CRITICAL ONES

1. Exhibits The primary nurse reviews the client's history and vital signs. Select the 3 priority assessment findings that require immediate follow up. [Orders] 1400: Chest and abdominal x-ray STAT Abdominal ultrasound STAT 12-lead electrocardiogram (ECG) Insert peripheral IV (PIV) catheter Continuous pulse oximetry and cardiac/telemetry monitoring per protocol Apply and titrate oxygen PRN via nasal cannula to maintain oxygen saturation greater than 92% [Vital signs] 1400: Temperature: 97.2° F (36.2° C) orally Heart rate: 62 beats/minute Respirations: 16 breaths/minute Blood pressure: 104/64 mm Hg Oxygen saturation: 94% on room air Height: 5 ft 8 in (172.72 cm) Weight: 212 lb (96.16 kg) Body mass index (BMI) 32.2 kg/m2 (normal 18 to 24.9 kg/m2) Pain: 7 on a 0 to 10 scale in abdomen and back [Imaging Studies] 1420: 12-lead electrocardiogram (ECG): Atrial fibrillation with controlled ventricular response (CVR); no ST-e

D, E, G

2. Exhibits For each of the findings listed, click to indicate which are consistent with the disease process of aortic aneurysm versus gastric cancer. Each column must have at least one response option selected. [Orders] 1400: Chest and abdominal x-ray STAT Abdominal ultrasound STAT 12-lead electrocardiogram (ECG) Insert peripheral IV (PIV) catheter Continuous pulse oximetry and cardiac/telemetry monitoring per protocol Apply and titrate oxygen PRN via nasal cannula to maintain oxygen saturation greater than 92% [Flow Sheet] 1400: Vital signs Temperature: 97.2° F (36.2° C) orally Heart rate: 62 beats/minute Respirations: 16 breaths/minute Blood pressure: 104/64 mm Hg Oxygen saturation: 94% on room air Height: 5 ft 8 in (172.72 cm) Weight: 212 lb (96.16 kg) Body mass index (BMI) 32.2 kg/m2 (normal 18 to 24.9 kg/m2) Pain: 7 on a 0 to 10 scale in abdomen and back [Nurses' Notes] 1400: An 18 gauge peripheral IV (PIV) cat

A: {"answers":"B"} B: {"answers":"B"} C: {"answers":"A,B"} D: {"answers":"A"} E: {"answers":"A"} F: {"answers":"B"}

3. Exhibits The nurse evaluates the client's findings and test results. Choose the most likely options for the information missing from the statements by selecting from the lists of options provided. The nurse recognizes that the client is most at risk for aneurysm dropdown. The risk for this complication is highest in individuals with a history ofdropdown. [Orders] 1400: Chest and abdominal x-ray STAT Abdominal ultrasound STAT 12-lead electrocardiogram (ECG) Insert peripheral IV (PIV) catheter Continuous pulse oximetry and cardiac/telemetry monitoring per protocol Apply and titrate oxygen PRN via nasal cannula to maintain oxygen saturation greater than 92% [Vital Signs] 1400: Temperature: 97.2° F (36.2° C) orally Heart rate: 62 beats/minute Respirations: 16 breaths/minute Blood pressure: 104/64 mm Hg Oxygen saturation: 94% on room air Height: 5 ft 8 in (172.72 cm) Weight: 212 lb (96.16 kg) Body mass index (BMI) 32.2

dropdown-group-1: A dropdown-group-2: B

4. Exhibits Nurse reviews updated chart data. For each intervention, click to indicate if it is indicated or contraindicated. Each row must have only one response option selected. [Orders] 1400: Chest and abdominal x-ray STAT Abdominal ultrasound STAT 12-lead electrocardiogram (ECG) Insert peripheral IV (PIV) catheter Continuous pulse oximetry and cardiac/telemetry monitoring per protocol Apply and titrate oxygen PRN via nasal cannula to maintain oxygen saturation greater than 92% [Vital Signs] 1400: Temperature: 97.2° F (36.2° C) orally Heart rate: 62 beats/minute Respirations: 16 breaths/minute Blood pressure: 104/64 mm Hg Oxygen saturation: 94% on room air Height: 5 ft 8 in (172.72 cm) Weight: 212 lb (96.16 kg) Body mass index (BMI) 32.2 kg/m2 (normal 18 to 24.9 kg/m2) Pain: 7 on a 0 to 10 scale in abdomen and back [Nurses Notes] 1400: An 18 gauge peripheral IV (PIV) catheter is inserted in the left antecubital. A

A: {"answers":"A"} B: {"answers":"A"} C: {"answers":"A"} D: {"answers":"B"} E: {"answers":"A"} F: {"answers":"A"}

5. Exhibits After two days of intensive care, the client is transferred to the telemetry floor. The floor nurse is preparing a plan of care for the client. Which modifiable risk factor(s) should the nurse include in the teaching for this client? Select all that apply. [Orders] 1400: Chest and abdominal x-ray STAT Abdominal ultrasound STAT 12-lead electrocardiogram (ECG) Insert peripheral IV (PIV) catheter Continuous pulse oximetry and cardiac/telemetry monitoring per protocol Apply and titrate oxygen PRN via nasal cannula to maintain oxygen saturation greater than 92% [Vital Signs] 1400: Temperature: 97.2° F (36.2° C) orally Heart rate: 62 beats/minute Respirations: 16 breaths/minute Blood pressure: 104/64 mm Hg Oxygen saturation: 94% on room air Height: 5 ft 8 in (172.72 cm) Weight: 212 lb (96.16 kg) Body mass index (BMI) 32.2 kg/m2 (normal 18 to 24.9 kg/m2) Pain: 7 on a 0 to 10 scale in abdomen and back [Imaging St

B, C, D, H

6. Exhibits The client is being considered for discharge to home where he will continue to recover. The nurse reassesses the client and evaluates him for discharge readiness. For each body system, click to specify the assessment finding(s) that would indicate the client is ready for discharge to home. Each body system may support more than one finding. Each category must have at least one response option selected. Body system Findings Cardiovascular Blood pressure of 120/74 mm Hg Capillary refill of 4 seconds in lower extremities Pedal pulse of 2+ or better Neurovascular Pupils equal and nonresponsive to light Absence of numbness or tingling in feet Skin that is pale, cool to touch Renal Perfusion Client has urine output of 1,600 mL in 24 hours Creatinine of 1.2 mg/dL (106 mmol/L) [Orders] 1400: Chest and abdominal x-ray STAT Abdominal ultrasound STAT 12-lead electrocardiogram (ECG) Insert peripheral IV (PIV) cathete

A, C, E, G, H

7. An adolescent with autism spectrum disorder (ASD) comes to the clinic for the first time. Which intervention(s) should the nurse implement? Select all that apply. A) Consider having the teen's caregiver wait in the clinic reception area. | B) Encourage the adolescent to handle the physical exam instruments. | C) Allow time for talking before beginning the physical assessment. | D) Familiarize the adolescent with the clinic setting and healthcare staff. | E) Make every effort to establish eye contact with the adolescent.

B, C, D

8. Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse? A) Muscle pain. | B) Diarrhea and flatulence. | C) Abdominal cramps. | D) Altered taste.

Muscle pain.

9. The nurse is assigned to care for two critical care clients. One client was admitted yesterday with pneumonia, is being mechanically ventilated and has an elevated temperature. The other client had a thoracotomy two days ago and is now complaining of incisional pain. Which intervention should the nurse implement first? A) Assess level of consciousness and vital signs for both clients. | B) Administered pain medication to the client with incisional discomfort. | C) Complete a head-to-toe physical assessment for the client with pneumonia. | D) Review the plan of care and the medications for both clients.

Assess level of consciousness and vital signs for both clients.

10. A client who weighs 110 lb receives a prescription for dalteparin 150 units/kg SUBQ daily for 4 months. The medication is available in 7,500 units/0.3 mL prefilled syringe. How many mL should the nurse administer? (Enter numerical value only.)

0.3

11. Four days after exposure to COVID-19 a client has a negative COVID-19 test result. Eight days after the negative test result, the client presents with fever, fatigue, and cough and the nurse performs a second COVID-19 test. Which action is most important for the nurse to take? A) Report the COVID-19 result to the local health department according to the Center for Disease Control (CDC) guidelines. | B) Isolate the client from other clients, family, and healthcare workers not wearing proper personal protective equipment (PPE). | C) Notify the charge nurse the client will need assignment to the COVID-19 specified area of the facility. | D) Place the nasal swab specimen for COVID-19 directly into a biohazard bag.

Isolate the client from other clients, family, and healthcare workers not wearing proper personal protective equipment (PPE).

12. The nurse administers ophthalmic timolol to a client with glaucoma. The client routinely takes carvedilol, spironolactone, and ibuprofen daily. Which medication(s) should the nurse withhold? Select all that apply. A) Any antianxiety medications. | B) Over-the-counter oral antipyretics. | C) Nonsteroidal antiinflammatory drugs. | D) Other beta-adrenergic blocker agents. | E) Oral and subcutaneous anticoagulants.

C, D

13. The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse to report to the healthcare provide? A) Elevated liver function tests. | B) Vomiting and diarrhea. | C) Decreased white blood cell count. | D) Pruritus and muscle aches.

Elevated liver function tests.

14. Exhibits The nurse evaluates the client findings. Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. The nurse evaluates the client and determines there are concerning symptoms, including subjective symptoms of dropdown and dropdown. [Orders] 1930: Admit to psychiatric unit for further evaluation [Vital Signs] 1945: Temperature 98.7° F (37° C) Heart rate 106 beats/minute Respiration 20 breaths/minute Blood pressure 144/92 mm Hg Oxygen saturation 99% on room air Pain rating of 0 on 0 to 10 pain scale [Nurse's Notes] 1900: The client appears quiet and withdrawn, requiring prodding to get information. The client is constantly surveying the environment and appears easily startled by noises. 1930: The healthcare provider is at the bedside to evaluate the client. New prescriptions are obtained. [History and Physical] A 47-year-old female is bro

dropdown-group-1: A dropdown-group-2: A

15. Exhibits The nurse reviews the clinical findings. For each of the findings listed, click to indicate which are consistent with the disease process of major depressive disorder, generalized anxiety disorder, or posttraumatic stress disorder. Each column must have at least one response selected. [Orders] 1930: Admit to psychiatric unit for further evaluation [Vital Signs] 1945: Temperature 98.7° F (37° C) Heart rate 106 beats/minute Respiration 20 breaths/minute Blood pressure 144/92 mm Hg Oxygen saturation 99% on room air Pain rating of 0 on 0 to 10 pain scale [Nurse's Notes] 1900: The client appears quiet and withdrawn, requiring prodding to get information. The client is constantly surveying the environment and appears easily startled by noises. 1930: The healthcare provider is at the bedside to evaluate the client. New prescriptions are obtained. [History and Physical] A 47-year-old female is brought to the eme

A: {"answers":"C"} B: {"answers":"B"} C: {"answers":"C"} D: {"answers":"B,C"} E: {"answers":"B"} F: {"answers":"A,B,C"}

16. Exhibits The nurse calms the client and deescalates the situation. The nurse notes that a diagnosis of posttraumatic stress disorder has been added to the care plan. Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. The nurse recognizes that elevated dropdown can cause increased alertness and dropdown. [Orders] 1930: Admit to psychiatric unit for further evaluation [Vital Signs] 1945: Temperature 98.7° F (37° C) Heart rate 106 beats/minute Respiration 20 breaths/minute Blood pressure 144/92 mm Hg Oxygen saturation 99% on room air Pain rating of 0 on 0 to 10 pain scale [Nurse's Notes] 1900: The client appears quiet and withdrawn, requiring prodding to get information. The client is constantly surveying the environment and appears easily startled by noises. 1930: The healthcare provider is at the bedside to evaluate the client. New prescri

dropdown-group-1: B dropdown-group-2: B

17. Exhibits The nurse receives the prescription for sertraline and prepares to give the medication. The nurse reviews the current medication prescription. Click to specify if the intervention is indicated or not indicated. Each row must have only one response selected. [Orders] 1930: Admit to psychiatric unit for further evaluation [Vital Signs] 1945: Temperature 98.7° F (37° C) Heart rate 106 beats/minute Respiration 20 breaths/minute Blood pressure 144/92 mm Hg Oxygen saturation 99% on room air Pain rating of 0 on 0 to 10 pain scale [Nurse's Notes] 1900: The client appears quiet and withdrawn, requiring prodding to get information. The client is constantly surveying the environment and appears easily startled by noises. 1930: The healthcare provider is at the bedside to evaluate the client. New prescriptions are obtained. [History and Physical] A 47-year-old female is brought to the emergency department after her

A: {"answers":"A"} B: {"answers":"A"} C: {"answers":"A"} D: {"answers":"B"} E: {"answers":"B"}

18. Exhibits The nurse evaluates the client and begins preparing for her discharge. Choose the most likely options for the information missing from the statements by selecting from the lists provided. The nurse teaches the client that it will take dropdown for the sertraline to reach full therapeutic effect and explains the client has been set up to receive dropdown and reprocessing as an outpatient. The nurse also teaches the client dropdown to complement the medication and therapy. [Orders] 1930: Admit to psychiatric unit for further evaluation [Vital Signs] 1945: Temperature 98.7° F (37° C) Heart rate 106 beats/minute Respiration 20 breaths/minute Blood pressure 144/92 mm Hg Oxygen saturation 99% on room air Pain rating of 0 on 0 to 10 pain scale [Nurse's Notes] 1900: The client appears quiet and withdrawn, requiring prodding to get information. The client is constantly surveying the environment and appears easily

dropdown-group-1: B dropdown-group-2: C dropdown-group-3: B

19. A client with bladder cancer had surgical placement of a ureteroileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately? A) Red edematous stomal appearance. | B) Stomal output of 40 mL in last hour. | C) Liquid brown drainage from stoma. | D) Mucous strings floating in the drainage.

Liquid brown drainage from stoma.

20. A toddler is brought to the emergency department after ingesting several tablets of acetaminophen from a bottle that the toddler found in the mother's purse. The healthcare provider prescribes N-acetylcysteine solution for oral administration. Which action should the nurse implement if the child vomits? A) Teach parents about poison prevention in young children. | B) Lavage activated charcoal before giving acetylcysteine dose. | C) If dose is vomited within 1 hour of administration, repeat that oral dose. | D) Obtain blood samples to monitor liver function.

If dose is vomited within 1 hour of administration, repeat that oral dose.

Standard pediatric emergency protocol dictates that if a child vomits an oral dose of NAC within 1 hour of administration, the nurse must repeat that dose to ensure the child receives an adequate therapeutic amount. If persistent vomiting prevents oral retention, the healthcare provider may transition to intravenous (IV) administration

21. An older adult with pneumonia and an exacerbation of chronic obstructive pulmonary disease (COPD) was intubated for 14 days and was sucessfully extubated yesterday. Currently, the client has a weak cough and poor appetite. Which intervention(s) should the nurse implement? Select all that apply. A) Encourage activity as tolerated. | B) Assess ability to swallow solids and liquids. | C) Assist client with active range of motion. | D) Reinforce deep breathing exercises. | E) Obtain dietary consult for meal supplements.

A, B, C, D, E

22. While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values? A) Platelet count. | B) Neutrophil count. | C) Serum sodium level. | D) Hematocrit.

Neutrophil count.

23. The first paddle has been placed on the chest of a client who needs defibrillation. Where should the nurse place the second paddle? (Mark the location where the second paddle should be placed on the image)

ANSWER NOT PROVIDED IN SOURCE

24. A female client with breast cancer is scheduled to receive a series of radiotherapy (RT). She has red hair, fair skin, and freckles. She tells the nurse that her skin is particularly sensitive to the sun, so she is worried that the radiation will adversely affect her skin. Which information should the nurse provide this client about RT? Select all that apply. A) Both the sun and radiation can damage the skin because it has a rapid renewal rate. | B) lonizing energy of RT penetrates to the target tumor and does not affect the skin like sun rays. | C) Shielding helps to localize the entrance of RT and protects other sensitive areas. | D) Special gels can be prescribed for local application to promote healing and comfort. | E) Application of cold compresses after treatment decreases the skin's sensitivity.

A, C, D

25. A client with diabetic peripheral neuropathy has been taking pregabalin for 4 days. Which finding indicates to the nurse that the medication is effective? A) Full volume of pedal pulses. | B) Reduced level of pain. | C) Granulating tissue in foot ulcer. | D) Improved visual acuity.

Reduced level of pain.

26. Exhibits Review H and P, nurse's notes, and prescriptions. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress. [Orders] Admit to the pediatric unit NPO Abdominal x-ray Start an IV line and give lactated Ringer's infusion at 56 mL/hour via infusion pump [Nurse's Notes] 1200: Admitted the child to the pediatric unit. Started a peripheral IV line in the right hand and started IV fluids as prescribed. The child has episodes of pain where she pulls her knees to her chest and cries inconsolably. Once the episode has passed, she rests quietly with her mother. She has had two episodes of vomiting of approximately 30 mL. Mother reports that she had noticed some blood in the client's stool this morning and then the pai

ANSWER NOT PROVIDED IN SOURCE

27. The nurse is preparing to administer enoxaparin 30 mg subcutaneously using a pre-filled syringe containing 30 mg in 0.3 mL. Which action should the nurse implement? A) Hold the skin fold throughout the injection. | B) Insert the needle at a 90 degree angle. | C) Retain the air bubble in the syringe barrel. | D) Massage the area after injection.

Retain the air bubble in the syringe barrel.

28. A client with a history of a bilateral adrenalectomy is admitted with a weak, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse? A) Decreased urinary output. | B) Profound weight gain. | C) Low blood glucose levels. | D) Ventricular arrhythmias.

Ventricular arrhythmias.

29. A client receives a prescription for 1 L of lactated Ringer's IV to be infused over 12 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

21

30. The nurse is caring for a client with elevated parathyroid hormone levels. Which safety precaution should the nurse include in the plan of care? A) Aspiration. | B) Falls. | C) Suicide. | D) Hypothermia.

Falls.

31. In determining the one minute Apgar score of a neonate, the nurse assesses a heart rate of 120 beats per minute and 44 respirations per minute. The neonate has flaccid muscle tone with slight flexion and slight resistance to straightening, a loud cry with stimulation, and acrocyanotic color. Which is the correct Apgar score for this neonate? A) 8. | B) 10. | C) 7. | D) 9.

8.

32. The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which activity should the nurse delegate to the UAP? A) Prepare the sterile field for a urinary catheter insertion. | B) Begin wound care for a client after an appendectomy. | C) Monitor an IV infusion rate on an established schedule. | D) Anchor an inserted urinary catheter in place with tape.

Anchor an inserted urinary catheter in place with tape.

33. A client with chronic kidney disease (CKD) has an arteriovenous (AV) fistula in the left forearm. Which observation by the nurse indicates that the fistula is patent?

A) The left radial pulse is 2+ bounding.

| B) Assessment of a bruit on the left forearm.

| C) Auscultation of a thrill on the left forearm.

| D) Distended, tortuous veins in the left hand.

Assessment of a bruit on the left forearm.

Why the Other Options Are Incorrect:

• A) The left radial pulse is 2+ bounding: A radial pulse confirms blood flow to the hand, but a bounding pulse does not directly evaluate the patency or flow within the fistula itself. [1, 2]

• C) Auscultation of a thrill on the left forearm: This option mixes up the assessment methods. A thrill is a tactile sensation that is palpated (felt) with the fingers, not auscultated (heard) with a stethoscope. [1, 2, 3]

• D) Distended, tortuous veins in the left hand: While a functioning fistula causes the arm veins to swell over time, distended and tortuous veins in the hand are abnormal and typically indicate complications like venous hypertension or outflow stenosis rather than healthy patency

34. An older adult client is having photocoagulation for macular degeneration. Which intervention should the nurse implement during the postprocedure care in the outpatient surgical unit? A) Apply bilateral eye patches while sleeping. | B) Arrange food on the plate in clockwise order. | C) Verbally identify self when entering the room. | D) Use a white board to communicate ideas.

Verbally identify self when entering the room.

35. A female client with degenerative disc disease and chronic sciatica is describing numbness and tingling down her left leg. Which assessment should the nurse obtain first? A) Duration of sensation. | B) Precipitous activiity. | C) Time of last analgesic. | D) Gait coordination.

Duration of sensation.

36. When providing education for a client newly diagnosed with type 1diabetes, which information is most important for the nurse to provide the client? A) Encourage wearing a medical alert identification bracelet. | B) Explain the importance of counting carbohydrate intake. | C) Provide printed materials about the treatment of diabetes. | D) Teach how to recognize and treat hypoglycemia.

Teach how to recognize and treat hypoglycemia.

37. The nurse receives report on four clients who are reporting an increase in pain. Which client requires immediate intervention by the nurse? A) Paresthesia of fingers due to carpal tunnel syndrome. | B) Burning pain due to a Morton's neuroma. | C) Sharp pain related to a crushed femur. | D) Stinging pain related to plantar fasciitis.

Sharp pain related to a crushed femur.

38. Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain? A) Balance and posture. | B) Risk for disuse syndrome. | C) Pressure sore risk. | D) Upper body muscle strength.

Upper body muscle strength.

39. Patient Data Exhibits The triage nurse does a rapid assessment of the client. Click to highlight the data that indicates the client is in need of immediate health interventions. A 70-year-old female presents to the emergency department (ED) through triage with a noticeable facial droop and garbled speech. After having a few drinks at a local seafood restaurant, the client's husband noticed his wife's speech became difficult to understand. [Nurse's Notes] 1915: Client arrives via personal car to emergency department (ED) with facial drooping and garbled speech. [History and Physical] An older adult client presents to the emergency department (ED) triage with a noticeable facial droop and garbled speech. After having a few drinks at a local seafood restaurant, the client's husband noticed his wife's speech became difficult to understand. A) noticeable facial droop | B) garbled speech | C) few drinks at a local seaf

A, B, D

40. Patient Data Exhibits The nurse performs an initial rapid assessment of the client and observes facial drooping and garbled speech. Drag one condition and one client finding to complete the sentence(s). Based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of dropdown as evidenced by dropdown. [Vital Signs] 1920: Temperature: 98.2° F (36.8° C) orally Heart rate: 92 beats/minute Respirations: 24 breaths/minute Blood pressure: 210/98 mm Hg Oxygen saturation: 95% on room air [Nurse's Notes] 1915: Client arrives via personal car to emergency department (ED) with facial drooping and garbled speech. [History and Physical] An older adult client presents to the emergency department (ED) triage with a noticeable facial droop and garbled speech. After having a few drinks at a local seafood restaurant, the client's husband noticed his wife's speech became difficult to understand.

dropdown-group-1: D dropdown-group-2: A

41. Patient Data Exhibits The client is ready for transfer to the neurological intensive care unit (ICU). The receiving nurse obtains report from the emergency department (ED) nurse. Received a computed tomography (CT) scan of the head 18 gauge peripheral IV (PIV) in bilateral antecubital spaces CMP, WBC, APTT, PT/INR drawn and results are all WNL 12-Lead ECG normal sinus rhythm (NSR) 0.9% sodium chloride infusing at 50mL/hour Sitting in a semi Fowler's position Client is NPO Pharmacy bringing tissue plasminogen activator (tPA) to the unit shortly Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided. During tPA administration, the nurse should prioritize dropdown to monitor for dropdown. [Orders] 1920: Obtain a computed tomography (CT) scan of the head 12-lead electrocardiogram (ECG) now Complete metabolic panel (CMP), white blood cell count

dropdown-group-1: C dropdown-group-2: A

42. Patient Data Exhibits The nurse administered tPA and conducted neurologic assessments every 15 minutes during the infusion. The tPA infusion finished and the nurse performed neurologic assessments every 30 minutes for the 6 hours following the administration. The client was noted to be stable with unchanged neurologic assessments. The nurse begins to plan care for the client's recovery and identifies interdisciplinary team members who can assist with the client's recovery. Which interdisciplinary team member(s) should assist the client in recovery? Select all that apply. [Orders] 1920: Obtain a computed tomography (CT) scan of the head 12-lead electrocardiogram (ECG) now Complete metabolic panel (CMP), white blood cell count (WBC), activated partial thromboplastin time (APTT), prothrombin time with International normalized ratio (PT/INR) Insert a large bore peripheral IV (PIV) catheter Start 0.9% sodium chloride

C, E, F, H

43. Patient Data Exhibits The client continues to have stable neurologic assessments. The nurse provides interventions to promote client safety while in the hospital. Click to indicate which interventions promote client safety. Each column must have at least one response selected. [Orders] 1920: Obtain a computed tomography (CT) scan of the head 12-lead electrocardiogram (ECG) now Complete metabolic panel (CMP), white blood cell count (WBC), activated partial thromboplastin time (APTT), prothrombin time with International normalized ratio (PT/INR) Insert a large bore peripheral IV (PIV) catheter Start 0.9% sodium chloride fusion at 50 mL/hour NPO 1940: Prepare for tissue plasminogen activator (tPA) [Vital Signs] 1920: Temperature: 98.2° F (36.8° C) orally Heart rate: 92 beats/minute Respirations: 24breaths/minute Blood pressure: 210/98 mm Hg Oxygen saturation: 95% on room air 1955: Temperature: 98.2° F (36.8° C) oral

A: {"answers":"A"} B: {"answers":"B"} C: {"answers":"A"} D: {"answers":"A"} E: {"answers":"B"} F: {"answers":"A"}

44. Patient Data Exhibits For each focused assessment area, click to specify which findings indicate early interventions for an ischemic stroke were effective. Each focused assessment area may support more than one clinical finding. Each category must have at least one response option selected. Focused Assessment Area Clinical Finding Musculoskeletal Ambulates with a walker Flaccidity of left arm Passive range of motion of the left leg Psychosocial Fits of laughter Angry outbursts Tearful sharing of stories Neurological Drinks with repetitive cough Decorticate posturing Speaks in short sentences [Orders] 1920: Obtain a computed tomography (CT) scan of the head 12-lead electrocardiogram (ECG) now Complete metabolic panel (CMP), white blood cell count (WBC), activated partial thromboplastin time (APTT), prothrombin time with International normalized ratio (PT/INR) Insert a large bore peripheral IV (PIV) catheter Start

A, F, I

45. A client who has type 2 diabetes mellitus is admitted to the intensive care unit with third degree burns over 20% of the body. To decrease the client's risk of developing hyperosmolar hyperglycemic syndrome (HHS), which intervention(s) should the nurse implement? Select all that apply. A) Assess for breath with a fruity odor. | B) Titrate an insulin infusion to maintain a low serum glucose level. | C) Monitor for elevated temperature and administer PRN antipyretics. | D) Monitor serum electrolyte levels and report any abnormal values. | E) Maintain large bore IV patency for aggressive fluid resuscitation.

B, D, E

46. A client is admitted with the diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use when developing the client's plan of care? A) Peripheral neuropathy. | B) Right lower abdominal pain. | C) Confusion. | D) Depression.

Confusion.

47. A client diagnosed with Parkinson's disease receives a prescription for carbidopa-levodopa, controlled release (CR) 25/100 mg PO daily each morning. Which information should the nurse include in the client's teaching plan? Select all that apply. A) An upset stomach may occur as a side effect of this medication. | B) A change in urine color to dark red often occurs while taking this drug. | C) The medication should only be taken during a meal. | D) Avoid sunlight and wear sunglasses while outdoors. | E) Parkinson symptoms should diminish within one week.

A, B

48. An older female client who resides at an assisted living facility comes for an annual gynecological visit at the clinic and states she has a burning sensation when urinating. Assessment findings include: blood pressure 128/88 mm Hg, urine negative for bacteria, and ecchymotic areas on both forearms. She reports being sexually active and drinks beer once or twice a month. During this clinic visit, which intervention(s) should the nurse implement? Select all that apply. A) Ask the client if someone brought her to the clinic. | B) Review list of daily medications for aspirin or other anticoagulants. | C) Question her if she previously or currently uses of any illicit drugs. | D) Inquire if she is being emotionally or physically abused. | E) Determine number of sexual partners she has had recently.

B, D, E

49. The public health nurse receives funding to initiate a primary prevention program in the community. Which program best fits the nurse's proposal? A) Vitamin supplements for high-risk pregnant women. | B) Lead screening for children in low-income housing. | C) Regional relocation center for earthquake victims. | D) Case management and screening for clients with HIV.

Vitamin supplements for high-risk pregnant women.

50. When assessing a recently delivered, multigravida client, the nurse finds that her vaginal bleeding is more than expected. Which factor in this client's history is related to this finding? A) She is a gravida 6, para 5. | B) She received butorphanol 2 mg IV during labor. | C) She is over 35 years of age. | D) The second stage of labor lasted 10 minutes.

She is a gravida 6, para 5.

51. Patient Data Exhibits The nurse reviews the findings in the history and physical. Drag from Word Choices to complete the sentence. The nurse recognizes that dropdown , dropdown and dropdown are findings consistent with elder mistreatment. [Vital Signs] 1000: Temperature: 97.9° F (36.6° C), orally Heart rate: 95 beats/minute Respirations: 16 breaths/minute Blood pressure: 142/69 mm Hg Oxygen saturation: 95% on room air Height: 5 ft 4 in (162.56 cm) Weight: 98 lb (44.5 kg) Pain: 0 on 0 to 10 scale [Nurse's Notes] 1000: The client's daughter has assumed the role of primary caregiver after moving her mother into her home following a hospitalization for an exacerbation of heart failure (HF). The client is able to participate in care discussions and was assessed independently. After performing the initial assessment, the client's daughter was invited back into the room. Assessment Neurological: Alert and oriented times

dropdown-group-1: A dropdown-group-2: B dropdown-group-3: D

52. Patient Data Exhibits Click to indicate if the listed manifestations of abuse is consistent with physical abuse, abandonment, or neglect. Each row must have only one response option selected. [Vital Signs] 1000: Temperature: 97.9° F (36.6° C), orally Heart rate: 95 beats/minute Respirations: 16 breaths/minute Blood pressure: 142/69 mm Hg Oxygen saturation: 95% on room air Height: 5 ft 4 in (162.56 cm) Weight: 98 lb (44.5 kg) Pain: 0 on 0 to 10 scale [Nurse's Notes] 1000: The client's daughter has assumed the role of primary caregiver after moving her mother into her home following a hospitalization for an exacerbation of heart failure (HF). The client is able to participate in care discussions and was assessed independently. After performing the initial assessment, the client's daughter was invited back into the room. Assessment Neurological: Alert and oriented times 4. Client reports fatigue. Daughter reports sh

A: {"answers":"C"} B: {"answers":"A"} C: {"answers":"C"} D: {"answers":"A"} E: {"answers":"C"} F: {"answers":"B"}

53. Patient Data Exhibits New data is reviewed. Choose the most likely options for the information missing from the statements by selecting from the lists of options provided. This client is exhibiting signs of dropdown. The nurse is a mandated reporter and therefore must report the elder mistreatment to dropdown. [Vital Signs] 1000: Temperature: 97.9° F (36.6° C), orally Heart rate: 95 beats/minute Respirations: 16 breaths/minute Blood pressure: 142/69 mm Hg Oxygen saturation: 95% on room air Height: 5 ft 4 in (162.56 cm) Weight: 98 lb (44.5 kg) Pain: 0 on 0 to 10 scale [Nurse's Notes] 1000: The client's daughter has assumed the role of primary caregiver after moving her mother into her home following a hospitalization for an exacerbation of heart failure (HF). The client is able to participate in care discussions and was assessed independently. After performing the initial assessment, the client's daughter was invi

dropdown-group-1: A dropdown-group-2: B

54. Patient Data Exhibits Which intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply. [Vital Signs] 1000: Temperature: 97.9° F (36.6° C), orally Heart rate: 95 beats/minute Respirations: 16 breaths/minute Blood pressure: 142/69 mm Hg Oxygen saturation: 95% on room air Height: 5 ft 4 in (162.56 cm) Weight: 98 lb (44.5 kg) Pain: 0 on 0 to 10 scale [Nurse's Notes] 1000: The client's daughter has assumed the role of primary caregiver after moving her mother into her home following a hospitalization for an exacerbation of heart failure (HF). The client is able to participate in care discussions and was assessed independently. After performing the initial assessment, the client's daughter was invited back into the room. Assessment Neurological: Alert and oriented times 4. Client reports fatigue. Daughter reports short-term memory loss and and halitosis. Skin is dry and flaky.

A, C, D, E, H

55. Patient Data Exhibits The nurse uses the Modified Caregiver Strain Index (MCSI) and determines that the daughter is under significant stress caused by the assumption of her mother's care. The nurse is planning to have a discussion with the daughter on decreasing the stress she is experiencing as a caregiver. Select the 3 statements that the nurse should include when discussing caregiver stress with the client's daughter. [Vital Signs] 1000: Temperature: 97.9° F (36.6° C), orally Heart rate: 95 beats/minute Respirations: 16 breaths/minute Blood pressure: 142/69 mm Hg Oxygen saturation: 95% on room air Height: 5 ft 4 in (162.56 cm) Weight: 98 lb (44.5 kg) Pain: 0 on 0 to 10 scale [Nurse's Notes] 1000: The client's daughter has assumed the role of primary caregiver after moving her mother into her home following a hospitalization for an exacerbation of heart failure (HF). The client is able to participate in care di

A, C, F

56. Patient Data Exhibits As a result of the Adult Protective Services investigation, additional care has been established for the client including physical and occupational therapy twice weekly and a home health aide to provide assistance with activities of daily living. Drag from statement options to complete the sentence. To assess outcomes, the nurse should consider information reported by the client and caregiver and focus on evaluating the client's dropdown and dropdown. [Vital Signs] 1000: Temperature: 97.9° F (36.6° C), orally Heart rate: 95 beats/minute Respirations: 16 breaths/minute Blood pressure: 142/69 mm Hg Oxygen saturation: 95% on room air Height: 5 ft 4 in (162.56 cm) Weight: 98 lb (44.5 kg) Pain: 0 on 0 to 10 scale [Nurse's Notes] 1000: The client's daughter has assumed the role of primary caregiver after moving her mother into her home following a hospitalization for an exacerbation of heart failu

dropdown-group-1: A dropdown-group-2: C

57. The nurse is assigned to care for a client diagnosed with psoriasis. Which behavior by the nurse addresses this client's psychosocial need for acceptance? A) Encouraging the client to join a support group. | B) Allowing the client to ventilate feelings. | C) Shaking the client's hand during an introduction. | D) Wearing gloves when interviewing the client.

Shaking the client's hand during an introduction.

58. When assessing an older adult client, the nurse finds that the client is experiencing orthopnea and has an oxygen saturation reading of 93% on room air. Auscultation of the lungs reveals crackles and bilateral pedal edema are present. In which order should the nurse implement these actions? (Arrange in the order from first on top to last on the bottom.) A) Raise the head of the bed to Fowler's position. | B) Provide oxygen per nasal cannula. | C) Administer a prescribed dose of furosemide. | D) Monitor urinary output.

A, B, C, D

59. The nurse is caring for a client with left-sided hemiparesis after a stroke. Which action should the nurse take to safely assist the client with ambulation? A) Provide support on the unaffected side. | B) Hook an arm under the client's left arm. | C) Use a gait belt standing on affected side. | D) Hold the gait belt with palms facing down.

Use a gait belt standing on affected side.

60. After diagnosis and initial treatment of a pre-school age child with cystic fibrosis, the nurse provides home care instructions to the parents. Which statement by the child's parents indicates that understanding of the home care treatment to promote pulmonary function? A) "Chest physiotherapy should be performed twice a day before a meal." | B) "Administer a cough suppressant every 8 hours." | C) "Energy should be conserved by scheduling minimally strenuous activities." | D) "Maintain supplemental oxygen at 4 to 6 L/minute."

"Chest physiotherapy should be performed twice a day before a meal."

61. The post anesthesia care unit (PACU) nurse uses the SBAR format in reporting to the surgical unit nurse regarding an older client who had a right total hip replacement for avascular necrosis. Vital signs are reported, which are all stable and within normal limits. The nurse also reports that the client was medicated for pain with morphine 2 mg IV and ondansetron 4 mg IV 45 minutes ago, which reduced the pain level to 4 on a 0 to 10 scale, but the client is still nauseated. Which additional information is critical for the PACU nurse to include in the SBAR format report? Select all that apply. A) The client should be monitored closely for persistent nausea or vomiting. | B) A large number of family members are in the surgical waiting area. | C) A patient controlled analgesic (PCA) pump is prescribed and needs to be started as soon as possible. | D) Surgical dressing is clean, dry, and intact and neurovascular statu

C, D, E

62. The charge nurse in an extended care facility is organizing unit activities for the day. Which action may be safely delegated to the practical nurse (PN)? A) Evaluate client teaching through return demonstration. | B) Establish blood pressure parameters for client monitoring. | C) Evaluate a staff member providing wound care. | D) Measure the client's body weight each morning.

Measure the client's body weight each morning.

63. Patient Data Exhibits Data is evaluated to determine possible condition and appropriate interventions. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress. [Vital Signs] 1900: Temperature: 100.2° F (37.9° C) Heart rate: 119 beats/minute Respirations: 22 breaths/minute Blood pressure: 146/94 mm Hg Oxygen saturation 99% on room air Pain: 3 on 0 to 10 scale, dull headache Height: 5 feet, 7 inches (170.18 cm) Weight: 144 pounds (65.32 kg) 0.8 inch (2 cm) wound to left temple with scant bright-red bleeding noted [Nurse's Notes] 1900: Client is agitated and insists that she be allowed to go home. [History and Physical] A 32-year-old female is brought to the emergency department (ED) by her spouse after she stumbled

ANSWER NOT PROVIDED IN SOURCE

64. A client with a history of gout presents to the clinic with an inflamed left knee. The client reports the knee is extremely painful to touch for the second time in 6 months. The healthcare provider prescribes colchicine and ibuprofen. Which instruction should the nurse include in the discharge teaching? A) Decrease consumption of red meat and most seafood. | B) Support joints in an extended position while resting. | C) Massage joints to relax muscles and decrease pain. | D) Replace dietary table salt with salt substitutes.

Decrease consumption of red meat and most seafood.

65. The nurse is caring for a client who has been admitted with recurring migraine headaches. To assess the quality of the client's pain experienced from the migraine headache, which approach should the nurse use? A) Ask the client to describe the pain. | B) Provide a numeric pain scale. | C) Identify effective pain relief measures. | D) Observe body language and movement.

Ask the client to describe the pain.

66. A client who has asthma receives a new prescription for a corticosteroid inhaler. The client expresses concern about taking steroid medications. Which information should the nurse provide the client about the use of this maintenance inhaler? A) Oral care is not required after each use of the inhaler. | B) Inhaled medications are easier to take than oral forms. | C) No weaning is required when stopping the use of this inhaler. | D) Systemic side effects are reduced when taken by inhalation.

Systemic side effects are reduced when taken by inhalation.

67. A client received a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, which action should the nurse implement? A) Assess for fatty yellow streaks in the client's stool. | B) Obtain a specimen for culture and sensitivity analysis. | C) Send a stool sample to the lab for a guaiac test. | D) Observe the stool for a clay-colored appearance.

Send a stool sample to the lab for a guaiac test.

68. The healthcare provider prescribes 500 mL of 0.45% normal saline with 100 units regular insulin to infuse at 15 units/hour. The drop factor is 20 gtt/mL. The nurse should regulate the IV to deliver how many gtt/minute? (Enter numerical value only.)

25

69. In caring for a client with chronic kidney disease (CKD), the nurse notes that the client's serum phosphate level is elevated, with a converse decrease in serum calcium. Which nursing care goal is a priority, based on these laboratory findings? A) Prevent injury. | B) Prevent infection. | C) Protect skin integrity. | D) Manage fluid volume.

Prevent injury.

70. A client with eczema is experiencing severe pruritus. Which PRN prescription(s) should the nurse administer? Select all that apply. A) Transdermal analgesic. | B) Topical alcohol rub. | C) Topical corticosteroid. | D) Oral antihistamine. | E) Topical scabicide.

C, D

71. Which dietary intervention(s) should the nurse include in the plan of care for a client who had bariatric surgery? Select all that apply. A) Separate fluids from meals. | B) Plan meals to include rice porridge. | C) Eliminate acidic food choices. | D) Offer more bread and cheese. | E) Provide small frequent meals.

A, E

72. The nurse observes a practical nurse (PN) placing a client on the right side with the left leg bent in preparation for a lumbar puncture. Which action should the nurse implement? A) Arrange for an unlicensed assistive personnel to assist the PN during the procedure. | B) Acknowledge that the PN has positioned the client safely and correctly. | C) Assume care of the client and assign the PN to the care of a different client. | D) Demonstrate to the PN how to position the client more effectively for the procedure.

Demonstrate to the PN how to position the client more effectively for the procedure.

73. The nurse is reviewing a pregnant client's prenatal immunization history. Which immunization should the nurse instruct the client to receive after pregnancy? A) Meningitis B. | B) Measles, mumps, rubella. | C) Diphtheria, pertussis, tetanus. | D) Influenza vaccine.

Measles, mumps, rubella.

74. The nurse caring for a toddler with Kawasaki disease who is receiving intravenous immunoglobulin for severe coronary inflammation is planning discharge teaching for the parents. Which instruction should the nurse provide during the discharge education? A) Plan for a follow-up echocardiogram occurring in 4 to 6 weeks. | B) Resume the toddler's normal immunization schedule. | C) Irritability and tinnitus are expected for up to 2 weeks. | D) Manage joint pain with a nonsteroidal antiinflammatory.

Plan for a follow-up echocardiogram occurring in 4 to 6 weeks.

75. A client with fibromyalgia asks the nurse to arrange for hospice care to help manage the severe, chronic pain. Which intervention should the nurse provide to address the client's problem? A) Arrange an appointment with a pain specialist. | B) Form an interdisciplinary team for evaluation. | C) Contact a hospice nurse for an evaluation. | D) Ask for a consultation with a psychologist.

Arrange an appointment with a pain specialist.

76. Patient Data Exhibits Initial testing is complete, and the nurse reviews the laboratory and imaging results. Choose the most likely options for the information missing from the statements by selecting from the lists of options provided. The nurse recognizes that the client likely has dropdown. Laboratory findings that support diagnosis of this disease process include dropdown and dropdown. [Vital Signs] Day 1, 0930: Temperature 98.6° F (37° C) Heart rate 101 beats/minute Respirations 28 breaths/minute Blood pressure 115/76 mm Hg Oxygen saturation 95% on room air Pain rating of 3 on a 0 to 10 scale [Imaging Studies] Hepatic ultrasound: nodular liver surface, round edge, and hypoechoic nodules in liver parenchyma which represent regenerative nodules of cirrhotic liver [Nurse's Notes] Day 1, 0930: The client arrives at the clinic for a new client physical examination. Assessment Neurological: Alert and oriented time

dropdown-group-1: A dropdown-group-2: A dropdown-group-3: A

77. An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, which nursing interventions should the nurse include in the client's plan of care? Select all that apply. A) Teach client to use incentive spirometer every 2 hours while awake. | B) Assess pain level and medicate PRN as prescribed. | C) Maintain sequential compression devices while in bed. | D) Remove urinary catheter as soon as possible and encourage voiding. | E) Administer low molecular weight heparin as prescribed.

A, D

78. The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having unprotected sex. Which response should the nurse provide? A) Clarify that all STIs are transmitted through sexual intercourse. | B) Emphasize that using safe sex practices removes the risk of STIs. | C) Explain that reinfections occur from sex with untreated partners. | D) Provide counseling that most contraceptives protect against infection.

Explain that reinfections occur from sex with untreated partners.

79. A client with Neisseria meningitidis calls the nurses station to report a severe headache and vomiting. The unlicensed assistive personnel (UAP) approaches the room to provide an emesis basin and is stopped by the nurse. Which action should the nurse take?

A) Remind the UAP to apply a fitted respirator mask before entering the client's room.

| B) Assign the UAP to provide care for another client and assume full care of the client.

| C) Review the need for the UAP to wear a face mask while in close contact with the client.

| D) Instruct the UAP to notify the nurse of any changes in the client's emesis.

| C) Review the need for the UAP to wear a face mask while in close contact with the client.

80. A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, which priority action should the nurse implement? A) The client's need for pain medication should be determined. | B) The impending signs of death should be documented. | C) The client's status should be conveyed to the chaplain. | D) The nurse manager should be updated on the client's status.

The client's need for pain medication should be determined.

81. The nurse is caring for a client who is immobile and developed a stage IV pressure injury on the sacrum. The nurse identifies eschar in the wound bed. Which intervention is most important for the nurse to implement? A) Place a foam surface on top of the mattress. | B) Raise the head of the bed only to 30 degrees. | C) Perform passive range of motion exercises. | D) Increase the daily intake of vitamin C.

Raise the head of the bed only to 30 degrees.

82. The healthcare provider prescribes 1 liter of lactate Ringer's to infuse in 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hour should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

125

83. The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective? A) A salad with three kinds of lettuce and fruit. | B) A peanut butter sandwich with soda and cookies. | C) Vegetable soup, crackers, and milk. | D) A tuna fish sandwich with chips and ice cream.

A tuna fish sandwich with chips and ice cream.

84. Which long-term outcome is most important for the nurse to include in the plan of care for an older adult client with chronic pyelonephritis? A) Manages activities of daily living independently. | B) Measures oral temperature daily. | C) Maintains blood pressure within normal limits. | D) Restricts fluid intake to 1 L/day.

Maintains blood pressure within normal limits.

85. The nurse is conducting a visual screening of a group of older adults. Which finding should the nurse report to the healthcare provider immediately? A) Recent change in the ability to read and drive after dark. | B) Gradual onset of continuous eye pain and blurred vision. | C) Cloudy opacity of the crystalline lens. | D) Gray-white circle around the iris of both eyes.

Gradual onset of continuous eye pain and blurred vision.

86. The nurse assumes care of a postoperative adult client with type 2 diabetes mellitus and learns that the client has a current blood glucose level of 750 mg/dL (42 mmol/L). When assessing the client, which is the priority? Reference Range: Glucose [Reference Range:74 to 106 mg/dL (4.1 to 5.9 mmol/L)] A) Observe wound drainage characteristics. | B) Assess for signs of fluid volume deficit. | C) Determine when the client last ate. | D) Measure the level of acute pain.

Assess for signs of fluid volume deficit.

87. When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse? A) Low intermittent suction prescribed for the nasogastric tube is turned off. | B) The urinary catheter drainage bag is almost completely full of amber urine. | C) Oxygen is being administered via nasal cannula at 4 L/min without humidification. | D) A Hemovac drain is partially full of serous drainage and is not compressed.

A Hemovac drain is partially full of serous drainage and is not compressed.

88. Which information is most important for the nurse to obtain when determining a client's risk for obstructive sleep apnea syndrome (OSAS)? A) Self-description of pain. | B) Body mass index. | C) Level of consciousness. | D) Breath sounds.

Body mass index.

89. Which situation indicates a need for the nurse to discuss the use of mitten restraints with the healthcare provider? A) A family member expresses concern about their relative "picking" at the nasal gastric tube (NG) tube. | B) A client is walking the halls at night rubbing his hands together. | C) A 16-year-old boy swung his fist at the nurse. | D) A disoriented client removed the mesh wrapped intravenous (IV) line for the second time.

A disoriented client removed the mesh wrapped intravenous (IV) line for the second time.

90. A client with Alzheimer's disease (AD) is receiving trazodone, a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the client's mood and sleep patterns are improved, but there is no change in cognitive ability. How should the nurse respond to this information? A) Confirm that the desired effect of the medication has been achieved. | B) Explain that it may take several weeks for the medication to be effective. | C) Evaluate when and how the medication is being administered to the client. | D) Notify the healthcare provider that a change in dosage may be needed.

Confirm that the desired effect of the medication has been achieved.

91. A client shares with the nurse concerns of a possible stomach ulcer. The client is experiencing heartburn and a dull gnawing pain that is relieved with eating. Which is the best response by the nurse? A) Encourage the client to obtain a complete physical exam, since these symptoms are consistent with an ulcer. | B) Advise the client that he needs to seek immediate medical evaluation and treatment of these symptoms. | C) Assure the client that his symptoms may only reflect reflux, since ulcer pain is not relieved with food. | D) Instruct the client that these mild symptoms can generally be controlled with changes in his diet.

Encourage the client to obtain a complete physical exam, since these symptoms are consistent with an ulcer.

92. A client with chronic kidney disease (CKD) and a bacterial infection receives a prescription for ciprofloxacin. The standard dose is 500 mg PO twice daily, but due to the patient's renal impairment, a dose adjustment of 50% is recommended. The medication is available in 250 mg tablets. How many tablets should the nurse administer? (Enter numerical value only.)

1

93. A 6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy. Which pre-operative nursing action has highest priority? A) Monitor amount of intake and infant's response to feedings. | B) Mark an outline of the "olive-shaped" mass in the right epigastric area. | C) Instruct parents regarding care of the incisional area. | D) Initiate a continuous infusion of IV fluids per prescription.

Initiate a continuous infusion of IV fluids per prescription.

94. The nurse is planning an educational session for new parents on ways to prevent sudden infant death syndrome (SIDS). Which information is most important to provide parents of newborns and infants? A) Position the infant in a supine position while sleeping. | B) Keep a bulb syringe accessible for use for an infant. | C) Remove pillows and soft toys from the crib at bedtime. | D) Do not prop bottles for an infant during naps and bedtime.

Position the infant in a supine position while sleeping.

95. The school nurse is preparing a presentation for elementary school teachers to inform them when a child should be referred to the school clinic for further follow-up. The teachers should be instructed to report which situations to the school nurse? Select all that apply. A) Shaking that changes the child's handwriting legibility. | B) Bruises on both knees after the weekend. | C) Sunburn with blisters on the face, arms, and hands. | D) Refuses to complete written homework assignments. | E) Thirst and frequent requests for bathroom breaks.

A, C, E

96. The nurse assisting the healthcare provider with a wound debridement at the bedside of a client who is mildly confused. The client is draped and a sterile field is created. Which nursing intervention should the nurse implement for client safety? A) Assess for discomfort when procedure is completed. | B) Verify that the client has given informed consent. | C) Instruct the client to keep hands under the sterile field. | D) Pour cleansing solution onto the sterile cloth field.

Instruct the client to keep hands under the sterile field.

97. After administering an antipyretic medication, which intervention should the nurse implement? A) Use fans to provide external cooling. | B) Encouraging liberal fluid intake. | C) Encourage the client to eat a bland diet. | D) Cover the client with warm blankets.

Encouraging liberal fluid intake.

98. During shift report, the charge nurse receives notice of several problems. Which problem should the nurse address first? A) A bucket of water was spilled in the hallway. | B) One staff member has not reported to work. | C) A client's wife has asked to speak with the charge nurse. | D) The census report has not been completed.

A bucket of water was spilled in the hallway.

99. While the nurse is conducting an admission assessment of a female client with bipolar disorder, the client suddenly begins to take off her clothes and throw them about the room. Which action should the nurse take first? A) Change to less anxiety-promoting questions. | B) Ignore the client's inappropriate behavior. | C) Leave the client's room so she can act out her anxiety. | D) State it is unacceptable to undress during the interview.

State it is unacceptable to undress during the interview.

100. Patient Data Exhibits For each action, identify if it is indicated or not indicated when monitoring the effects of lorazepam administration. Each row must have one response action selected. [Orders] 1030: Bloodwork: troponin I and creatine kinase- MB (CK-MB) STAT Establish peripheral IV access 1035: Continuous cardiac monitoring 12-lead electrocardiogram (ECG) STAT 1045: Lorazepam 2 mg IV STAT x 1 1050: Social worker assessment to evaluate and treat [Vital Signs] 1030: Temperature 98.7° F (37° C) Heart rate 118 beats/minute Respiration 22 breaths/minute Blood pressure 136/88 mm Hg Oxygen saturation 95% on room air Pain rating of 10 on a 0 to 10 scale constant non-radiating chest pain 1045: Temperature 98.8° F (37.1° C) Heart rate 124 beats/minute Respiration 22 breaths/minute Blood pressure 138/88 mm Hg [Imaging Studies] 1040: 12-lead electrocardiogram (ECG) results: Atrial tachycardia with no noted ST- elevatio

A: {"answers":"A"} B: {"answers":"B"} C: {"answers":"B"} D: {"answers":"A"} E: {"answers":"A"} F: {"answers":"A"}