled shoes from now on."
A nurse on a medical-surgical unit is planning to delegate tasks to an adult volunteer. Which of the following tasks should the charge nurse avoid assigning to the volunteer?
Delivering a routine urine specimen to the laboratory
Assisting a client who has difficulty seeing the foods on the tray while eating
Observing a postoperative client who is confused and need constant assessment
Delivering meal trays to clients in their rooms
A nurse receives a unit of packed RBs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the following times?
As soon as the nurse can prepare the client and the administration set
When the client has finished eating lunch
When the client states he is ready to stars the infusion
2 hr after obtaining blood from the blood bank
A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs?
рН 7.22
PaCO, 68 mm Hg
Base excess -2
Pa0, 78 mm Hg
Saturation 80%
Bicarbonate 26 mEq/L
Respiratory alkalosis
Respiratory acidosis
Metabolic alkalosis
Metabolic acidosis
A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Which of the following actions is an example of a violation of confidentiality?
Discussing a client's surgical procedure with the nurse manager
Reporting laboratory findings to a member of the client's family
Identifying the client by name when making a referral for home health services
Notifying the provider of physical examination findings
A nurse is preparing to remove staples from a client's surgical incision. Which of the following actions should the nurse take? (Select all that apply.)
Clean the surgical site.
Do not explain the procedure to the patient.
Assure the client there will be no discomfort during the procedure.
Examine the incision.
Verify the prescription for staple removal.
A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CA). Which of the following parameters should the nurse use first in order to assess the client's pain level?
scheduled treatments and client illness
behavioral indicators and effect
pulse and blood pressure findings
a self-report pain rating scale
A nurse is providing care to a client who is on strict bed rest following surgery. The nurse assists the patient to the bedside commode and the client sustains an injury to the operative area. Which of the following types of torts has the nurse committed?
Assault
Invasion of privacy
Battery
Negligence
A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider?
Urinary output 35 mL/hr
Pain of 2 on a scale of 0 to 10
Heart rate 89/min
Difficulty swallowing
A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client?
A room in the ICU
A room that is within view of the nurses' station
A room with another nonsurgical client
A room with negative pressure.
A nurse is receiving change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process?
Collect and organize client data.
Critically analyze client data to determine priorities.
Determine effectiveness of interventions.
Set client-centered, measurable and realistic goals.
A nurse is setting goals for a client who has AIDS and is at the end of life. Which of the following are realistic goals?
The client will experience a weight gain of one to two pounds per week.
The client will receive medication to minimize episodes of breakthrough pain.
The client will verbalize an understanding of the mode of disease transmission.
The client will increase attendance at community social activities.
A nurse is having difficulty caring for a client due to variables affecting the communication process. Which of the following should the nurse identify as an interpersonal variable? (Select all that apply.)
Education
Time
financial status
Gender
Perception
A nurse is reviewing the laboratory test results from a client who has prerenal acute kidney injury (AKI). Which of the following electrolyte imbalances should the nurse expect?
Hypercalcemia
Hyperkalemia
Hypophosphatemia
Hypernatremia
A nurse is assessing a client who has malnutrition. Which of the following findings should the nurse expect?
Decreased mental status
Maist skin
Heat intolerance
Increased vital capacity
A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?
Advise the client to add citrus juices and bananas to her diet.
Obtain a blood sample for a serum sodium level.
Obtain a 12-lead ECG.
Suggest that the client use a salt substitute.
A nurse is planning home care for a 9-year-old child following an acute exacerbation of asthma. Which of the following of Erikson's developmental stages should the nurse consider in the planning?
Initiative vs. guilt
Autonomy vs. shame and doubt
Industry vs. inferiority
Identity vs. role confusion
A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. Which of the following statements should the nurse make?
"Everyone knows there are others who can chair this committee better than me."
"I decline the opportunity at this time."
"It's just not the right time for me to do this."
"Can you tell me why you chose me?"
While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care?
Impaired tissue perfusion
Alteration in body image
Impaired skin integrity
Alteration in activity tolerance
A nurse is reviewing the laboratory results of an adolescent female client and notes a WBC count of 16,000/mm? with increased immature neutrophils (bands) and normal monocytes. Which of the following is the appropriate analysis of the results?
A resolving inflammatory process
Allergic reaction
Neutropenia
An acute infectious process
A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the priority?
Assign a staff member to stay with the client at all times.
Remove any objects from the client's environment that could be used for self-harm.
Lock the doors to the unit and secure windows so they cannot be opened.
Provide the client with plastic eating utensils for meals.
A nurse is instructing a young adult client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further teaching?
"I have a small snack and take a bath before going to bed each day."
"I don't take naps throughout the day."
"I watch television until I fall asleep at night."
"I go to bed and get up routinely at the same time each day."
A nurse is assessing a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding?
Increasing sense of attachment to others.
Sleeping 12 hr or more each day.
Constant need to talk about the event.
Increasing feelings of anger.
A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse?
Determine if the client uses hearing aids
Stand directly in front of the client
Rephrase statements the dient does not hear.
Speak using his usual tone of voice.
A nurse is caring for a client who has an indwelling urinary catheter and notes blood tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations?
Bladder infection
Bladder decrees
