1.A nurse is admitting a client who has a diagnosis of preterm labor. The nurse anticipates a prescription by the provider for which of the following medications? (Select all that apply.)
- Prostaglandin E₂
- Indomethacin
- Magnesium sulfate
- Methylergonovine
- Oxytocin
Explanation: In preterm labor, the goal is to delay delivery to allow the fetus more time to develop. Indomethacin is a nonsteroidal anti-inflammatory drug (NSAID) often used as a tocolytic to reduce uterine contractions. **Magnesium sulfate** is also used as a tocolytic to relax the uterus and is sometimes given for neuroprotection of the fetus in preterm labor.
2.A nurse in a pediatric clinic is caring for a client who is postpartum and asks the nurse what to do when her newborn cries persistently. Which of the following strategies should the nurse suggest? (Select all that apply.)
- Take the newborn for a ride in the car.
- Keep the newborn in the center of a large crib.
- Carry the newborn in a front or back pack.
- Swaddle the newborn in a receiving blanket.
- Allow the newborn to continue crying.
Explanation: Persistent crying in a newborn can often be soothed by comforting techniques. Carrying the newborn in a front or back pack provides close physical contact, which can be calming. Swaddling the newborn in a receiving blanket mimics the womb environment, helping to soothe the baby.
3.A nurse on an inpatient eating disorders unit is caring for a client who has anorexia nervosa and has a body mass index of 17.2. Which of the following actions should the nurse take? (Select all that apply.)
- Provide the client with small meals frequently.
- Monitor the client’s weight daily.
- Allow the client to choose the meals she will eat.
- Stay with the client during meals and for 1 hr afterward.
- Offer specific privileges for sustained weight gain.
Explanation: For a client with anorexia nervosa, the focus is on safe weight restoration and addressing disordered eating behaviors. Providing small meals frequently helps prevent overwhelming the client and supports gradual refeeding. Monitoring the client’s weight daily ensures progress and helps detect any complications like refeeding syndrome. Staying with the client during meals and for 1 hr afterward prevents purging or hiding food, which are common behaviors in anorexia. Offering specific privileges for sustained weight gain can motivate the client to meet treatment goals.
4.A nurse is teaching a client who has a new diagnosis of urge incontinence. Which of the following information should the nurse include in the teaching? (Select all that apply.)
- "Your provider might prescribe anticholinergic medications."
- "You should limit fluids in the evening."
- "You should restrict your intake of caffeine."
- "You might require intermittent urinary catheterization."
- "You might require an anterior vaginal repair."
Explanation:
Urge incontinence involves sudden, involuntary bladder contractions leading to urine leakage. Anticholinergic medications help relax the bladder muscle, reducing urgency. Limiting fluids in the evening can decrease nighttime urgency and incontinence episodes. Restricting caffeine intake is advised because caffeine is a bladder irritant that can worsen symptoms.
5.A nurse is planning to assign care activities to the assistive personnel (AP) on her team. Which of the following activities can the nurse assign to the AP? (Select all that apply.)
- Accompany a client who has depression to occupational therapy.
- Assess a client who has hypomania for exhaustion.
- Check the position of a client in soft wrist restraints.
- Set limits with a client who has mania.
- Sit with a client who has alcohol use disorder and whose last drink was five days ago.
Explanation:
Assistive personnel (AP) can perform tasks that do not require nursing judgment or assessment. Accompanying a client to occupational therapy is a supportive task that an AP can handle. Checking the position of a client in soft wrist restraints involves ensuring comfort and safety, which is within an AP’s scope under nurse supervision. Sitting with a client who has alcohol use disorder (who is likely past the acute withdrawal phase if the last drink was five days ago) provides companionship and observation, which an AP can do.
6.A charge nurse is preparing an educational session about addictive disorders for nursing staff. Which of the following should the nurse include as an etiological factor of addictive disorders? (Select all that apply.)
- Being female
- Low self-esteem
- Family history of addiction
- Personality disorder
- Asian ethnicity
Explanation:
Addictive disorders have multiple etiological factors. Low self-esteem can contribute to substance use as a coping mechanism. Family history of addiction indicates a genetic predisposition and environmental influence, increasing risk. Personality disorders, such as borderline or antisocial personality disorder, are often associated with higher rates of addiction due to impulsivity and emotional dysregulation.
7.A nurse is teaching a client about risk factors for osteoarthritis. Which of the following factors should the nurse include in the teaching? (Select all that apply.)
- Bacteria
- Diuretics
- Aging
- Obesity
- Smoking
Explanation:
Osteoarthritis is a degenerative joint disease influenced by mechanical and physiological factors. Aging is a primary risk factor because cartilage wears down over time. Obesity increases stress on weight-bearing joints like the knees and hips, accelerating cartilage breakdown.
8.A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder? (Select all that apply.)
- Genetic predisposition
- Hypercholesterolemia
- Hypertension
- Obesity
- Smoking
Explanation:
Atherosclerosis involves plaque buildup in arteries, and modifiable risk factors are those that can be changed through lifestyle or medical intervention. Hypercholesterolemia (high cholesterol) contributes to plaque formation and can be managed with diet, exercise, or medication. Hypertension (high blood pressure) damages arterial walls, increasing plaque buildup, and can be controlled with lifestyle changes or medication. Obesity increases the risk of atherosclerosis by contributing to other risk factors like hypertension and hypercholesterolemia, and it can be addressed through weight management. Smoking damages blood vessels and promotes plaque formation, but it can be stopped.
9.A nurse is preparing a client for surgery. Prior to administering the prescribed hydroxyzine, the nurse should explain to the client that the medication is for which of the following indications? (Select all that apply.)
- Controlling emesis
- Diminishing anxiety
- Reducing the amount of narcotics needed for pain relief
- Preventing thrombus formation
- Drying secretions
Explanation:
Hydroxyzine is an antihistamine with multiple uses in the preoperative setting. It helps in controlling emesis (nausea and vomiting) by acting on the central nervous system. It is also used for diminishing anxiety due to its sedative properties, helping to calm the client before surgery. Additionally, hydroxyzine has anticholinergic effects that help in drying secretions, which can reduce the risk of aspiration during anesthesia.
10.A nurse is providing dietary teaching to a client who has chronic kidney disease (CKD). The nurse should instruct the client to limit the following nutrients? (Select all that apply.)
- Protein
- Calcium
- Calories
- Phosphorus
- Sodium
Explanation:
In chronic kidney disease (CKD), dietary restrictions are necessary to reduce the workload on the kidneys and prevent complications. Protein should be limited because the kidneys struggle to excrete the waste products of protein metabolism (e.g., urea), though some protein is still needed for nutrition. Phosphorus must be restricted because impaired kidney function leads to phosphorus buildup, which can cause bone disease and calcification of tissues. Sodium should be limited to prevent fluid retention, hypertension, and edema, as the kidneys cannot effectively regulate sodium balance.
11.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
- Feedback
- Gender
- Perception
- Time
Explanation:
Interpersonal variables in communication are factors related to the individuals involved, such as their personal characteristics or experiences. Education affects how a person processes and understands information, impacting communication. Gender can influence communication styles and expectations (e.g., differences in emotional expression). Perception refers to how individuals interpret messages based on their beliefs, experiences, and biases, which can create barriers in communication.
12.A nurse is reviewing medication records for several clients who have bipolar disorder. The nurse should recognize that which of the following medications are used to treat clients who have bipolar disorder? (Select all that apply.)
- Paroxetine
- Lithium
- Donepezil
- Valproate
- Carbamazepine
Explanation:
Bipolar disorder is typically managed with mood stabilizers. Lithium is a first-line treatment for bipolar disorder, helping to stabilize mood and prevent manic and depressive episodes. Valproate (valproic acid) is another mood stabilizer commonly used, especially for acute mania. Carbamazepine is an anticonvulsant that can also be used as a mood stabilizer in bipolar disorder.
13.A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.)
- Report of feeling pressure
- Tenderness over the symphysis pubis
- Distended bladder
- Voiding 30 mL frequently
- Dysuria
Explanation:
Prostatic hypertrophy (benign prostatic hyperplasia) often leads to urinary retention due to obstruction of the urethra. Report of feeling pressure and tenderness over the symphysis pubis occur because of bladder distension from retained urine. A distended bladder is a physical finding the nurse can palpate or percuss due to the accumulation of urine. Dysuria (painful urination) can result from irritation or infection caused by incomplete bladder emptying.
14.A nurse is caring for an adolescent who is experiencing indications of depression. Which of the following findings should the nurse expect? (Select all that apply.)
- Irritability
- Euphoria
- Insomnia
- Low self-esteem
Explanation:
Depression in adolescents often presents differently than in adults. Irritability is a common symptom in adolescents with depression, often more prominent than sadness. Insomnia (or hypersomnia) is a classic symptom of depression, affecting sleep patterns. Low self-esteem is frequently associated with depression, as adolescents may feel worthless or inadequate.
15.A nurse is providing teaching to a client who has rheumatoid arthritis and a new prescription for methotrexate. Which of the following instructions should the nurse include? (Select all that apply.)
- Expect to feel the medication’s effects immediately.
- Do not drink alcoholic beverages while taking this medication.
- Report unexplained bruising to the provider.
- Avoid people who have infections.
- Take NSAIDs to help minimize the adverse effects of the medication.
Explanation:
Methotrexate is an immunosuppressive medication used for rheumatoid arthritis, and patients need specific instructions to use it safely. Do not drink alcoholic beverages while taking this medication because methotrexate can cause liver toxicity, and alcohol increases this risk. Report unexplained bruising to the provider since methotrexate can cause bone marrow suppression, leading to low platelet counts and increased bleeding risk. Avoid people who have infections because methotrexate suppresses the immune system, increasing the risk of infections.
16.A nurse is teaching a client who has chronic kidney disease about limiting foods that are high in potassium. Which of the following foods should the nurse instruct the client to avoid? (Select all that apply.)
- Green beans
- Tomatoes
- Bananas
- Asparagus
- Raisins
Explanation:
In chronic kidney disease (CKD), the kidneys cannot effectively excrete potassium, so high-potassium foods must be limited to prevent hyperkalemia. Tomatoes (especially in concentrated forms like tomato sauce) are high in potassium. Bananas are well-known for their high potassium content. Raisins (dried grapes) are also high in potassium due to the concentration of nutrients during drying.
17.A nurse is teaching staff which factors to include in an abuse assessment of a client. Which of the following factors should the nurse include in the teaching? (Select all that apply.)
- Suicide risk
- Socioeconomic status
- Coping patterns
- Support systems
- Alcohol use
Explanation:
An abuse assessment requires a holistic approach to identify risk factors and the client’s situation. Suicide risk is critical because abuse victims often experience depression and may be at higher risk for self-harm. Coping patterns help assess how the client deals with stress, which can indicate resilience or vulnerability. Support systems are important to determine if the client has resources or is isolated, a common tactic in abusive situations. Alcohol use is a risk factor, as substance use can exacerbate abusive dynamics or be a coping mechanism for the victim.
18.A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.)
- Excessive laxative use
- Ignoring the urge to defecate
- Inadequate fluid intake
- Increased fiber in the diet
- Increased activity
Explanation:
Constipation can result from various factors. Excessive laxative use can lead to dependency, reducing the bowel’s natural ability to function. Ignoring the urge to defecate can cause stool to become harder and more difficult to pass over time. Inadequate fluid intake leads to dehydration, making stools harder and more difficult to pass.
- A nurse is caring for an older adult client who has had surgery for an intestinal obstruction and has an NG tube to wall suction. Which of the following interventions should the nurse include in the client’s postoperative plan of care? (Select all that apply.)
- Discontinue suction when assessing for peristalsis.
- Irrigate the NG tube with 0.9% sodium chloride irrigation solution.
- Place sequential compression devices on the bilateral lower extremities.
- Reposition the client from side to side every 2 hr.
- Encourage the use of an incentive spirometer every 2 hr while the client is awake.
Explanation:
Postoperative care for a client with an intestinal obstruction and an NG tube focuses on monitoring recovery and preventing complications. Discontinue suction when assessing for peristalsis because the suction noise can interfere with hearing bowel sounds, which indicate the return of bowel function. Place sequential compression devices on the bilateral lower extremities to prevent deep vein thrombosis (DVT), a risk in postoperative clients with limited mobility. Reposition the client from side to side every 2 hr to prevent pressure ulcers and promote circulation. Encourage the use of an incentive spirometer every 2 hr while the client is awake to prevent atelectasis and pneumonia, common postoperative complications in older adults.
20.A nurse is caring for a client who is 1 day postoperative following a mastectomy. Which of the following exercises should the nurse assist the client to perform on the affected side? (Select all that apply.)
- Squeezing a rolled washcloth
- Flexing and extending her hand
- Flexing and extending her elbow
- Rotation of her shoulder
- Hand wall climbing
Explanation:
Post-mastectomy exercises on the affected side aim to restore mobility and prevent lymphedema while avoiding strain in the early postoperative period (1 day post-op). Squeezing a rolled washcloth and flexing and extending her hand are gentle exercises that promote circulation and prevent stiffness in the hand and fingers. Flexing and extending her elbow is a safe early exercise to maintain arm mobility without overextending the surgical site.
21.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.)
- Skipping more than three meals per week
- Eating fast food once weekly
- Hearty appetite
- Eating with family supervision frequently
- Frequently skipping breakfast
Explanation:
Nutritional risk in adolescents can lead to inadequate intake of essential nutrients, affecting growth and development. Skipping more than three meals per week indicates a pattern of inadequate food intake, which can lead to nutritional deficiencies. Frequently skipping breakfast is a common behavior in adolescents that can result in poor energy levels, reduced concentration, and overeating later due to hunger.
22.A nurse is assessing a client who has narcolepsy. Which of the following findings should the nurse expect? (Select all that apply.)
- A lack of rapid eye movement (REM) sleep
- Sudden attacks of sleep
- Hallucinations at the onset of sleep
- Sleep apnea
- The urge to move the legs when trying to sleep
Explanation:
Narcolepsy is a neurological disorder characterized by excessive daytime sleepiness and abnormal REM sleep patterns. Sudden attacks of sleep are a hallmark symptom, where the client falls asleep uncontrollably during the day. Hallucinations at the onset of sleep (hypnagogic hallucinations) are common in narcolepsy, often occurring as the client transitions into sleep.
23.A nurse is preparing to discharge a child who has a new prescription for an oral antibiotic. Which of the following information should the nurse include in the discharge instructions? (Select all that apply.)
- The reason why the child is taking the medication
- Written information about the medication
- Stopping the medication when the child feels better
- The adverse effects of the medication
- Using a kitchen spoon to administer the medication
Explanation:
Discharge instructions for a child starting an oral antibiotic should ensure safe and effective use. The reason why the child is taking the medication helps the caregiver understand the purpose (e.g., treating an infection) and encourages adherence. Written information about the medication provides a reference for dosing and administration. The adverse effects of the medication should be explained so the caregiver can monitor for and report any concerning side effects (e.g., rash, diarrhea).
24.A nurse is developing a plan of care for a client who has a new ileal conduit. The nurse should include that the client is at risk for which of the following? (Select all that apply.)
- Anxiety
- Disturbed body image
- Impaired skin integrity
- Infection
- Fluid volume deficit
Explanation:
An ileal conduit is a urinary diversion created after bladder removal (e.g., for bladder cancer), where a stoma is formed to drain urine. Anxiety is common due to the significant lifestyle change and adjustment to the stoma. Disturbed body image occurs because of the altered appearance and function of the body. Impaired skin integrity is a risk due to potential irritation or breakdown around the stoma from urine leakage or improper appliance fit. Infection is a concern because the stoma provides a direct entry point for bacteria, and urinary tract infections are common.
25.A nurse is caring for a client who has Cushing’s syndrome. The nurse should recognize that which of the following are manifestations of Cushing’s syndrome? (Select all that apply.)
- Alopecia
- Tremors
- Moon face
- Purple striations
- Buffalo hump
Explanation:
Cushing’s syndrome results from excessive cortisol levels, leading to characteristic physical changes. Moon face is a classic sign, with a rounded, full face due to fat redistribution. Purple striations (striae) occur on the abdomen, thighs, or breasts due to weakened connective tissue from cortisol excess. Buffalo hump refers to fat accumulation at the base of the neck, another hallmark of cortisol-induced fat redistribution.
26.A nurse is assessing a client who is withdrawing from alcohol. Which of the following findings should the nurse expect? (Select all that apply.)
- Severe hypotension
- Visual hallucinations
- Hyperglycemia
- Insomnia
- Tremors
Explanation:
Alcohol withdrawal occurs when a dependent individual stops drinking, leading to central nervous system hyperactivity. Visual hallucinations are common in severe withdrawal, such as in delirium tremens, which can occur 48-72 hours after the last drink. Insomnia is a frequent symptom due to the stimulatory effects of withdrawal on the brain. Tremors (shakiness) are a classic early sign of alcohol withdrawal, often starting within 6-12 hours.
27.A nurse in a mental health clinic is conducting a staff education session on schizophrenia. Which of the following manifestations should the nurse identify as negative symptoms? (Select all that apply.)
- Delusions
- Hallucinations
- Anhedonia
- Poor judgment
- Blunt affect
Explanation:
Negative symptoms of schizophrenia refer to the absence or reduction of normal behaviors and emotions. Anhedonia is the inability to experience pleasure, a common negative symptom. Blunt affect refers to a lack of emotional expression, another negative symptom.
28.A home health nurse is conducting a home safety assessment for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? (Select all that apply.)
- Bathtub with rails
- Electric cords behind the furniture
- Raised toilet seats
- Water heater temperature 54.4°C (130°F)
- Throw rugs
Explanation:
Home safety assessments for older adults focus on reducing fall risks and preventing injuries. Electric cords behind the furniture pose a tripping hazard if they are not secured properly. Water heater temperature 54.4°C (130°F) is too high; it should be set at 49°C (120°F) or lower to prevent scalding. Throw rugs are a fall risk because they can slip or cause tripping, especially for older adults with mobility issues.
29.A nurse is performing care activities for a client in the zone of touch that requires his consent. Which of the following activities should the nurse perform in this zone? (Select all that apply.)
- Removing the client’s dentures
- Checking capillary refill beneath the client’s fingernail
- Palpating for pedal edema
- Counting a radial pulse
- Assessing a mole on the client’s shoulder
Explanation:
The zone of touch requiring consent (intimate zone) includes areas of the body that are private or sensitive, where touch may feel invasive without permission. Removing the client’s dentures involves touching the mouth, an intimate area, and requires consent. Assessing a mole on the client’s shoulder may involve exposing and touching a potentially private area, also requiring consent.
31.A nurse in the emergency department is implementing a plan of care for a conscious client who has a suspected cervical cord injury. Which of the following immediate interventions should the nurse implement? (Select all that apply.)
- Hypotension
- Polyuria
- Hyperthermia
- Absence of bowel sounds
- Weakened gag reflex
Explanation:
A suspected cervical cord injury requires immediate interventions to stabilize the patient and prevent further damage. Hypotension is a critical concern in cervical cord injuries due to neurogenic shock, which results from disrupted autonomic nervous system regulation, leading to vasodilation and decreased blood pressure. A weakened gag reflex is also a concern because cervical injuries can affect cranial nerve function (e.g., the vagus nerve) and increase the risk of aspiration, requiring airway protection.
32.A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)
- Increased heart rate
- Increased blood pressure
- Increased respiratory rate
- Increased hematocrit
- Increased temperature
Explanation:
Fluid overload, often due to conditions like heart failure or excessive IV fluid administration, leads to increased circulating volume, which the body tries to compensate for. Increased heart rate occurs as the heart works harder to pump the excess fluid. Increased blood pressure results from the increased volume putting pressure on the vascular system. Increased respiratory rate is expected as the body attempts to oxygenate properly, especially if pulmonary edema develops from fluid backing up into the lungs.
33.A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia? (Select all that apply.)
- Polyuria
- Blurred vision
- Polydipsia
- Tachycardia
- Moist, clammy skin
Explanation:
Hypoglycemia in type 2 diabetes occurs when blood sugar levels drop too low, often due to medication, fasting, or excessive insulin. Blurred vision can occur as the brain is deprived of glucose, affecting visual processing. Tachycardia is a compensatory response as the body releases adrenaline to counteract low blood sugar. Moist, clammy skin results from sweating, another sympathetic response to hypoglycemia.
34.A nurse in a mental health clinic is caring for a client who has bipolar disorder and a prescription for an antipsychotic medication. The provider and nursing staff suspect the client is not adhering to his medication therapy. Which of the following interventions should the staff use to encourage the client’s adherence? (Select all that apply.)
- Perform mouth checks following the administration of the medication.
- Provide for once-daily dosing.
- Use sustained-release forms.
- Engage the client in conversation following medication administration.
- Rotate staff that administer the medications.
Explanation:
To encourage adherence in a client with bipolar disorder, interventions should focus on simplifying the regimen and ensuring the medication is taken. Performing mouth checks ensures the client has swallowed the medication, addressing potential non-adherence directly. Providing once-daily dosing simplifies the schedule, making it easier for the client to comply. Using sustained-release forms reduces the frequency of dosing, further improving adherence.
35.A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? (Select all that apply.)
- Urinary retention and constipation
- Tongue thrusting and lip smacking
- Fine hand tremors and pill rolling
- Facial grimacing and eye blinking
- Involuntary pelvic rocking and hip thrusting movements
Explanation:
Tardive dyskinesia is a side effect of long-term use of typical antipsychotics like haloperidol, characterized by involuntary, repetitive movements. Tongue thrusting, lip smacking, facial grimacing, eye blinking, and involuntary pelvic rocking or hip thrusting are all classic signs of tardive dyskinesia, often affecting the face, mouth, and limbs. Urinary retention and constipation are more associated with anticholinergic side effects of antipsychotics, not tardive dyskinesia.
36.A nurse is planning postoperative care for a client who is scheduled for an ileal conduit procedure. The nurse should include which of the following in the client’s plan of care? (Select all that apply.)
- Notify the provider immediately if mucus is present in the urine.
- Maintain the client on a fluid restriction.
- Apply skin barrier around the stoma site.
- Educate the client that hematuria is expected following the procedure.
- Monitor hourly urine output.
Explanation:
An ileal conduit procedure involves creating a urinary diversion using a segment of the ileum, with a stoma on the abdomen for urine drainage. Applying a skin barrier around the stoma site is essential to protect the skin from irritation due to urine leakage. Educating the client that hematuria (blood in the urine) is expected post-procedure helps set realistic expectations, as some blood is normal due to surgical trauma. Monitoring hourly urine output is critical to ensure the conduit is functioning and to detect any obstruction or complications early. Mucus in the urine is expected after an ileal conduit because the ileum naturally produces mucus, so notifying the provider is unnecessary unless other symptoms are present.
41.A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (Select all that apply.)
- Dyspnea
- Bradycardia
- Barrel chest
- Clubbing of the fingers
- Deep respirations
Explanation:
Emphysema is a chronic obstructive pulmonary disease (COPD) characterized by the destruction of alveoli, leading to impaired gas exchange and air trapping. Dyspnea (shortness of breath) is a hallmark symptom due to reduced oxygen exchange and increased work of breathing. Barrel chest develops over time as the lungs become hyperinflated, causing the chest to take on a rounded, barrel-like shape. Clubbing of the fingers occurs due to chronic hypoxia, leading to changes in the nail beds and fingertips. Bradycardia (slow heart rate) is not typical; tachycardia is more common as the body compensates for low oxygen levels.
42.A nurse is preparing to administer vaccines to a 1-year-old child. Which of the following vaccines should the nurse give? (Select all that apply.)
- Measles, mumps, rubella (MMR)
- Diphtheria, tetanus, and acellular pertussis (DTaP)
- Varicella (VAR)
- Rotavirus (RV)
- Human papillomavirus (HPV4)
Explanation:
According to the CDC immunization schedule, a 1-year-old child (12–15 months) should receive the first dose of MMR, the fourth dose of DTaP, and the first dose of varicella (VAR). Rotavirus (RV) vaccination is typically completed by 8 months of age, with the last dose given between 2–8 months, so it is not appropriate at 1 year. HPV4 (human papillomavirus vaccine) is recommended starting at 11–12 years of age, not at 1 year.
43.A nurse in an urgent care center is caring for a client who experienced an ankle injury. Prior to examination by the provider, which of the following nursing actions should the nurse perform? (Select all that apply.)
- Apply ice to the affected area.
- Encourage range of motion of the foot.
- Provide the client with a light snack.
- Apply a compression bandage.
- Elevate the foot.
Explanation:
For an acute ankle injury, the RICE protocol (Rest, Ice, Compression, Elevation) is the standard initial management to reduce swelling and pain. Applying ice helps decrease inflammation and numb the area. A compression bandage reduces swelling by limiting fluid accumulation. Elevating the foot above heart level also helps reduce swelling by promoting venous return.
44.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
- Polyuria
- Diarrhea
- Crackles in the lungs
- Pressure ulcers
Explanation:
Immobility leads to several complications due to lack of movement and prolonged pressure on tissues. Contractures of the extremities occur when muscles and joints stiffen from lack of use. Crackles in the lungs can result from atelectasis or pneumonia due to shallow breathing and inability to clear secretions. Pressure ulcers develop from prolonged pressure on the skin, especially over bony prominences.
45.A nurse is caring for a client within the intimate zone of the client’s personal space. The nurse should perform which of the following activities in this space? (Select all that apply.)
- Auscultating heart sounds
- Teaching about a medication
- Changing a dressing
- Discussing intake and output
- Talking with the client’s partner
Explanation:
The intimate zone of personal space (typically within 0–18 inches) involves activities that require close physical contact and are often invasive or personal. Auscultating heart sounds requires the nurse to use a stethoscope on the client’s chest, which is within this zone. Changing a dressing involves direct contact with the client’s body, often in a sensitive area, also within the intimate zone. Teaching about a medication, discussing intake and output, and talking with the client’s partner are activities that occur in the personal zone (18 inches to 4 feet), as they involve communication rather than physical contact.
46.A nurse is caring for a client who requires isolation for active pulmonary tuberculosis. Which of the following precautions should the nurse include when creating a sign to post outside the client’s room? (Select all that apply.)
- Graphic 1 (Illustration of a person wearing a mask)
- Graphic 2 (Illustration of a closed door)
- Graphic 3 (Illustration of a person in full protective gear)
Explanation:
Active pulmonary tuberculosis requires airborne precautions because it is transmitted via droplet nuclei. Graphic 1 (a person wearing a mask) indicates that anyone entering the room must wear a mask, specifically an N95 respirator, to protect against airborne transmission. Graphic 3 (a person in full protective gear) suggests the need for additional protective equipment, such as gowns and gloves, which may be used in certain situations to prevent contact with contaminated surfaces, though the primary focus is on respiratory protection.
47.A nurse is planning care for a client who is scheduled to have a kidney biopsy. Which of the following information should the nurse include in the plan? (Select all that apply.)
- Obtain a urine specimen prior to the procedure.
- Obtain written, informed consent.
- Administer diphenhydramine (Benadryl) prior to the procedure.
- Maintain NPO status prior to the procedure.
- Obtain coagulation studies.
Explanation:
A kidney biopsy is an invasive procedure that requires careful preparation. Obtaining written, informed consent is necessary because it is a surgical procedure with risks, such as bleeding or infection. Maintaining NPO status (nothing by mouth) prior to the procedure is standard to reduce the risk of aspiration, especially if sedation or anesthesia is used. Obtaining coagulation studies (e.g., PT, INR, platelet count) is critical because the kidney is a highly vascular organ, and bleeding is a significant risk; abnormal coagulation could contraindicate the procedure.
48.A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? (Select all that apply.)
- Keep the client’s room dark at night.
- Teach the client to use the call light.
- Keep the client’s bed in the lowest position.
- Place a fall-risk identification band on the client’s wrist.
- Assess the client every 4 hr.
Explanation:
Fall prevention is a priority for at-risk clients. Teaching the client to use the call light ensures they can request assistance when needed, reducing the risk of falling while trying to get up alone. Keeping the bed in the lowest position minimizes the distance to the floor if a fall occurs, reducing injury risk. Placing a fall-risk identification band on the client’s wrist alerts all staff to the client’s risk, ensuring consistent precautions.
49.A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for clients who have surgical incisions. Which of the following factors should the nurse include in the teaching? (Select all that apply.)
- Poor nutritional state
- Altered mental status
- Obesity
- Pain medication administration
- Wound infection
Explanation:
Wound dehiscence (the reopening of a surgical incision) is influenced by factors that impair healing or increase stress on the incision. A poor nutritional state, particularly low protein or vitamin C levels, impairs wound healing by limiting tissue repair. Obesity increases the risk because excess adipose tissue can create tension on the incision and impair blood supply to the healing area. A wound infection disrupts the healing process by causing inflammation and tissue breakdown, leading to dehiscence.
50.A nurse is teaching a client about the seven warning signs of cancer. Which of the following signs should the nurse include as manifestations of cancer? (Select all that apply.)
- A nonhealing sore
- Bloating
- Change in bowel pattern
- Change in moles
- Nagging cough
Explanation:
The seven warning signs of cancer are often summarized by the acronym CAUTION: Change in bowel or bladder habits, A sore that does not heal, Unusual bleeding or discharge, Thickening or lump, Indigestion or difficulty swallowing, Obvious change in a wart or mole, and Nagging cough or hoarseness. A nonhealing sore aligns with “A sore that does not heal.” Change in bowel pattern matches “Change in bowel or bladder habits.” Change in moles corresponds to “Obvious change in a wart or mole.” Nagging cough fits “Nagging cough or hoarseness.”
51.A nurse is caring for a client who has Cushing’s syndrome. Which of the following interventions should the nurse expect to perform? (Select all that apply.)
- Assess blood glucose level
- Assess for neck vein distention
- Monitor for an irregular heart rate
- Monitor for postural hypotension
- Weigh the client daily
Explanation:
Cushing’s syndrome is caused by excessive cortisol levels, which can lead to several physiological changes.
- Assess blood glucose level: Cortisol increases blood glucose by promoting gluconeogenesis, so hyperglycemia is common in Cushing’s syndrome. Monitoring blood glucose is essential.
- Monitor for postural hypotension: Clients with Cushing’s syndrome may experience fluid and electrolyte imbalances, which can lead to postural hypotension (a drop in blood pressure upon standing).
- Weigh the client daily: Weight gain due to fluid retention is a hallmark of Cushing’s syndrome, so daily weight monitoring helps track fluid status.
52.A nurse is providing teaching to a client who has osteoporosis and a new prescription for alendronate. Which of the following adverse effects should the nurse instruct the client to report to the provider? (Select all that apply.)
- Tinnitus
- Jaw pain
- Blurred vision
- Drowsiness
- Dysphagia
Explanation:
Alendronate is a bisphosphonate used to treat osteoporosis by inhibiting bone resorption. However, it has specific adverse effects that clients should report.
- Jaw pain: Alendronate can cause osteonecrosis of the jaw, a serious condition where the jawbone deteriorates. Jaw pain is a key symptom to report.
- Dysphagia: Alendronate can irritate the esophagus, leading to difficulty swallowing (dysphagia). This is a common adverse effect and should be reported to prevent esophageal damage.
53.A nurse is planning to teach a client about a low-potassium diet. Which of the following foods should the nurse instruct the client to avoid? (Select all that apply.)
- Butter
- Poultry
- Yogurt
- Frozen vegetables
- Orange juice
Explanation:
A low-potassium diet is often prescribed for clients with hyperkalemia (high potassium levels). The nurse should instruct the client to avoid high-potassium foods.
- Yogurt: Dairy products like yogurt are high in potassium (about 350-400 mg per cup), so they should be avoided.
- Orange juice: Citrus juices, especially orange juice, are high in potassium (about 500 mg per cup) and should be avoided.
54.A nurse is caring for a male client who has peripheral vascular disease (PVD), is taking dietary supplements, and has a new prescription for warfarin. The nurse should instruct the client to stop which of the following supplements prior to starting the warfarin? (Select all that apply.)
- Saw palmetto
- Flaxseed oil
- Glucosamine
- Black cohosh
- Ginkgo biloba
Explanation:
Warfarin is an anticoagulant that prevents blood clotting, and certain supplements can interact with it, increasing the risk of bleeding.
- Flaxseed oil: Contains omega-3 fatty acids, which can have anticoagulant effects and increase the risk of bleeding when combined with warfarin.
- Ginkgo biloba: Known to have antiplatelet effects, which can enhance warfarin’s anticoagulant effects and increase bleeding risk.
55.A nurse is performing a mental status examination (MSE) on a client who has a new diagnosis of dementia. Which of the following components should the nurse include? (Select all that apply.)
- Grooming
- Long-term memory
- Support systems
- Affect
- Presence of pain
Explanation:
A mental status examination (MSE) assesses a client’s cognitive and emotional functioning, which is critical in dementia.
- Grooming: This assesses the client’s appearance and self-care abilities, which can be impaired in dementia due to cognitive decline.
- Long-term memory: Memory, especially long-term memory, is often affected in dementia (e.g., Alzheimer’s disease), and assessing it is a key part of the MSE.
- Affect: This refers to the client’s emotional expression, which can be altered in dementia (e.g., flat affect or inappropriate emotions).
56.A nurse is assessing a 3-year-old child who has aortic stenosis. Which of the following findings should the nurse expect? (Select all that apply.)
- Hypotension
- Bradycardia
- Clubbing of the nail beds
- Weak pulses
- Murmur
Explanation:
Aortic stenosis in a child involves narrowing of the aortic valve, which obstructs blood flow from the left ventricle to the aorta, leading to specific clinical findings.
- Clubbing of the nail beds: Chronic hypoxia from poor circulation can lead to clubbing, a sign of long-term oxygen deprivation.
- Weak pulses: The obstruction in aortic stenosis reduces blood flow to the periphery, resulting in weak or diminished pulses.
- Murmur: Aortic stenosis typically causes a systolic murmur due to turbulent blood flow across the narrowed valve.
57.A nurse manager is providing staff education about working with clients who have a history of anger and aggression. Which of the following information should the nurse include in the teaching? (Select all that apply.)
- Avoid wearing necklaces during client care.
- Know the layout of the facility.
- Stand directly in front of the client when talking.
- Bring security with you for all client interactions.
- Provide immediate verbal feedback for escalating behavior.
Explanation:
When working with clients who have a history of anger and aggression, safety and de-escalation techniques are critical.
- Avoid wearing necklaces during client care: Necklaces can be grabbed, posing a safety risk during an aggressive outburst.
- Know the layout of the facility: This ensures the nurse can navigate to safety or call for help if needed.
- Provide immediate verbal feedback for escalating behavior: Addressing escalating behavior early with calm, clear communication can help de-escalate the situation.
58.A nurse is assessing for the presence of extrapyramidal side effects (EPS) in a client who is taking chlorpromazine. Which of the following findings should the nurse recognize as EPS? (Select all that apply.)
- Muscle spasms of the neck
- Fidgeting behavior
- Blurred vision
- Tremors of the hands
- Sexual dysfunction
Explanation:
Chlorpromazine is a typical antipsychotic that can cause extrapyramidal side effects (EPS) due to its effect on dopamine receptors in the brain.
- Muscle spasms of the neck: This is a sign of dystonia, a common EPS where involuntary muscle contractions occur.
- Fidgeting behavior: This can indicate akathisia, another EPS characterized by restlessness and an urge to move.
- Tremors of the hands: Tremors are a sign of parkinsonism, a type of EPS that mimics Parkinson’s disease symptoms.
59.A nurse is providing teaching to a client who has cancer about foods that prevent protein-energy malnutrition. Which of the following foods should the nurse include in the teaching? (Select all that apply.)
- Cottage cheese
- Milkshakes
- Tuna fish
- Strawberries and bananas
- Egg and ham omelet
Explanation:
Protein-energy malnutrition is a concern in cancer patients due to increased metabolic demands and potential loss of appetite. The nurse should recommend high-protein, high-calorie foods.
- Cottage cheese: High in protein (about 25g per cup), making it a good choice.
- Milkshakes: Can be made high in protein and calories (e.g., with protein powder or ice cream), ideal for cancer patients.
- Tuna fish: A lean protein source (about 25g per 3 oz), excellent for preventing malnutrition.
- Egg and ham omelet: Eggs and ham are both high in protein (eggs: 6g each, ham: varies but high), making this a good option.
60.A nurse is educating coworkers about how to minimize back strain and avoid repeated episodes of low back pain. Which of the following strategies should the nurse include? (Select all that apply.)
- Avoid prolonged sitting.
- Apply heat for 10 min every hour.
- Sleep in a side-lying position with flexed knees.
- Sleep on a soft mattress.
- Try padded shoe insoles.
Explanation:
Low back pain can be mitigated by proper posture, positioning, and support strategies.
- Avoid prolonged sitting: Sitting for long periods puts strain on the lower back; taking breaks to stand or move helps.
- Sleep in a side-lying position with flexed knees: This position reduces strain on the spine by maintaining its natural curve.
- Try padded shoe insoles: Proper foot support can improve posture and reduce back strain during standing or walking.
61.A nurse is developing a program about strategies to prevent foodborne illnesses for a community group. The nurse should plan to include which of the following recommendations? (Select all that apply.)
- Avoid unpasteurized dairy products.
- Keep cold food temperatures below 4.4°C (40°F).
- Reheat leftovers before eating.
- Wash raw vegetables thoroughly in clean water.
- Keep cooked foods at 48.9°C (120°F).
Explanation:
Preventing foodborne illnesses involves proper food handling, storage, and preparation to minimize bacterial growth and contamination.
- Avoid unpasteurized dairy products: Unpasteurized dairy can harbor harmful bacteria like Listeria or Salmonella, increasing the risk of foodborne illness.
- Keep cold food temperatures below 4.4°C (40°F): This temperature prevents bacterial growth in perishable foods, keeping them in the safe "cold zone."
- Wash raw vegetables thoroughly in clean water: This removes potential contaminants like E. coli or Salmonella from the surface of vegetables.
62.A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care? (Select all that apply.)
- "I’ll expect the plastic ring to fall off by itself within a week."
- "I’ll apply petroleum jelly to his penis with diaper changes."
- "I’ll wash his penis with warm water and mild soap each day."
- "I’ll call the doctor if I see any bleeding."
- "I’ll make sure his diaper is loose in the front."
Explanation:
The Plastibell technique involves placing a plastic ring around the foreskin, which cuts off circulation, causing the foreskin to necrose and fall off with the ring. Proper care is essential for healing.
- "I’ll expect the plastic ring to fall off by itself within a week": This is correct; the Plastibell ring typically falls off within 5-8 days as the tissue heals.
- "I’ll wash his penis with warm water and mild soap each day": Gentle cleaning prevents infection while the area heals.
- "I’ll call the doctor if I see any bleeding": Bleeding is a potential complication of circumcision, and the client should report it immediately.
- "I’ll make sure his diaper is loose in the front": A loose diaper prevents irritation and pressure on the healing penis.
63.A nurse and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the nurse delegate to the LPN? (Select all that apply.)
- Provide discharge instructions to a confused client’s spouse.
- Obtain vital signs from a client who is 6 hr postoperative.
- Administer a tap-water enema to a client who is preoperative.
- Initiate a plan of care for a client who is postoperative from an appendectomy.
- Catheterize a client who has not voided in 8 hr.
Explanation:
Delegation involves assigning tasks to the appropriate level of staff based on their scope of practice. LPNs can perform certain tasks under the supervision of a registered nurse (RN).
- Obtain vital signs from a client who is 6 hr postoperative: This is within the LPN’s scope, as it involves basic assessment and monitoring.
- Administer a tap-water enema to a client who is preoperative: LPNs can perform this procedure as it is a routine intervention.
- Catheterize a client who has not voided in 8 hr: LPNs are trained to perform urinary catheterization, which is within their scope.
64.A nurse is caring for a client who is to undergo a biophysical profile. The client asks the nurse what is being evaluated during this test. Which of the following should the nurse include? (Select all that apply.)
- Fetal breathing
- Fetal motion
- Fetal neck translucency
- Amniotic fluid volume
- Fetal gender
Explanation:
A biophysical profile (BPP) is a prenatal test that assesses fetal well-being through ultrasound and non-stress testing. It evaluates five components, each scored 0 or 2, for a total of 10 points.
- Fetal breathing: The BPP checks for fetal breathing movements, which indicate a healthy respiratory system.
- Fetal motion: Fetal body movements are assessed to ensure the fetus is active and healthy.
- Amniotic fluid volume: This measures the amount of amniotic fluid, which reflects kidney function and overall fetal health.
65.A nurse is caring for a client who is being evaluated for acromegaly. Which of the following manifestations should the nurse expect to find during assessment? (Select all that apply.)
- Loss of color discrimination
- Coarse facial features
- Enlarged distal extremities
- Hepatomegaly
- Moon face
Explanation:
Acromegaly is caused by excessive growth hormone (GH) production, typically from a pituitary tumor, leading to overgrowth of bones and tissues.
- Coarse facial features: Excess GH causes enlargement of facial bones, leading to a prominent jaw, forehead, and coarse features.
- Enlarged distal extremities: Hands and feet enlarge due to bone and soft tissue growth, a hallmark of acromegaly.
66.A nurse is planning care for a client who is postoperative. Which of the following statements about pain management should the nurse consider when implementing client care? (Select all that apply.)
- Use of analgesics will eventually lead to addiction.
- Each client’s expression of pain may be different and individualized.
- Patient-controlled analgesia (PCA) offers a constant level of opioids within therapeutic range.
- Pain level and pain tolerance can be assessed using a scale from 0 to 10.
Explanation:
Effective pain management in postoperative care requires understanding pain assessment and treatment options.
- Each client’s expression of pain may be different and individualized: Pain is subjective, and clients express it differently based on cultural, emotional, and personal factors.
- Patient-controlled analgesia (PCA) offers a constant level of opioids within therapeutic range: PCA allows clients to self-administer small doses of opioids, maintaining pain control within a safe range.
- Pain level and pain tolerance can be assessed using a scale from 0 to 10: The 0-10 pain scale is a standard tool to quantify pain intensity and guide treatment.
67.A nurse is caring for a child who has autism spectrum disorder. Which of the following findings should the nurse expect? (Select all that apply.)
- Short attention span
- Delayed language development
- Spinning a toy repetitively
- Ritualistic behavior
- Consistent limit testing
Explanation:
Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by challenges in social interaction, communication, and repetitive behaviors.
- Short attention span: Children with ASD often struggle with focus, especially in unstructured settings.
- Delayed language development: Many children with ASD have delayed or impaired language skills.
- Spinning a toy repetitively: Repetitive behaviors, like spinning objects, are common in ASD.
- Ritualistic behavior: Children with ASD often engage in rituals or routines, such as needing things to be done in a specific way.
68.A nurse is teaching a client about risk factors for osteoporosis. Which of the following factors should the nurse include in the teaching? (Select all that apply.)
- Sedentary lifestyle
- Obesity
- Aging
- Caffeine intake
- Secondhand smoke
Explanation:
Osteoporosis is characterized by reduced bone density, increasing fracture risk. Several factors contribute to its development.
- Sedentary lifestyle: Lack of weight-bearing exercise reduces bone density over time.
- Aging: Bone density naturally decreases with age, especially after menopause in women due to lower estrogen levels.
- Caffeine intake: Excessive caffeine can interfere with calcium absorption, contributing to bone loss.
- Secondhand smoke: Exposure to tobacco smoke is linked to lower bone density.
69.A nurse is planning to apply a transdermal analgesic cream prior to inserting an IV for a preschool-age child. Which of the following actions should the nurse plan to take? (Select all that apply.)
- Spread the cream over the lateral surface of both forearms.
- Apply to intact skin.
- Apply the medication an hour before the procedure begins.
- Cleanse the skin prior to procedure.
- Use a visual pain rating scale to evaluate the effectiveness of the treatment.
Explanation:
Transdermal analgesic creams (e.g., EMLA) are used to numb the skin before procedures like IV insertion, especially in children.
- Apply to intact skin: The cream should only be applied to unbroken skin to ensure safe absorption.
- Apply the medication an hour before the procedure begins: EMLA cream typically requires 60 minutes to achieve full numbing effect.
- Cleanse the skin prior to procedure: Cleaning ensures the area is free of dirt or bacteria, reducing infection risk during IV insertion.
- Use a visual pain rating scale to evaluate the effectiveness of the treatment: A visual scale (e.g., faces scale) is appropriate for preschoolers to assess pain and the cream’s effectiveness.
70.A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following characteristics are expected findings of OCD? (Select all that apply.)
- Difficulty relaxing
- Irrational fear of certain objects
- Rule-conscious behavior
- Unaware of compulsions
- Perfectionist behavior
Explanation:
Obsessive-compulsive disorder (OCD) involves intrusive thoughts (obsessions) and repetitive behaviors (compulsions) to reduce anxiety.
- Difficulty relaxing: The anxiety from obsessions makes it hard for clients with OCD to relax.
- Irrational fear of certain objects: Obsessions often involve irrational fears, such as contamination from touching objects.
- Rule-conscious behavior: Clients with OCD often follow strict self-imposed rules to manage their compulsions.
- Perfectionist behavior: Perfectionism is common, as clients may feel a need for things to be "just right."
71.A nurse is caring for a client who is postoperative following an appendectomy. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse offer the client? (Select all that apply.)
- Broth
- Grape juice
- Nonfat milk
- Custard
- Lemon gelatin
Explanation:
A clear liquid diet is prescribed to provide hydration and minimal residue in the gastrointestinal tract, often used post-surgery to ease the digestive system. Clear liquids include items that are transparent and liquid at room temperature. Broth (like chicken or beef broth) and lemon gelatin fit this description as they are clear and easily digestible. Grape juice, while a liquid, is not considered "clear" due to its color and potential pulp. Nonfat milk and custard are not clear liquids; they are part of a full liquid diet, which includes opaque liquids and is typically introduced later in recovery.
72.A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of the following indications should the nurse include? (Select all that apply.)
- Relief of urinary retention
- Convenience for the nursing staff or the client’s family
- Measurement of residual urine after urination
- Routine acquisition of a urine specimen
- An open perineal wound
Explanation:
Urinary catheterization is a medical procedure that should only be performed for specific clinical indications, not for convenience. Relief of urinary retention is a primary indication, as it helps alleviate discomfort and prevent complications like bladder damage. Measurement of residual urine after urination is another valid indication, often used to assess bladder function, especially in conditions like neurogenic bladder. Convenience for the nursing staff or client’s family is not a medically justified reason for catheterization, as it increases the risk of infection.
73.A nurse is developing an education program for a community group about dietary intake of vitamins and minerals in the diet. The nurse should include which of the following foods as sources of vitamin C? (Select all that apply.)
- Green pepper
- Orange
- Cabbage
- Strawberries
- Milk
Explanation:
Vitamin C is a water-soluble vitamin found in many fruits and vegetables, particularly those that are brightly colored or citrus-based. Green peppers, oranges, cabbage, and strawberries are all excellent sources of vitamin C. For example, a medium orange provides nearly 100% of the daily recommended intake of vitamin C, and strawberries are also a rich source. Milk, however, is not a significant source of vitamin C; it is more associated with calcium, vitamin D, and protein.
74.A nurse is caring for a client who is postoperative following a cholecystectomy and reports pain. Which of the following actions should the nurse take? (Select all that apply.)
- Offer the client a back rub.
- Remind the client to use incisional splinting.
- Identify the client’s pain level.
- Assist the client to ambulate.
- Change the client’s position.
Explanation:
Postoperative pain management after a cholecystectomy (gallbladder removal) involves both non-pharmacological and assessment strategies. Offering a back rub can provide comfort and relaxation, helping to alleviate pain. Reminding the client to use incisional splinting (e.g., holding a pillow against the incision while coughing or moving) reduces strain on the surgical site, minimizing pain. Identifying the client’s pain level is a critical first step in pain management, allowing the nurse to assess the severity and determine if further intervention (like medication) is needed. Changing the client’s position can also help reduce discomfort by relieving pressure points.
75.A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to assistive personnel (AP)? (Select all that apply.)
- Bathe a client who had an amputation 2 days ago.
- Assist a client to ambulate using a gait belt.
- Review a low-sodium diet for a client who has hypertension.
- Explain oral hygiene to a client receiving chemotherapy.
- Feed a client who had a stroke 3 months ago.
Explanation:
Assistive personnel (AP), such as certified nursing assistants, can perform tasks that involve basic care and do not require nursing judgment or education. Bathing a client who had an amputation 2 days ago is a routine hygiene task that an AP can handle, assuming the client is stable. Assisting a client to ambulate using a gait belt is also within the AP’s scope, as it involves physical support rather than assessment. Feeding a client who had a stroke 3 months ago is appropriate for an AP, provided the client has no swallowing difficulties (not indicated here).
76.A nurse is teaching a newly-admitted client about the possible physical effects of alcohol withdrawal. Which of the following manifestations should the nurse include in the teaching? (Select all that apply.)
- Seizures
- Illusions
- Tremors
- Polyphagia
- Nystagmus
Explanation:
Alcohol withdrawal can cause a range of physical and neurological symptoms, often assessed using the CIWA-Ar scale. Seizures are a serious manifestation, typically occurring within 12-48 hours after the last drink, due to the brain’s hyperexcitability. Illusions (misperceptions of real stimuli, like seeing shadows as objects) are common in alcohol withdrawal, often preceding hallucinations. Tremors, especially in the hands, are a hallmark sign of withdrawal, starting within hours of cessation.
77.A nurse is providing hygiene care for a client who is immobile. Which of the following actions should the nurse take? (Select all that apply.)
- Check for personal items when changing the bed linens.
- Place a clean gown on the strongest arm first.
- Keep the bath water temperature between 43.3°C (110°F) and 46.1°C (115°F).
- Shave the client’s hair in the direction of the hair growth.
- Wash the client’s extremities from proximal to distal.
Explanation:
When providing hygiene care to an immobile client, the nurse must ensure safety, comfort, and proper technique. Checking for personal items when changing bed linens prevents loss of belongings and ensures safety (e.g., avoiding leaving items that could cause pressure injuries). Placing a clean gown on the strongest arm first makes dressing easier and more comfortable for the client, especially if one arm is weaker. Shaving in the direction of hair growth reduces the risk of irritation and ingrown hairs.
78.A nurse is caring for a client who is postoperative and in skeletal traction. When assessing the client, the nurse should expect which of the following findings? (Select all that apply.)
- Slight pain at the insertion site
- Serous drainage on the dressing
- Movement of the pin at the insertion site
- Elastic bandages secure around the traction ropes
- Minimal edema around the pin
Explanation:
Skeletal traction involves pins inserted into bones to align fractures, and certain findings are expected while others indicate complications. Slight pain at the insertion site is normal due to the invasive nature of the procedure, though severe pain should be investigated. Minimal edema around the pin is also expected as a normal inflammatory response, provided it’s not excessive. Serous drainage on the dressing could indicate an infection or complication, not a normal finding.
79.A nurse is teaching a client who has constipation about a high-fiber diet. Which of the following foods should be included as sources of fiber? (Select all that apply.)
- Kidney beans
- Blackberries
- Refined cereals
- Whole wheat bread
- Lean turkey
Explanation:
A high-fiber diet helps alleviate constipation by adding bulk to the stool and promoting bowel movements. Kidney beans are an excellent source of fiber, with about 6 grams per half-cup serving. Blackberries are also high in fiber, providing around 8 grams per cup. Whole wheat bread is a good source of dietary fiber, unlike refined bread.
80.A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect? (Select all that apply.)
- Cracked, peeling skin
- Positive Moro reflex
- Short, soft fingernails
- Abundant lanugo
- Vernix in the folds and creases
Explanation:
A postmature newborn is one born after 42 weeks of gestation, and certain physical characteristics are expected due to prolonged time in the womb. Cracked, peeling skin is a common finding in postmature infants because the vernix (a protective coating) has diminished, and the skin has been exposed to amniotic fluid for an extended period, leading to dryness.
81.A nurse is providing teaching to a client who has stable angina and a new prescription for transdermal nitroglycerin. Which of the following instructions should the nurse include? (Select all that apply.)
- Apply the patch to a hairless area and rotate sites.
- Apply a new patch each morning.
- Remove the patch for 10 to 12 hr daily.
- Apply the patch to dry skin and cover the area with plastic wrap.
- Apply a new patch at the onset of anginal pain.
Explanation:
Transdermal nitroglycerin is used to prevent angina in clients with stable angina by providing a steady release of the medication. Applying the patch to a hairless area and rotating sites prevents skin irritation and ensures proper absorption. Applying a new patch each morning establishes a consistent dosing schedule, typically once daily. Removing the patch for 10 to 12 hours daily (often at night) is crucial to prevent nitrate tolerance, which can reduce the drug’s effectiveness over time.
82.A nurse in a clinic is assessing a client who is at 8 weeks of gestation and has hyperemesis gravidarum. Which of the following findings should the nurse expect? (Select all that apply.)
- History of migraines
- Nulliparous
- Twin gestations
- History of gestational hypertension
- Oligohydramnios
Explanation:
Hyperemesis gravidarum is severe nausea and vomiting during pregnancy, often leading to dehydration and weight loss. A history of migraines is a risk factor, as women with migraines are more prone to nausea and vomiting. Twin gestations increase the likelihood of hyperemesis gravidarum due to higher levels of human chorionic gonadotropin (hCG), which is associated with nausea.
83.A nurse is providing a community health education class about suicide prevention. Which of the following should the nurse identify as risk factors for suicide? (Select all that apply.)
- Substance use disorder
- Age greater than 45 years old
- Female gender
- Currently married
- Schizophrenia
Explanation:
Suicide risk factors are well-documented in mental health literature. Substance use disorder increases the risk of suicide due to impaired judgment, increased impulsivity, and co-occurring mental health issues. Age greater than 45 years old is a risk factor, particularly for men, as suicide rates rise with age, especially in older adults. Schizophrenia is a significant risk factor due to the high prevalence of depression, psychosis, and social isolation in this population.
84.A nurse is caring for a client who has dementia. When performing a Mental Status Examination (MSE) the nurse should include which of the following data? (Select all that apply.)
- Ability to perform calculations
- Coping skills
- Recall ability
- Long-term memory
- Level of orientation
Explanation:
A Mental Status Examination (MSE) assesses cognitive and emotional functioning, which is critical in clients with dementia. The ability to perform calculations (e.g., serial 7s or simple math) evaluates cognitive processing and attention, often impaired in dementia. Recall ability (e.g., remembering a list of words after a delay) tests short-term memory, which is typically affected early in dementia. Long-term memory assessment (e.g., recalling past events) helps determine the extent of memory impairment, as long-term memory may remain intact longer in some types of dementia. Level of orientation (to person, place, and time) is a core component of the MSE, as disorientation is common in dementia.
85.A nurse is caring for a 3-year-old child whose parents report that she has an intense fear of painful procedures, such as injections. Which of the following strategies should the nurse add to the child’s plan of care? (Select all that apply.)
- Have a parent stay with the child during procedures.
- Cluster invasive procedures whenever possible.
- Perform the procedure as quickly as possible.
- Allow the child to keep a toy from home with her.
- Use mummy restraints during painful procedures.
Explanation:
For a 3-year-old with a fear of painful procedures, the nurse should focus on reducing anxiety and providing comfort. Having a parent stay with the child during procedures offers emotional support and a sense of security, which can reduce fear. Allowing the child to keep a toy from home provides a familiar object for comfort, helping to distract and soothe her.
86.A nurse on a medical-surgical unit is assigning tasks to assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP? (Select all that apply.)
- Demonstrate the technique to instil eye drops.
- Ambulate a client who has a cane.
- Irrigate a wound.
- Transfer a client to a stretcher.
- Record urinary output.
Explanation:
Assistive personnel (AP), such as certified nursing assistants, can perform tasks that involve basic care and do not require nursing judgment or advanced skills. Ambulating a client who has a cane is within the AP’s scope, as it involves physical support and encouragement, assuming the client is stable. Transferring a client to a stretcher is also appropriate for an AP, as it involves physical assistance with proper body mechanics. Recording urinary output (e.g., measuring and documenting the amount in a urinal or catheter bag) is a task APs can perform, as it involves observation and documentation, not assessment.
87.A nurse in the emergency department is creating a plan of care for a client experiencing alcohol intoxication. Which of the following interventions should the nurse plan to include? (Select all that apply.)
- Contact the laboratory to obtain a blood sample.
- Prepare the client for a CT scan.
- Check the client’s pupil reactivity.
- Obtain a urine specimen.
- Perform a developmental screening test.
Explanation:
Alcohol intoxication in the emergency department requires assessment and monitoring to ensure the client’s safety and identify any complications. Contacting the laboratory to obtain a blood sample is essential to measure the blood alcohol level and check for other substances or electrolyte imbalances. Checking the client’s pupil reactivity is part of a neurological assessment, as alcohol can affect the central nervous system and pupil response, helping to identify the severity of intoxication or other issues like head trauma. Obtaining a urine specimen can be used for a toxicology screen to identify other substances that may be contributing to the client’s condition.
88.A nurse at a provider’s office is providing teaching to a client who is taking chemotherapy and losing weight. Which of the following should the nurse recommend to increase calorie and protein intake? (Select all that apply.)
- Top fruits with yogurt.
- Add cream to soups.
- Use milk instead of water in recipes.
- Increase fluids during meals.
- Dip meats in eggs and bread crumbs before cooking.
Explanation:
Chemotherapy often causes weight loss due to nausea, loss of appetite, and altered taste, so the nurse should recommend strategies to increase calorie and protein intake in a palatable way. Topping fruits with yogurt adds both calories and protein, as yogurt is a good source of protein and fat. Adding cream to soups increases the calorie density of the meal, making it easier to consume more calories in a smaller volume. Using milk instead of water in recipes (e.g., for oatmeal or mashed potatoes) boosts both calories and protein, as milk contains more nutrients than water. Dipping meats in eggs and bread crumbs before cooking adds calories from the breading and protein from the eggs, while also making the meat more palatable.
89.A nurse is providing health promotion teaching to the parents of a toddler. Which of the following information should the nurse include in the teaching? (Select all that apply.)
- Management of tantrums
- How to establish trust
- How to encourage cooperative play
- Dental care
- Need for increased caloric intake
Explanation:
Health promotion teaching for parents of a toddler (typically 1-3 years old) should focus on developmental milestones, safety, and health maintenance. Management of tantrums is appropriate, as toddlers often have tantrums due to their limited ability to express emotions, and parents need strategies to handle them (e.g., staying calm, setting limits). Encouraging cooperative play is relevant, as toddlers are beginning to develop social skills and can learn to share and interact with peers. Dental care is crucial, as toddlers should start brushing their teeth with fluoride toothpaste (a smear amount) and have regular dental checkups to prevent cavities.
90.A nurse is working with a team of nursing personnel within a facility. Which of the following are necessary task performance roles that members of the group or the leader must perform? (Select all that apply.)
- Self-confessor
- Coordinator
- Evaluator
- Energizer
- Dominator
Explanation:
In a team setting, certain roles are necessary for effective task performance and group dynamics, as outlined in group role theory (e.g., Benne and Sheats’ functional roles). A coordinator helps organize the team’s efforts, ensuring tasks are assigned and progress is made toward goals. An evaluator assesses the team’s performance, providing feedback to improve outcomes and ensure quality care. An energizer motivates the team, boosting morale and encouraging productivity, which is essential in a high-stress nursing environment.
91.A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.)
- Bradycardia
- An increase in neutrophils
- An increase in RBCs
- An increase in platelets
- Localized edema
Explanation:
In a client with diabetes mellitus reporting foot pain, the nurse should assess for signs of infection, as diabetic foot infections are common due to poor wound healing and neuropathy. An increase in neutrophils is a key indicator of infection, as neutrophils are the primary white blood cells involved in fighting bacterial infections, and their count rises during an acute inflammatory response. Localized edema (swelling) is another sign of infection, as inflammation causes fluid accumulation in the affected area.
92.A nurse is caring for a group of clients on a medical-surgical unit. Which of the following situations requires that the nurse wear gloves? (Select all that apply.)
- Emptying urine from an indwelling urine collection bag
- Providing oral care
- Changing an ostomy pouch
- Delivering a food tray to a client who has AIDS
- Placing oral medication tablets in the client’s hand
Explanation:
Gloves are required when there is a risk of contact with body fluids, mucous membranes, or non-intact skin, as per standard precautions. Emptying urine from an indwelling urine collection bag requires gloves because urine is a body fluid, and there’s a risk of splashing or contamination. Changing an ostomy pouch also requires gloves, as it involves handling stool (a body fluid) and potential contact with the stoma, which is a mucous membrane.
93.A nurse is completing discharge teaching to a client about nutrition therapy for wound healing following major surgery. Which of the following vitamins that promote wound healing should the nurse include in the teaching? (Select all that apply.)
- Vitamin A
- Vitamin B12
- Vitamin C
- Vitamin D
- Vitamin K
Explanation:
Nutrition plays a critical role in wound healing after major surgery, and certain vitamins are essential for this process. Vitamin A promotes wound healing by supporting epithelialization (skin cell growth), collagen formation, and immune function, all of which are crucial for tissue repair. Vitamin C is vital for collagen synthesis, as it acts as a cofactor in the hydroxylation of proline and lysine, which stabilizes collagen; it also has antioxidant properties that reduce inflammation and support healing.
94.A nurse is caring for an adolescent female who has an eating disorder. The client is 162.6 cm (64 in) tall and weighs 38.56 kg (85 lb). Upon assessment, which of the following manifestations should the nurse expect? (Select all that apply.)
- Amenorrhea
- Verbalized desire to gain weight
- Altered body image
- Hyperactivity
- Bradycardia
Explanation:
The client’s height and weight indicate a very low body mass index (BMI), approximately 14.6, which is consistent with an eating disorder like anorexia nervosa (normal BMI is 18.5–24.9). Amenorrhea (absence of menstruation) is a common manifestation in anorexia nervosa due to low body fat and hormonal imbalances, such as decreased estrogen levels. Altered body image is a hallmark of eating disorders, where the client perceives themselves as overweight despite being underweight, driving restrictive behaviors. Bradycardia (slow heart rate) is expected due to the body’s attempt to conserve energy in a state of malnutrition, as the metabolism slows down.
95.A nurse is caring for a client who is 2 days postpartum, is breastfeeding, and reports nipple soreness. Which of the following measures should the nurse suggest to reduce discomfort during breastfeeding? (Select all that apply.)
- Apply breast milk to the nipples before each feeding.
- Place breast pads inside the nursing bra.
- Massage the breasts and nipples prior to feeding.
- Start breastfeeding with the nipple that is less sore.
- Change the infant’s position on the nipples.
Explanation:
Nipple soreness is common in the early days of breastfeeding as the mother and infant adjust. Applying breast milk to the nipples before each feeding can help, as breast milk has natural healing properties and can soothe irritation (though applying it after feeding and letting it air dry is more common). Massaging the breasts and nipples prior to feeding can stimulate milk flow and soften the areola, making it easier for the infant to latch and reducing soreness. Starting breastfeeding with the nipple that is less sore encourages the infant to feed more gently on the sorer side later, as the infant’s suckling is typically stronger at the start of a feeding. Changing the infant’s position on the nipples (e.g., using different holds like the football or cross-cradle hold) can reduce pressure on sore areas and prevent further irritation.
96.A nurse on a medical unit is planning care for an older adult client who takes several medications. Which of the following prescribed medications places the client at risk for orthostatic hypotension? (Select all that apply.)
- Furosemide
- Telmisartan
- Duloxetine
- Clopidogrel
- Atorvastatin
Explanation:
Orthostatic hypotension is a drop in blood pressure upon standing, common in older adults due to age-related changes and medications. Furosemide, a loop diuretic, can cause orthostatic hypotension by reducing blood volume through diuresis, leading to decreased preload and blood pressure. Telmisartan, an angiotensin II receptor blocker (ARB), lowers blood pressure by blocking vasoconstriction, which can contribute to orthostatic hypotension, especially in older adults who may already have impaired baroreceptor reflexes.
97.A nurse is discussing comorbidities associated with eating disorders with a newly admitted client. Which of the following conditions should the nurse include in the discussion? (Select all that apply.)
- Anxiety
- Obsessive-compulsive disorder
- Schizophrenia
- Breathing-related sleep disorder
- Depression
Explanation:
Eating disorders, such as anorexia nervosa or bulimia nervosa, are often associated with psychiatric comorbidities. Anxiety is a common comorbidity, as individuals with eating disorders often experience intense worry about food, weight, and body image. Obsessive-compulsive disorder (OCD) is frequently seen, as the rigid eating patterns, rituals around food, and preoccupation with control in eating disorders mirror OCD symptoms. Depression is also prevalent, as malnutrition, social isolation, and low self-esteem in eating disorders can lead to or exacerbate depressive symptoms.
98.A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which of the following changes should the nurse include in the discussion? (Select all that apply.)
- More difficulty seeing due to a greater sensitivity to glare
- Decreased cough reflex
- Decreased bladder capacity
- Decreased systolic blood pressure
- Dehydration of intervertebral discs
Explanation:
Aging brings several physiologic changes that the nurse should discuss. More difficulty seeing due to a greater sensitivity to glare is expected, as the lens of the eye yellows and becomes less flexible with age, leading to increased glare sensitivity and difficulty with night vision. A decreased cough reflex is common, as respiratory muscle strength and neural sensitivity decline, increasing the risk of aspiration and infections like pneumonia. Decreased bladder capacity occurs due to reduced elasticity of the bladder wall and weaker pelvic floor muscles, leading to more frequent urination. Dehydration of intervertebral discs is a normal aging change, as discs lose water content, contributing to reduced flexibility and height loss.
99.A nurse is adhering to standard precautions while caring for a group of clients. For which of the following tasks should the nurse wear protective eye equipment? (Select all that apply.)
- Providing hygiene care to a client who is HIV-positive
- Emptying a urinary drainage bag for a client who has pneumonia
- Irrigating a client’s abdominal wound
- Transporting a cerebrospinal fluid specimen to the laboratory
- Suctioning a client’s new tracheostomy tube
Explanation:
Protective eye equipment is required under standard precautions when there is a risk of splashing or spraying of body fluids into the eyes. Irrigating a client’s abdominal wound requires eye protection because wound irrigation can cause splashing of wound exudate or irrigation fluid, which may contain blood or other body fluids. Suctioning a client’s new tracheostomy tube also requires eye protection, as suctioning can cause respiratory secretions to splatter, posing a risk of exposure to the eyes.
100.A nurse is receiving a provider’s prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (Select all that apply.)
- Repeat the order back to the provider.
- Question any part of the order that is unclear or inappropriate.
- Transcribe the order into the client’s health record.
- Obtain the provider’s signature within 8 hr.
- Implement a recorded message if the nurse can hear and understand it clearly.
Explanation:
Ensuring the accuracy of a telephone prescription is critical to prevent medication errors. Repeating the order back to the provider (read-back verification) confirms that the nurse understood the order correctly, reducing the risk of miscommunication. Questioning any part of the order that is unclear or inappropriate ensures patient safety by clarifying potential errors or unsafe instructions (e.g., incorrect dosage). Transcribing the order into the client’s health record is necessary for documentation and to ensure the order is followed correctly by the healthcare team.
[/et_pb_text][/et_pb_column][/et_pb_row][/et_pb_section][et_pb_section fb_built="1" fullwidth="on" _builder_version="4.9.3" _module_preset="default"][et_pb_fullwidth_header title="GET YOUR PROCTORED EXAM DONE FOR YOU SEAMLESSLY BY OUR EXPERT TEAM, UNDETECTED TODAY AT AN AFFORDABLE PRICE." button_one_text="Click Here" button_one_url="https://academiascholars.com/wgu-fast-track-service/" _builder_version="4.9.3" _module_preset="default"]
Are you currently in session at Western Governors University, and you're stuck with your exams, or even writing the long papers? We're here for you. Let's take full control of that course and see yourself graduating in less than 6 months. We promise nothing less than exemplary in your scores, and here's the kicker: We're completely undetectable!
Reach us on any of the following channels:
- Discord Server - https://discord.gg/38d7A4VJea
- WhatsApp: https://wa.me/+19178105386
- Call/SMS: +19178105386
- Website: Academiascholars.com
- Reddit: https://www.reddit.com/r/Homewrkdomain/
- Email: [email protected]