Which of the following client statements indicates a need for additional teaching about selfcare during pregnancy?

The patient's intake and output record contains the following information: milk, 180 ml; orange juice, 60 ml; one serving scrambled eggs; one slice toast; one can Ensure oral nutritional supplement, 240 ml; I.V. dextrose 5% in water at 100 mL/hour; 50 ml water after twice daily medications. Medications are given at 9:00 a.m. and 9:00 p.m. What is the patient's total intake for the 7 a.m. to 3 p.m. shift?

A client with breast cancer is returned to the room following a right total mastectomy. The nurse should:

The nurse is performing a physical assessment on a client. The nurse asks the client to flex the neck. The neck flexion results in flexion of the hip and knee which is known as Brudzinski's sign.Which condition is associated with Brudzinski's sign?

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:

The nurse studies an electrocardiogram (EKG) and notices a U-wave. The nurse suspects that this is caused by:

The nurse cares for client who is status post lung transplant. The client has a double thoracotomy incision. Which drug may impair healing of the incision?

The client is admitted to the unit after a motor vehicle accident with a temperature of 102ºF rectally. The nurse is aware that the most likely explanation for the elevated temperature is:

The nurse is providing dietary teaching for a client with elevated cholesterol levels. Which cooking oil is not suggested for the client on a low-cholesterol diet?

A client is admitted to the hospital with a blood pressure of 85/53 mm Hg and is complaining of light-headedness and near syncope. The client's current medications include carvedilol (Coreg), amiodarone (Cordarone), warfarin (Coumadin), lanoxin (Digoxin), furosemide (Lasix), potassium (K-Dur), and a daily vitamin. The client also reports using both St. John's wort and cat's claw. Based upon this information, what is the nurse's best action?

A secondary latency phase that occurs in some diseases that is commonly followed by another acute phase is referred to as:

An elderly client comes to the physician's office with complaints of sleep deprivation.What is the best action the nurse can take to help the client promote sleep?

The nurse is teaching the parents of an infant with osteogenesis imperfecta. The nurse should explain the need for:

For which client would the use of acetaminophen (Tylenol) pose a higher risk?

The client is having fetal heart rates of 100-110bpm during the contractions. The first action the nurse should take is:

Which of the following play activities is most developmentally appropriate for the toddler?

The nurse cares for a client who recently underwent surgery to create a stoma for colostomy. The nurse notes that the stoma is dark and dusky in color.What action should the nurse immediately take?

A nurse working in a Planned Parenthood clinic routinely asks clients about experiencing possible domestic violence. The advantage of this line of questioning is that it:

A client with rheumatoid arthritis is being treated with daily steroid medication. Which food should the client avoid?

A patient with a gunshot wound requires an emergency blood transfusion. His blood type is AB Rh-negative. Which blood type would be the safest for him to receive?

A client is admitted with a diagnosis of hypothyroidism. An initial assessment of the client would reveal:

Which one of the following factors has the greatest influence on the recovery and sobriety of a client with a chemical addiction?

Which of the following is a characteristic of a reassuring fetal heart rate pattern?

Which of the following recommendations would be most helpful to suggest to a primigravid client at 37 weeks' gestation who is complaining of leg cramps?

After administering hydralazine (Apresoline) 5 mg intravenously as ordered for a primigravid client with severe preeclampsia at 39 weeks' gestation, the nurse should assess the client for:

A patient, age 58, is admitted with complaints of anorexia, weight loss, and general body wasting. After a diagnostic workup, he is diagnosed with Addison's disease. Which statement best describes the pathophysiology of Addison's disease?

If the nurse is unable to illicit the deep tendon reflexes of the patella, the nurse should ask the client to:

The physician has ordered that the client's medication be administered intrathecally. The nurse is aware that medications will be administered by which method?

Sensitive and skilled end-of-life care for clients and family members is critical for gerontological family nurses. Which is a common concern for clients and families experiencing the end of life?

The chart indicates that a client has expressive aphasia following a stroke. The nurse understands that the client will have difficulty with:

Which of the following laboratory results would cause the most concern in the immunosuppressed client?

An 82-year-old female client who recently relocated to the United States from a small Caribbean island is treated for a laceration to the right forearm. The physician orders both tetanus immune globulin human (Baytet) (TIG), and diptheriatetanus (DT).Which is a true statement regarding this client's medication care?

While monitoring a patient's cardiac rhythm, the nurse observes seven multifocal premature ventricular contractions (PVCs) on a 1-minute rhythm strip. What should the nurse do first?

The patient is prescribed metronidazole (Flagyl) for adjunct treatment for a duodenal ulcer. When teaching about this medication, the nurse would say:

Which of the following statements reflects Kohlberg's theory of the moral development of the preschool-age child?

A client is admitted with a diagnosis of hypothyroidism. An initial assessment of the client would reveal:

A client in sickle cell crisis has been hospitalized during her pregnancy. After giving discharge instructions, the nurse determines the client needs further teaching when she states which of the following?

A client receiving an injection of morphine requests "my buttocks be used for the injection." The nurse explains that this site is not preferred because it is in close proximity to:

A client is hospitalized with hepatitis A. Which of the client's regular medications is contraindicated due to the current illness?

The nurse provides education to a client after the client receives an initial external beam radiation treatment for melanoma. The nurse should instruct the client to:

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:

The physician has ordered a straight catheterization for a female client. When performing a straight catheterization on a female client, the nurse should:

A patient with peptic ulcer disease secondary to chronic NSAID use is prescribed misoprostol (Cytotec). The nurse would be most accurate in informing the patient that the drug:

A nurse working in a Planned Parenthood clinic routinely asks clients about experiencing possible domestic violence. The advantage of this line of questioning is that it:

An elderly patient has a wound that is not healing normally. Interventions should be based on which principle or test results?

When developing the teaching plan for a primigravid client at 30 weeks' gestation diagnosed with mild preeclampsia who is being treated at home, which of the following would the nurse identify as the most appropriate client-centered goal?

After administering hydralazine (Apresoline) 5 mg intravenously as ordered for a primigravid client with severe preeclampsia at 39 weeks' gestation, the nurse should assess the client for:

Many facilities allow the client's family to be present during resuscitative efforts of the client.What is the advantage to having family present during resuscitation of a client?

A child with cystic fibrosis takes pancreatic enzymes with each of his meals and between meal snacks. Which finding indicates that the prescribed amount of pancreatic replacement is adequate?

A patient with a gunshot wound requires an emergency blood transfusion. His blood type is AB Rh-negative. Which blood type would be the safest for him to receive?

The nurse is caring for a client with a head injury who has increased ICP. The physician plans to reduce the cerebral edema by constricting the cerebral blood vessels. Which of the following would accomplish this action?

A client tells the nurse, "There's no point in quitting cigarette smoking at my age. I have smoked for 40 years." The nurse:

An intravenous infusion of normal saline is ordered at 150 milliliters per hour. Using tubing that has a drip rate factor of 15, how many drops per minute should the nurse deliver?

A client with a total hip replacement requires special equipment. Which equipment would assist the client with a total hip replacement with prevention of dislocation of the prosthesis?

The nurse is obtaining a history of an 80-year-old client. Which statement made by the client might indicate a possible fluid and electrolyte imbalance?

A client with congestive heart failure loses 4.1kg while hospitalized. The client's weight loss is approximately:

A patient, age 63, is resuscitated successfully after cardiac arrest. Blood studies show he is acidotic—a common finding in patients who have suffered cardiac arrest. What is the most likely explanation for the acidic serum pH?

A 25-year-old male is brought to the emergency room with a piece of metal in his eye. Which action by the nurse is correct?

An obese 36-year-old multigravid client at 12 weeks' gestation has a history of chronic hypertension. She was treated with methyldopa (Aldomet) before becoming pregnant. When counseling the client about diet during pregnancy, the nurse realizes that the client needs additional instruction when she states which of the following?

A child with cystic fibrosis takes pancreatic enzymes with each of his meals and between meal snacks. Which finding indicates that the prescribed amount of pancreatic replacement is adequate?

When developing the teaching plan for a primigravid client at 30 weeks' gestation diagnosed with mild preeclampsia who is being treated at home, which of the following would the nurse identify as the most appropriate client-centered goal?

An antenatal G 2, T 1, P 0, Ab 0, L 1 client is discussing her postpartum plans for birth control with her health care provider. In analyzing the available choices, which of the following factors has the greatest impact on her birth control options?

The nurse is teaching the patient with multiple sclerosis. When teaching the patient how to reduce fatigue, the nurse should tell the patient to:

The Joint Commission for Accreditation of Hospital Organizations (JCAHO) specifies that two client identifiers are to be used before medication administration. Which method is best for identifying patients using two patient identifiers?

The nurse prepares a client for a bedside thoracentesis. The nurse helps the client into a sitting position with a pillow placed on top of the overbed table in front of the client for support. The nurse understands that this is the correct client position for a thoracentesis because:

The nurse notes that a client has a blood pressure of 102/56 mm Hg, pulse of 94 beats/minute, and respiratory rate of 6 breaths/minute. The client is pale, with cyanotic lips and nail beds. The nurse suspects a reaction to medication.Which medication is most likely the cause of these symptoms?

A patient with a gunshot wound requires an emergency blood transfusion. His blood type is AB Rh-negative. Which blood type would be the safest for him to receive?

The nurse who works in the emergency department cares for a client who was bitten by a stray cat. Which gram-negative causative organism is found in 75% of cat bite wound infections?

The physician orders intravenous magnesium sulfate for a primigravid client at 38 weeks' gestation diagnosed with severe preeclampsia. Which of the following medications should the nurse have readily available at the client's bedside?

The physician has ordered that the client's medication be administered intrathecally. The nurse is aware that medications will be administered by which method?

The nurse is caring for a client with a head injury who has increased ICP. The physician plans to reduce the cerebral edema by constricting the cerebral blood vessels. Which of the following would accomplish this action?

Medications used to treat peptic ulcer disease such as ranitidine (Zantac) work by:

An hour after receiving pyridostigmine bromide, a patient reports difficulty swallowing and excessive respiratory secretions. The nurse notifies the physician and prepares to administer which medication?

A client with ulcerative colitis has impaired nutrition due to diarrhea. Which diet selection by the client would indicate a need for further teaching about foods that can worsen the diarrhea?

A client has just had a nasogastric tube placed. What is the best method for verifying correct placement of the tube in the stomach?

The physician has prescribed Gantrisin (sulfasoxazole) 1 gram in divided doses for a client with a urinary tract infection. The nurse should administer the medication:

The physician has prescribed Cognex (tacrine) for a client with dementia. The nurse should monitor the client for adverse reactions, which include:

If the nurse is unable to illicit the deep tendon reflexes of the patella, the nurse should ask the client to:

During an initial morning assessment, a client appears to be hallucinating; complaining about "bugs on the wall" and "the dog that ran under the bed." The nurse reorients the client to person, place, and time and the client demonstrates good recall of the information. After the client receives the morning medications, the hallucinations begin again. The nurse notifies the physician that the client's hallucinations returned shortly after the medications were administered. The physician requests the nurse to call the clinical pharmacist to evaluate the client's medication list for a possible medication source of the hallucinations. The actions of the nurse resulted in:

A 2-year-old client has an order for instillation of antipyrine and benzocaine otic (Auralgan) into the external ear canal. Which action by the nurse is correct?

The nurse who works in the emergency department cares for a client who was bitten by a stray cat. Which gram-negative causative organism is found in 75% of cat bite wound infections?

The nurse is assessing a multigravida, 36 weeks gestation for symptoms of pregnancy-induced hypertension and preeclampsia. The nurse should give priority to assessing the client for:

The client is having fetal heart rates of 100-110bpm during the contractions. The first action the nurse should take is:

A client undergoes hip replacement surgery and requires assistance to ambulate. The client needs to use the bathroom, but the call light has been left out of reach rendering the client unable to summon staff for assistance. Which client right is violated?

A nurse is assessing a client hospitalized with peptic ulcer disease. Which finding should be reported to the charge nurse immediately?

The nurse is caring for a client with an opportunistic infection of the central nervous system. The nurse knows that opportunistic infections affecting the central nervous system are extremely likely once the CD4 count drops below which level?

The client is receiving peritoneal dialysis. If the dialysate returns cloudy, the nurse should:

The nurse is caring for a 22-year-old G 2, P 2 client who has disseminated intravascular coagulation after delivering a dead fetus. Which findings are the highest priority to report to the health care provider?

A patient, age 48, is recovering from an MI. When preparing him for discharge, the nurse should include all of the following instructions except:

A client's potassium level is 5.38 mEq/L. Which drug should the nurse expect the physician to order?

A client starts filgrastim (Neupogen) injections 11 days after completing a course of chemotherapy. Which lab value indicates the neupogen is effective?

A secondary latency phase that occurs in some diseases that is commonly followed by another acute phase is referred to as:

The client is having fetal heart rates of 100-110bpm during the contractions. The first action the nurse should take is:

The influenza vaccine is contraindicated in clients with allergies to which of the following?

A client is admitted to the hospital with a blood pressure of 85/53 mm Hg and is complaining of light-headedness and near syncope. The client's current medications include carvedilol (Coreg), amiodarone (Cordarone), warfarin (Coumadin), lanoxin (Digoxin), furosemide (Lasix), potassium (K-Dur), and a daily vitamin. The client also reports using both St. John's wort and cat's claw. Based upon this information, what is the nurse's best action?

The nurse is reviewing laboratory results. Serum sodium of 156mEq/L is noted. What changes would the nurse expect the client to exhibit?

A client receives rabies immunization after being bitten by a bat. Which statement is correct?

The nurse cares for client who is status post lung transplant. The client has a double thoracotomy incision. Which drug may impair healing of the incision?

A primigravid adolescent client at approximately 15 weeks' gestation who is visiting the prenatal clinic with her mother is to undergo alphafetoprotein (AFP) screening. When developing the teaching plan for this client, the nurse should include which of the following?