Test Mode Assessment

No.

1 :
A male preoperative client who has already signed the informed consent for a surgical procedure confides in the practical nurse (PN) that he is really frightened and unsure about undergoing the surgery. Which priority action should the PN take?

Encourage the client to continue with the scheduled surgery.

Document that the client has expressed concerns about the surgery.

Notify the charge nurse of the client's concerns about surgery.

Remind the client that the consent has already been obtained.

Hint : 🔍Escalate client uncertainty.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

2 :
The parents of a one-year-old child with the diagnosis of hypospadias informed the practical nurse (PN) that they plan to delay corrective surgery to see if the child will outgrow the problem. Which information should the PN provide to these parents?

Whatever the parents decide, the staﬀ will be available to support the decision.

The child's prognosis will not develop complications if surgery is delayed.

Some children do outgrow this type of problem and waiting may be beneficial.

Ask the parents to explain what they understand about the child's diagnosis.

Hint : 🧸Start with understanding.

Correct Answers:

No Correct Answers Available !

Rationale :

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3 :
Before administering an antibiotic that can cause nephrotoxicity, which laboratory value is most important for the practical nurse (PN) to review?

Serum calcium

Hemoglobin and hematocrit

White blood cell count (WBC)

Blood urea nitrogen (BUN) and creatinine

Hint : 🚰Check kidney labs first.

Correct Answers:

No Correct Answers Available !

Rationale :

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4 :
The practical nurse (PN) is assessing an older client with left-sided heart failure (HF). What intervention is most important for the PN to implement?

Inspect for sacral edema.

Measure urinary output.

Auscultate all lung fields.

Check mental acuity.

Hint : 🫁 Listen for crackles.

Correct Answers:

No Correct Answers Available !

Rationale :

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5 :
The practical nurse (PN) receives a report of a stable client who experienced partial-thickness burns over 30% of the body surface area (BSA) 3 days ago. Which complication is most important for the PN to anticipate?

Elevated blood pressure.

Curling's ulcer.

Compartment syndrome.

Excruciating pain.

Hint : 🔥Watch GI post-burn.

Correct Answers:

No Correct Answers Available !

Rationale :

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6 :
The practical nurse (PN) is providing care for a client who is receiving an aminoglycoside to treat a bacterial infection. To assess for signs of ototoxicity, which action should the PN take?

Check for changes in vision.

Monitor the client's hearing.

Observe the skin for a rash.

Measure the urinary output.

Hint : 🎧Listen for hearing loss.

Correct Answers:

No Correct Answers Available !

Rationale :

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7 :
A client who is reaching saturation with medication reports the onset of muscle soreness and fatigue, and the practical nurse (PN) notes that the client's skin is warm to the touch. Which action by the PN is a priority?

Administer a PRN dose of acetaminophen.

Encourage the client to drink ﬂuids.

Report the findings to the charge nurse.

Monitor the client's serum lipid levels.

Hint : 🚨Notify for new symptoms.

Correct Answers:

No Correct Answers Available !

Rationale :

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8 :
A college student brings his roommate to the clinic because the roommate has been talking to someone who is not present. The student tells the practical nurse (PN) that his roommate is acting strange. Which question should the PN ask the client next?

"Are you planning to obey the voices?"

"Have you taken any hallucinogens?"

"When did these voices begin?"

"Do you believe the voices are real?"

Hint : 🧠Ask about danger first.

Correct Answers:

No Correct Answers Available !

Rationale :

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9 :
The practical nurse (PN) notices that one of the unlicensed assistive personnel (UAP) working in the long- term care facility consistently records subnormal temperatures when using the thermometer. Which action should the PN take first?

Show the UAP how to chart temperatures.

Return the thermometer for recalibration.

Observe how the UAP obtains temperatures.

Demonstrate how to use the equipment.

Hint : 👀Observe technique first.

Correct Answers:

No Correct Answers Available !

Rationale :

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10 :
At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best?

"It's okay if you don't want to look or talk about the mastectomy. It will be available when you're ready."

"Would you like me to call another nurse to be here while I show you the wound?"

"Part of recovery is accepting your new body image, and you will need to look at your incision."

"You will feel better when you see that the incision is not as bad as you may think."

Hint : 🌷Respect emotional readiness.

Correct Answers:

No Correct Answers Available !

Rationale :

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11 :
The practical nurse (PN) is auscultating a client's lung sounds. Which description should the PN use to document this sound? (Please listen to the audio clip provided). Audio: [Wheezing sound]

Wheeze

Rhonchi

Stridor

Fine crackles

Hint : 🎵 High-pitched = wheeze.

Correct Answers:

No Correct Answers Available !

Rationale :

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12 :
The medication aide at a long-term care facility is sick and requests to go home before all medications are administered. Which action should the practical nurse (PN) take in this situation?

Deny the medication aide's request to leave before all medications are given.

Ask each unlicensed assistive personnel (UAP) to give medications to their assigned residents.

Assign the remainder of medication administration to another PN who is performing treatments.

Document why all the medications were not given to each of the residents.

Hint : 🩺Reassign to licensed nurse.

Correct Answers:

No Correct Answers Available !

Rationale :

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13 :
The medication aide at a long-term care facility is sick and requests to go home before all medications are administered. Which action should the practical nurse (PN) in charge take?

Deny the medication aide's request to leave before all medications are given.

Ask each unlicensed assistive personnel (UAP) to give medications to their assigned residents.

Assign the remainder of medication administration to another PN who is performing treatments.

Document why all the medications were not given to each of the residents.

Hint : 💊 Delegate meds to PN.

Correct Answers:

No Correct Answers Available !

Rationale :

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14 :
A male client tells the practical nurse (PN) that the pill he has been taking at home is a diﬀerent color and size than the one the PN is trying to give him now.
How should the PN respond?

Explain that the healthcare provider probably prescribed a diﬀerent medication while he is hospitalized.

Tell the client that he is probably confused since being hospitalized tends to disorient clients.

Tell the client that the PN will verify that the dispensed medication is the valid prescription.

Explain that the pharmacy often substitutes generic equivalents for more expensive brands.

Hint : 🧐Verify before administering.

Correct Answers:

No Correct Answers Available !

Rationale :

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15 :
The practical nurse (PN) learns that a client who is receiving chemotherapy has developed stomatitis. Which information should the PN obtain from the client during a focused assessment?

Urinary output.

Ability to swallow.

Frequency of bowel movements.

Blood pressure while standing.

Hint : 👄Focus on swallowing safety.

Correct Answers:

No Correct Answers Available !

Rationale :

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16 :
In assessing a client with an indwelling urinary catheter following the provision of care by an unlicensed assistive personnel (UAP), the practical nurse (PN) observes that the catheter drainage bag, which is half- full, is attached to the side rail and the tubing is looped on the bed. Which action should the PN implement?

Apply gloves and empty the drainage bag

Remove the looped tubing from the bed

Measure the urinary output in the bag

Attach the drainage bag to the bed frame

Hint : 🚫No rails—use bed frame.

Correct Answers:

No Correct Answers Available !

Rationale :

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17 :
The unlicensed assistive personnel (UAP) tells the practical nurse (PN) that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times. Which action should the PN implement first?

Ask the client to describe what happened

Inform the charge nurse of the situation

Complete a client adverse incident report

Call the agency-based client advocate

Hint : 🗣️Let client explain first.

Correct Answers:

No Correct Answers Available !

Rationale :

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18 :
The mother of a school-aged boy tells the practical nurse (PN) that he fell out of a tree and hurt his arm and shoulder. The mother says the boy is in pain and needs medical help. The nurse should assess the injury and decide the appropriate action to take. Help the nurse reason out the best assessment.

The injury may require medical attention, as the mother mentioned that the boy is in pain

The abrasions on the boy's leg and hand have healed

The mother describes what she did after her child got injured

The boy lacks coordination when answering the nurse's questions

Hint : 🧠Neuro changes = urgent.

Correct Answers:

No Correct Answers Available !

Rationale :

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19 :
Which information should the practical nurse (PN) collect during the admission assessment of a terminally ill client to an acute care facility?

Health care proxy documentation.

Name of funeral home to contact.

Client's wishes regarding organ donation.

Contact information for the client's next of kin.

Hint : 📄Confirm decision-maker early.

Correct Answers:

No Correct Answers Available !

Rationale :

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20 :
When performing a focused gastrointestinal system assessment, the practical nurse (PN) asks a male client when his last bowel movement occurred. The client answers, "Three days ago." Which action should the PN implement first?

Administer a prescribed PRN stool softener

Determine the client's usual bowel pattern

Encourage the client to ambulate more frequently

Recommend increasing high-fiber foods daily

Hint : 📅Know the baseline first.

Correct Answers:

No Correct Answers Available !

Rationale :

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21 :
The practical nurse (PN) observes a newly hired unlicensed assistive personnel (UAP) who is counting a client's radial pulse as seen in the picture. Which action should the PN take?

Instruct the UAP to report any abnormal findings.

Remind the UAP to check the client's pulse volume.

Demonstrate the correct pulse site to the UAP.

Confirm the accuracy of the pulse rate obtained by the UAP.

Hint : 👆 Teach with demonstration.

Correct Answers:

No Correct Answers Available !

Rationale :

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22 :
When the practical nurse (PN) attempts to assist an 18-year-old client with a mild mental disability to ambulate on the first postoperative day after an appendectomy, she becomes angry and says, "PN, 'Get out of here! I'll get up when I'm ready!" Which response is best for the PN to make?

"You must ambulate to avoid complications which could cause more discomfort than ambulating."

"I know you feel angry about the pain of ambulation, but this is a necessary part of getting well."

"Your healthcare provider has left specific instructions to ambulate on the first postoperative day."

"I will be back in 30 minutes to help you get out of bed and walk around the room today."

Hint : ⏱ Respect + redirect = success.

Correct Answers:

No Correct Answers Available !

Rationale :

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23 :
A client who received an open reduction and internal fixation (ORIF) of the right femur after experiencing a fall at home experiences a sudden onset of increasing confusion and agitation. When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?

Client's healthcare power of attorney.

Fall at home as reason for admission.

Currently prescribed medications.

Increasing confusion of the client.

Hint : 📣Lead with the problem.

Correct Answers:

No Correct Answers Available !

Rationale :

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24 :
A nurse is teaching a client with hypertension about antihypertensive drugs. Which of the following statements by the client indicates an understanding of the teaching?

“Antihypertensive drugs work by increasing the blood flow to my heart and kidneys.”

“Antihypertensive drugs can lower my blood pressure by affecting different parts of my cardiovascular system.”

Antihypertensive drugs are safe to use with any other medications or supplements I might take.”

“Antihypertensive drugs will cure my hypertension if I take them as prescribed.”.

Hint : 💓Multi-system BP control.

Correct Answers:

No Correct Answers Available !

Rationale :

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25 :
A nurse is teaching a group of older adults about the effects of aging on the neurological system. Which of the following statements should the nurse include as correct? (Select all that apply.).

“You may notice that your reaction time is slower than before.”.

“You may experience some difficulty with learning new things.”.

“You may have more neurotransmitters in your brain as you age.”

“You may lose some of your sense of smell and taste over time.”

“You may have more oxygen delivery to your brain cells as you age.”

Hint : 🧠Aging affects senses & speed.

Correct Answers:

No Correct Answers Available !

Rationale :

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26 :
A client with renal calculi is experiencing hematuria and reports severe flank pain. Which intervention should the nurse implement first?

Obtain a urine specimen for analysis.

Administer a prescribed opioid analgesic.

Strain the urine for the presence of stones.

Prepare the client for a prescribed computed tomography (CT) scan.

Hint : 💢Pain control comes first.

Correct Answers:

No Correct Answers Available !

Rationale :

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27 :
A nurse is providing education to a client prescribed an antidepressant for their phobia. Which statement by the client indicates a need for further teaching?

"This medication will help regulate my mood and anxiety.".

"I should expect to see immediate results after taking this medication."

"I may experience side effects such as nausea and drowsiness."

"It's important to take this medication consistently as prescribed."

Hint : ⏳ Effects take time.

Correct Answers:

No Correct Answers Available !

Rationale :

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28 :
A nurse is planning care for a client with a phobia. Which nursing intervention is appropriate for this client?

Encouraging the client to face their fear gradually.

Administering benzodiazepines as needed for acute anxiety.

Providing psychoeducation about the causes and effects of phobias.

Teaching the client relaxation techniques to manage anxiety.

Hint : 😨Gradual + educate + relax.

Correct Answers:

No Correct Answers Available !

Rationale :

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29 :
A nurse is caring for a client with a specific phobia. Which statement by the nurse is accurate regarding phobias?

"Phobias are characterized by persistent and irrational fear.".

"Phobias can be caused by biological factors only."

"Phobias can be diagnosed based on physical symptoms."

"Phobias can be managed with medication alone."

Hint : 🚫Persistent fear defines phobia.

Correct Answers:

No Correct Answers Available !

Rationale :

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30 :
After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home.
Which intervention(s) should the nurse take to prepare the body before the family enters the room? (Select all that apply.).

Take out dentures and place in a labeled cup.

Gently close the eyes.

Place a small pillow under the head.

Apply a body shroud.

Remove resuscitation equipment from the room.

Hint : 🕊️Create dignified appearance.

Correct Answers:

No Correct Answers Available !

Rationale :

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31 :
The nurse interviews a client admitted for an outpatient procedure and enters a long list of home medications into the medical record. The nurse observes several medications that are prescribed for the same indications. Which instruction is best for the nurse to communicate to the client regarding the multiple prescriptions?

Bring all medications, supplements, and herbs currently being taken to the next clinic appointment.

Use a medication reminder system to prevent omitting to take the right medications at the right time.

Make certain a family member knows the name and use of all medications currently being taken.

Do not take any over-the-counter drugs while taking medications prescribed by a healthcare provider.

Remove resuscitation equipment from the room.

Hint : 💊Bring meds for review.

Correct Answers:

No Correct Answers Available !

Rationale :

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32 :
A client with bleeding esophageal varices receives vasopressin intravenously (IV). Which adverse effect should the nurse monitor for during the IV infusion of this medication?

Decreasing gastrointestinal (GI) cramping and nausea.

Chest pain and dysrhythmia.

Vasodilation of the extremities.

Hypotension and tachycardia.

Hint : ❤️Monitor for cardiac ischemia.

Correct Answers:

No Correct Answers Available !

Rationale :

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33 :
When assessing a client, the nurse should establish which finding(s) as objective? (Select all that apply.).

Urticaria.

Hypertension.

Diaphoresis.

Nausea.

Anxiety.

Edema.

Hint : 🧾Look for measurable signs.

Correct Answers:

No Correct Answers Available !

Rationale :

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34 :
A client asks a nurse about the differences between major depressive disorder (MDD) and dysthymia. Which of the following responses by the nurse is accurate?

"MDD is less severe than dysthymia but lasts for at least 2 years."

"Dysthymia is characterized by alternating episodes of mania and depression."

"Unlike MDD, dysthymia does not impair social or occupational functioning."

"Dysthymia is chronic and lasts for at least 2 years, but is less severe than MDD."

Anxiety.

Hint : 📆Chronic but milder form.

Correct Answers:

No Correct Answers Available !

Rationale :

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35 :
A nurse is providing education to a group of healthcare professionals about suicide and suicidal ideation. Which of the following statements accurately describes suicidal ideation?

Suicidal ideation is a diagnosis in itself.

Suicidal ideation is more common in older adults.

Suicidal ideation always involves a detailed plan for self-harm.

Suicidal ideation can be a symptom of various underlying mental health conditions.

Hint : 🧠Symptom of deeper issue.

Correct Answers:

No Correct Answers Available !

Rationale :

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36 :
A client who is obese reports severe pain and is unable to bear weight in the right ankle after making dietary changes 3 weeks ago for weight loss. The client's medical history includes hypertension, gouty arthritis, and cholecystitis. Which instruction should the nurse include in the discharge teaching?

Substitute natural fruit juices for carbonated drinks.

Encourage active range of motion to limit stiffness.

Use electric heating pad when pain is at its worst.

Avoid the consumption of wine, beer, and coffee.

Hint : 🍷Alcohol worsens gout.

Correct Answers:

No Correct Answers Available !

Rationale :

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37 :
Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

Diarrhea and flatulence.

Muscle pain.

Altered taste.

Abdominal cramps.

Hint : 💪Myopathy = statin red flag.

Correct Answers:

No Correct Answers Available !

Rationale :

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38 :
A client has been diagnosed with depression and has a history of suicide attempts. What intervention is essential for the nurse to implement?

Leaving the client alone to give them space.

Removing any potential means of self-harm from the client's environment.

Encouraging the client to confront their feelings of hopelessness.

Telling the client that they should be grateful for what they have.

Hint : 🔐Safety first always.

Correct Answers:

No Correct Answers Available !

Rationale :

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39 :
What is the most common type of shock in children?

septic

anaphylactic

distributive

hypovolemic

Hint : 🩸Volume loss leads shock.

Correct Answers:

No Correct Answers Available !

Rationale :

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40 :
A nurse is establishing a therapeutic relationship with a client with anxiety disorder. What is the primary goal of this intervention?

Prescribe medication for immediate relief.

Educate the client about various relaxation techniques.

Assist the client in challenging irrational thoughts.

Develop measurable and realistic outcomes.

Hint : 🧠Reshape anxious thinking.

Correct Answers:

No Correct Answers Available !

Rationale :

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41 :
The nurse is caring for a client who receives a prescription for valproic acid in which the maximum safe dosage is 60 mg/kg/day. How many mg/day is the maximum safe dosage for a client who weighs 176 pounds? (Enter numerical value only.).

4012 mg/day.

4800 mg/day.

3520 mg/day.

6171 mg/day.

Hint : 🧮Convert lbs to kg first.

Correct Answers:

No Correct Answers Available !

Rationale :

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42 :
A client with diabetic peripheral neuropathy has been taking pregabalin for 4 days. Which finding indicates to the nurse that the medication is effective?

Granulating tissue in foot ulcer.

Reduced level of pain.

Improved visual acuity.

Full volume of pedal pulses.

Hint : ⚡Less nerve pain = effective.

Correct Answers:

No Correct Answers Available !

Rationale :

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43 :
The nurse observes a client with amyotrophic lateral sclerosis (ALS) is excessively drooling and prepares to suction the client's oral cavity. Which action should the nurse include?

Instill 3 mL of normal saline before suctioning.

Instruct the client to cough as the suction tip is removed.

Apply a water-soluble lubricant to the catheter.

Wear protective goggles while performing the procedure.

Hint : 🥽Goggles protect during suction.

Correct Answers:

No Correct Answers Available !

Rationale :

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44 :
A nurse is providing interventions for a client with panic disorder. Which interventions should the nurse include in the plan of care? (Select all that apply).

Provide a safe and calm environment for the client during a panic attack.

Use therapeutic communication skills to establish rapport and trust with the client.

Educate the client about panic disorder and its treatment options.

Encourage the client to participate in cognitive-behavioral therapy (CBT).

Refer the client to self-help groups for peer support and education.

Hint : 💬Combine safety, trust, education, therapy, and peer support.

Correct Answers:

No Correct Answers Available !

Rationale :

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45 :
A nurse is assessing a client with panic disorder. Which statement by the nurse would be appropriate during the assessment?

"Tell me about your coping strategies and support system."

"How often do you experience panic attacks and what triggers them?"

"What medications are you currently taking for your panic disorder?"

"Have you ever had any laboratory tests done for your panic disorder?"

Hint : 🎯Ask about triggers and patterns.

Correct Answers:

No Correct Answers Available !

Rationale :

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46 :
After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

Continue with the blood pressure assessment.

Reposition the stethoscope over the brachial artery.

Reinflate the cuff to a higher number.

Note the presence of an auscultatory gap.

Hint : 🫀Silence = possible gap.

Correct Answers:

No Correct Answers Available !

Rationale :

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47 :
A client is admitted with an exacerbation of heart failure secondary to chronic obstructive pulmonary disease (COPD). Which observation(s) by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply.).

The client’s oxygen saturation level is 85%.

The client is eating less than half of meals.

The client’s heart rate is 110 beats per minute.

The client is reading a book.

The client’s blood pressure is 160/90 mmHg.

Hint : 💓Act on O₂ + HR signs.

Correct Answers:

No Correct Answers Available !

Rationale :

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48 :
An adolescent who is brought to the emergency department (ED) with a fever and persistent lower right quadrant abdominal pain is anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid-base imbalance?

Metabolic alkalosis.

Respiratory alkalosis.

Metabolic acidosis.

Respiratory acidosis.

Hint : 🫁Hyperventilation = alkalosis.

Correct Answers:

No Correct Answers Available !

Rationale :

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49 :
While caring for a client with a full-thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Serum blood glucose (BG) level.

Neutrophil count.

Serum albumin.

Hematocrit.

Hint : 🦠Check for immune response.

Correct Answers:

No Correct Answers Available !

Rationale :

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50 :
The nurse is preparing a community outreach program on primary disease prevention. Which topic should the nurse plan to include in this event?

Domestic violence assistance.

Blood pressure screening.

Immunizations that are available.

Outreach for support group information.

Hint : 💉Prevention starts with vaccines.

Correct Answers:

No Correct Answers Available !

Rationale :

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51 :
A client who weighs 176 pounds receives a prescription for norepinephrine 2 mcg/min intravenously (IV). The IV bag is labeled, "Norepinephrine 4 mg in dextrose 5% in water (D;W) 1,000 mL." How many mL/hour should the nurse program the infusion pump? (Enter numerical value only.).

Hint : 💉Use mcg/mL and convert.

Correct Answers:

No Correct Answers Available !

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52 :
A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely?

Ketonuria.

Peripheral edema.

Hypokalemia.

Elevated blood pressure.

Hint : ⚡Think potassium with polyuria.

Correct Answers:

No Correct Answers Available !

Rationale :

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53 :
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?

Emphasize that using safe sex practices removes the risk of STIs.

Explain that reinfections occur from sex with untreated partners.

Clarify that all STIs are transmitted through sexual intercourse.

Provide counseling that most contraceptives protect against infection.

Hint : 🔁Reinfection = untreated partners.

Correct Answers:

No Correct Answers Available !

Rationale :

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54 :
When conducting diet teaching for a client who was diagnosed with hypertension, which food(s) should the nurse encourage the client to eat? (Select all that apply.)

Fresh or frozen vegetables without sauce.

Fruits without sauce.

Pickled olives.

Canned soup.

Cottage cheese.

Hint : 🥦Choose fresh, unprocessed produce.

Correct Answers:

No Correct Answers Available !

Rationale :

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55 :
A nurse is teaching a client who has a fungal infection about fluconazole. Which of the following statements by the client indicates an understanding of the teaching?

“I should take this medication with food to prevent stomach upset.”

“I should avoid drinking alcohol while taking this medication.”

“I should use a barrier method of contraception while taking this medication.”

“I should stop taking this medication if I develop a rash.”

Hint : 🚫Add barrier contraception.

Correct Answers:

No Correct Answers Available !

Rationale :

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56 :
The nurse on the medical-surgical unit is receiving a transfer report from the post-anesthesia care unit (PACU) nurse for a client who had an exploratory laparotomy. The PACU nurse provides the following information: "1000 mL normal saline is infusing at 125 mL/hr into the left wrist with 600 mL remaining.
Ondansetron 4 mg intravenously every 8 hours is prescribed for nausea. The last dose was administered at 0700.The client is currently describing pain at a level 2 on a 0 to 10 pain scale. The client has a prescription for hydromorphone 1 mg intravenously every 2 hours as needed for pain. The last dose was administered at 1000." Which additional information should the PACU nurse report?

History of vomiting at home for 3 days prior to surgery.

Soft abdomen, absent bowel sounds, no bleeding on dressing.

Declining to take ice chips for complaints of dry mouth.

Peripheral pulses present with full range of motion of both legs.

Hint : 🤢Vomiting history affects recovery.

Correct Answers:

No Correct Answers Available !

Rationale :

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57 :
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?

Serum sodium level.

Hematocrit.

Neutrophil count.

Platelet count.

Hint : 🦠Neutrophils confirm infection suspicion.

Correct Answers:

No Correct Answers Available !

Rationale :

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58 :
Which is the best approach for the nurse to use when interviewing a client about intimate partner violence?

Ask questions in a vague, non-specific format.

Begin with questions that are less sensitive in nature.

Get the most difficult questions over with first.

Share personal values to put the client at ease.

Hint : 🌱Start gentle, then go deeper.

Correct Answers:

No Correct Answers Available !

Rationale :

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59 :
The nurse observes an 18-month-old toddler keeping a bottle of milk in the mouth throughout the history-taking and assessment process during a well-child visit. The mother confirms that the child has a bottle available most of the day and remarks that it makes a great pacifier. Which response should the nurse provide?

A bottle is generally much better than using a pacifier.

The bottle will assist in preventing thumb sucking.

Prolonged bottle use can increase the risk for cavities.

Using milk rather than juice helps to avoid tooth decay.

Hint : 🍼Bottles + sugar = decay risk.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

60 :
The nurse is preparing an older male adult for discharge who does not read and has bilateral hearing loss. The client's daughter who lives close to her father tells the nurse that she will stop by daily to check on her father. Which intervention(s) should the nurse implement? (Select all that apply.).

Include the family in the discharge teaching.

Encourage the client to attend reading classes.

Face the client when speaking.

Speak loudly when teaching.

Provide the daughter with written instructions.

Hint : 📘Hearing loss needs tailored teaching.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

61 :
A client arrives at the emergency department with chest pain after taking sildenafil. Based on the client's history, which medication should the nurse withhold?

Aspirin.

Heparin.

Morphine.

Nitroglycerin.

Hint : 🚫No nitrates with sildenafil.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

62 :
A client with delusions tells the nurse, "You aren't doing your job. Go get those people over there and shoot them before they get me." Which statement is the nurse's best response?

"There is no one who will hurt you."

"You seem quite frightened right now."

"You are in a safe place .No one can get to you here."

"What would you like to see me do to protect you?"

Hint : 🧠Validate feelings, not content.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

63 :
When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?

Refer client to the social worker for support therapy.

Encourage client to implement relaxation techniques.

Leave the client's room and return later in the day.

Explain that insulin is a life-saving drug for the client.

Hint : ⏱Respect readiness to learn.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

64 :
The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu item(s) should the nurse request for this client? (Select all that apply).

Orange juice.

Apple juice.

Hot chocolate.

Chicken broth.

Black coffee.

Hint : 🍗Choose clear, caffeine-free liquids.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

65 :
A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? (Select all that apply.)

Monitor ETT markings between 22 and 26 cm at teeth line.

Check for capillary refill of 3 seconds or less.

Obtain a portable chest x-ray to verify ETT location.

Assess for symmetrical chest movement.

Auscultate for presence of bilateral breath sounds.

Hint : 🫁Confirm placement with 4-point check.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

66 :
When caring for an older male client with urinary frequency, which measure is most important for the nurse to implement to help the client prepare to go to bed for the night?

Reassure the client that someone will check on him hourly.

Place fresh water and a glass within reach on the bedside table.

Ensure that the call bell is easily accessible to the client.

Offer the client an evening snack before providing oral care.

Hint : 🛎️Access to help reduces fall risk.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

67 :
A nurse is caring for a client who has variant angina and is prescribed verapamil. Which of the following are expected outcomes of this medication? (Select all that apply.)

Decreased heart rate

Increased contractility

Dilated coronary arteries

Reduced blood pressure

Relieved chest pain

Hint : 💛Blocks calcium = less strain.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

68 :
A client who has been prescribed propranolol for the treatment of arrhythmias reports experiencing shortness of breath and difficulty breathing while lying down at night. Which of the following should the nurse instruct the client to do?

Sleep with an extra pillow under their head

Sleep on their left side

Sleep on their right side

Sleep on their back

Relieved chest pain

Hint : 🛏️Elevate to ease breathing.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

69 :
A nurse is caring for a client who has hypertension and is prescribed metoprolol, a beta blocker. The nurse should monitor the client for which of the following adverse effects?

Tachycardia

Hyperglycemia

Bronchospasm

Hyperkalemia.

Hint : 🌬️Beta-blockers may tighten airways.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

70 :
A client with chronic kidney disease receives a prescription for darbepoetin alfa 40 mcg subcutaneous every 7 days.The darbepoetin alfa vial is labeled, "60 mcg/mL." How many mL should the nurse administer? round to the nearest tenth.

0.7 mL.

1.0 mL.

1.3 mL.

1.7 mL.

Hint : 🧮Use dose ÷ concentration.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

71 :
The nurse is assessing an adolescent female diagnosed with anorexia nervosa who is admitted to the unit with severe malnutrition and electrolyte imbalance. Which pathological process results from the adolescent's consistent maladaptive behavior?

Sinus tachycardia.

Menstrual cramps.

Hypertension.

Amenorrhea.

Hint : 🩸Starvation suppresses menstruation.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

72 :
A 5-year-old child with a history of a waddling gait and frequent falls is brought into the hospital for diagnostic testing. When explaining the diagnostic testing to the parents, the nurse should provide information based on which understanding of the underlying disease pathology?

Systemic autoimmune vasculopathy.

Autonomic neuropathy.

Impaired neuron function.

Muscle fiber degeneration.

Hint : 💪Weak muscles = fiber loss.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

73 :
The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the educational materials include which characteristics? (Select all that apply.).

Contains a list with definitions of unfamiliar terms.

Written at a twelfth-grade reading level.

Uses common words with few syllables.

Uses pictures to help illustrate complex ideas.

Printed using a 12-point type font.

Hint : 📘Make it simple + visual.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

74 :
A client is diagnosed with influenza A and is prescribed oseltamivir. Which of the following statements by the client indicates a need for further education?

“This medication will shorten the duration of my symptoms.”.

“This medication will prevent me from spreading the virus to others.”.

“This medication will work best if I start taking it within 48 hours of symptom onset.”.

“This medication may cause nausea and vomiting as side effects.”.

Hint : 😷Med ≠ no transmission.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

75 :
A nurse is caring for a client who has meningitis caused by Streptococcus pneumoniae. The provider orders penicillin G IV for this client. Before administering the medication, which of the following actions should the nurse take?

Check the client’s temperature.

Assess the client’s level of consciousness.

Ask the client about any history of allergies.

Obtain a blood sample for culture and sensitivity.

Hint : 🚨Check for allergies first.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

76 :
A nurse is teaching a client who has a urinary tract infection (UTI) about trimethoprim/sulfamethoxazole. The client asks why he needs to take two antibiotics together. What should the nurse say?

“The combination of trimethoprim and sulfamethoxazole has a synergistic effect that inhibits bacterial growth more effectively than either drug alone.”.

“The combination of trimethoprim and sulfamethoxazole has an additive effect that reduces the dosage and frequency of administration of each drug.”.

“The combination of trimethoprim and sulfamethoxazole has an antagonistic effect that prevents the development of resistance to either drug.”.

“The combination of trimethoprim and sulfamethoxazole has a selective effect that targets only the bacteria causing the UTI and spares the normal flora.”.

Hint : 🧪2 drugs = stronger kill.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

77 :
A nurse is administering tetracycline to a client who has acne vulgaris. The client tells the nurse that he usually takes calcium supplements with his meals.
How should the nurse respond?

“You can continue to take calcium supplements as long as you take them with food.”.

“You should avoid taking calcium supplements while you are on tetracycline therapy.”.

“You can take calcium supplements with tetracycline as long as you drink plenty of water.”.

“You should take calcium supplements at least 2 hours before or after tetracycline.”.

Hint : ⏳Space calcium and tetracycline.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

78 :
A nurse is reviewing laboratory results for a client who has been taking amoxicillin-clavulanate (Augmentin) for a bacterial respiratory tract infection. Which of the following findings should alert the nurse to a possible adverse effect of this medication? (Select all that apply.).

Elevated serum creatinine level.

Elevated serum alanine aminotransferase level.

Elevated serum potassium level.

Elevated white blood cell count.

Hint : 🧪Watch kidneys and liver.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

79 :
An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies. Which is the best response by the nurse?

Gather information regarding how long it will take for the children to arrive.

Explain that the client will start to lose consciousness and the body systems will slow down.

Offer to discuss the client's health status with each of the adult children.

Reassure the spouse that the healthcare provider will notify when to call the children.

Hint : 🌅Describe slowing of life signs.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

80 :
A male client who is admitted with bipolar disorder, manic psychosis, is placed in seclusion after unsuccessful attempts to de-escalate him during a sudden mood swing from laughter to jumping and screaming threats while waving a plastic dinner knife. The client is given haloperidol. 5 mg intramuscularly STAT prior to seclusion. Which intervention is most important for the nurse to implement immediately after seclusion?

Release the client as soon as composure is regained.

Observe for extrapyramidal symptoms, such as dystonia.

Secure the room with padded walls and minimal furnishings.

Provide one-on-one observation at all times.

Hint : 🧠EPS = early antipsychotic risk.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

81 :
The nurse is providing education to a client who receives a prescription for zolpidem. Which information about the medication should the nurse include?

Crush to increase absorption.

Store at room temperature.

Administer with a meal.

Take before bedtime.

Hint : 🌛Take right before sleep.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

82 :
Which computer documentation indicates that activities to prevent postoperative venous stasis were performed correctly?

Leg exercises not performed because of placement of antiembolism hose.

Antiembolism stockings removed hourly during leg exercises

Client demonstrates ability to move all extremities well.

Antiembolism stockings on, leg exercises performed hourly.

Hint : 🧦Stockings + hourly movement.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

83 :
The nurse is planning care for a client who has a fourth-degree midline laceration that occurred during vaginal delivery of an 8-pound 10-ounce (3674 grams) infant. Which intervention has the highest priority for this client?

Administer prescribed PRN sleep medications.

Encourage use of prescribed analgesic perineal sprays.

Administer prescribed stool softener.

Encourage breastfeeding to promote uterine involution.

Hint : 💩Prevent straining post-delivery.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

84 :
A client at 42-weeks gestation arrives at the labor and delivery unit for a scheduled induction but refuses the prescribed oxytocin infusion because she wants to have a "natural" delivery. Which action is most important for the nurse to implement?

Discuss the character of labor from endogenous vs. exogenous oxytocin.

Ask the healthcare provider to discuss the issue with the client.

Discuss alternative ways to support the client's birth plan.

Explain the indications for induction related to post-term pregnancy.

Hint : 👶Post-term = more risk.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

85 :
A woman at 12 weeks' gestation comes to the clinic for her first prenatal visit. After completing a health history, the nurse should discuss which topic about pregnancy at this initial visit?

Concerns about parenting.

Cultural practices related to childbearing.

Complications associated with childbirth.

Knowledge about labor and delivery.

Hint : 🌍Respect client traditions.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

86 :
After a client receives a dose of albuterol, the nurse evaluates the medication's effects by auscultating the client's lung fields. Which action should the nurse take next based on the assessment?

Use a peak flow meter to assess the respiratory status.

Administer a stat dose of corticosteroids.

Document the normal finding in the client's health record.

Repeat a dose of the client's rescue drug.

Hint : 🩺Evaluate then document.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

87 :
A client who has atrial fibrillation is prescribed warfarin therapy. Which of the following statements by the client indicates an understanding of the medication?

“I should avoid foods that are high in vitamin K.”.

“I should take this medication with food.”.

“I should report any unusual bleeding or bruising to my provider.”.

“I should avoid taking aspirin while taking this medication.”.

Hint : 🩸Bleeding = urgent report.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

88 :
A nurse is reviewing the laboratory results of a client who is receiving intravenous unfractionated heparin. The nurse notes that the client’s activated partial thromboplastin time (aPTT) is 120 seconds. What are the appropriate nursing actions in this situation? Select all that apply.

Stop the heparin infusion immediately.

Administer protamine sulfate as ordered.

Notify the health care provider of the result.

Draw a prothrombin time (PT) and international normalized ratio (INR) level.

Monitor the client for signs and symptoms of bleeding.

Hint : 🧪 aPTT ↑ = assess & reverse.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

89 :
What are some important nursing considerations for this medication?

Protamine sulfate should be given slowly intravenously within 30 minutes of heparin administration.

Protamine sulfate should be given rapidly intramuscularly within 60 minutes of heparin administration.

Protamine sulfate should be given slowly intravenously within 60 minutes of heparin administration.

Protamine sulfate should be given rapidly intramuscularly within 30 minutes of heparin administration.

Hint : 💉Slow IV = safe reversal.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

90 :
Four days after exposure to the coronavirus (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?

Notify the charge nurse the client will need assignment to the COVID-19 specified area of the facility.

Institute droplet precautions, place the client in a private room, and keep the door closed.

Explain to the client to inform others that they may have been potentially exposed in the last 14 days.

Place the nasal swab specimen for COVID-19 directly into a biohazard bag.

Hint : 😷Suspected case = isolate.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

91 :
A child who weighs 55 pounds receives a prescription for cefotaxime 150 mg/kg/day intravenously in divided doses every 6 hours. How many mg should the nurse administer each day?

3000 mg.

3300 mg.

3600 mg.

3750 mg.

Hint : 🧮Use kg × mg/kg/day.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

92 :
A client arrives at a hurricane disaster medical area seeking treatment for diarrhea. Which source of contamination should the nurse consider when interviewing the client about exposure?

Nosocomial transmission in the medical area.

Food contamination from flood waters.

Drinking water contaminated by sewage.

Close living quarters at evacuation centers.

Hint : 🚱Floods = unsafe water.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

93 :
A nurse is teaching a group of nursing students about the components of critical thinking. Which of the following statements by a student indicates a need for further teaching?

“Reflection is thinking about what I did and how I can improve.”

“Analysis is breaking down a complex situation into smaller parts.”

“Inference is making assumptions based on my experience.”

“Evaluation is checking the reliability and validity of information.”.

Hint : 🧩Inference ≠ assumption.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

94 :
A nurse is documenting the data collected from an ongoing assessment of a client who has diabetes mellitus. The nurse writes, “The client reports feeling thirsty and hungry all the time.” How should the nurse label this type of data?

Objective data

Subjective data

Primary data

Secondary data

Hint : ✍️Subjective = client’s words.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

95 :
A nurse is updating the plan of care for a client who has a pressure ulcer on the sacrum. Which of the following outcomes are appropriate for this client? (Select all that apply.)

The client will have no signs of infection in the wound by day 7.

The client will report pain level of 4/10 or less during dressing changes.

The client will consume at least 75% of meals and snacks daily.

The client will reposition self in bed every 2 hours with assistance.

The client will demonstrate proper wound care technique before discharge.

Hint : 🛏️SMART goals = better healing.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

96 :
The nurse is caring for four clients: Client A, who has emphysema and whose oxygen saturation is 94%; Client B, with a postoperative hemoglobin of 8.2 mg/dL (82 g/L); Client C, newly admitted with a potassium level of 3.8 mEq/L (3.8 mmol/L); and Client D, scheduled for an appendectomy who has a white blood cell (WBC) count of 14,000 mm (14 x 10^9/L). Which intervention should the nurse implement? Reference Range:. Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]. Potassium [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]. White Blood Cell [5000 to 10,000/mm² (5 to 10 x 10^9/L)].

Move Client D into an isolation room 24 hours before surgery.

Ask the dietitian to add a banana to Client C's breakfast tray.

Increase Client A's oxygen to 4 liters a minute per cannula.

Verify that Client B has two units of packed cells available.

Hint : 🩸Low Hgb = prep transfusion.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

97 :
An older client with dementia who is refusing to allow an unlicensed assistive personnel (UAP) bathe her is becoming increasingly agitated and stating the UAP wants to hurt her and tie her up. Which approach should the nurse use with the client?

Reduce the client's interaction with others during the day.

Use distraction and therapeutic communication skills.

Awaken the client earlier for daily morning care.

Clarify reality with the client about delusional thoughts.

Hint : 🧠Distract, don't confront.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

98 :
A nurse is caring for a client who has Alzheimer's disease. Which of the following findings should the nurse expect?

Altered level of consciousness.

Rapid mood swings.

Excessive motor activity.

Failure to recognize familiar objects.

Hint : 🧠Memory-based object loss.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

99 :
A nurse is teaching a newly licensed nurse about contributing factors that can lead to the development of conduct disorder. Which of the following factors related to family dynamics should the nurse include in the teaching?

The client is the oldest of their siblings.

The client's father lives in the client's home.

The client's mother has asthma.

The client has several siblings.

Hint : 👨‍👩‍👧‍👦Large family = risk.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

100 :
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?

Observe body language and movement.

Identify effective pain relief measures.

Provide a numeric pain scale.

Ask the client to describe the pain.

Hint : 💬Ask to describe pain.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

101 :
When developing a teaching plan for a client with newly diagnosed type 1 diabetes, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs?

Drink electrolyte fluid replacements.

Give a dose of regular insulin as prescribed.

Resume normal physical activity.

Measure urine output over the next 24 hours.

Hint : 💧Rehydrate with electrolytes.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

102 :
A client who is admitted for primary hypothyroidism has early signs of myxedema coma. In assessing the client, in which sequence should the nurse complete these actions? (Rank the first action at the top with the remainder in descending order.).

Palpate for pedal edema.
Assess blood pressure.
Measure body temperature.
Observe breathing patterns.

Hint : 🫁Airway always comes first.

Correct Order:

No correct order available !

Rationale :

Rationale to be Available Soon

103 :
The nurse completes percussion of the abdomen on an older adult client. Which finding is considered normal for this client?

Tenderness.

Musical and drum like.

Absent sounds.

Pain.

Hint : 🥁Tympany = normal gas sound.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

104 :
An adult client is admitted to the psychiatric unit because of a daily, complex handwashing ritual that takes two hours or longer to complete. The client worries about staying clean and refuses to sit on any of the chairs in the day area. This client's handwashing is an example of which clinical behavior?

Addiction.

Phobia.

Compulsion.

Obsession.

Hint : 🧼Repetitive actions = compulsion.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

105 :
During a fecal impaction removal, an older client complains of feeling dizzy and cold. Which intervention should the nurse implement?

Instruct the unlicensed assistive personnel (UAP) to apply a warm blanket and massage the client's back.

Insert a gloved finger into the rectum and gently massage the rectal sphincter.

Stop the procedure and observe for a reduction in symptoms before continuing.

Encourage the client to take slow, deep breaths while continuing the procedure.

Hint : 🛑Stop at signs of vagal response.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

106 :
A client is recovering in the critical care unit following a cardiac catheterization. Intravenous (IV) nitroglycerin and heparin are infusing. The client is sedated but responds to verbal instructions. After changing positions, the client complains of pain at the right groin insertion site. Which action should the nurse implement?

Check femoral site for hematoma formation.

Stimulate the client to take deep breaths.

Evaluate the integrity of the IV insertion site.

Assess distal lower extremity capillary refill.

Hint : 💉Groin pain = check site.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

107 :
A nurse is instructing a nursing assistant on how to assist a patient with bathing. The patient has hemiparesis on the left side due to a stroke. Which of the following statements by the nursing assistant demonstrates understanding of the teaching?

"I will wash the patient's left side first, then move to the right side.”.

"I will wash the patient's right side first, then move to the left side.”.

"I will wash both sides of the patient at the same time, starting from the head and moving down.”.

"I will ask the patient which side they prefer to wash first, then follow their preference."

Hint : 🧼Start with strong side.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

108 :
A nurse is planning recreational activities for a group of patients who are receiving rehabilitation and restorative care. Which of the following factors should the nurse consider when selecting appropriate activities? (Select all that apply.).

The patient's physical abilities and limitations.

The patient's cognitive abilities and limitations.

The patient's interests and preferences.

The patient's age and gender.

The patient's cultural and religious background.

Hint : 🎨Tailor activities to individual.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

109 :
After years of struggling with weight management, a middle-age man is evaluated for gastroplasty. He has experienced difficulty with managing his diabetes mellitus and hypertension, but he is approved for surgery. Which intervention is most important for the nurse to include in this client's plan of care?

Observe for signs of depression.

Monitor for urinary incontinence.

Provide a wide variety of meal choices.

Apply sequential compression stockings.

Hint : 🧦Prevent DVT post-op.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

110 :
A client with intestinal obstruction has a nasogastric tube to low intermittent suction and is receiving an intravenous (IV) infusion of lactated Ringer's at 100 mL/hour. Which finding is most important for the nurse to report to the healthcare provider? Reference Range: Potassium (3.5 to 5 mEq/L (3.5 to 5 mmol/L).

24-hour intake at the current infusion rate.

Serum potassium level of 3.1 mEq/L (3.1 mmol/L).

Gastric output of 900 mL in the last 24 hours.

Increased blood urea nitrogen (BUN).

Hint : 🍌Low K+ = cardiac risk.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

111 :
A client with a long history of migraine headaches asks the nurse if there are non-pharmaceutical ways to help obtain pain relief. Which intervention should the nurse offer?

Monitor your blood pressure.

Take a few days off work.

Learn muscle relaxation techniques.

Lie down in a dark, quiet room.

Hint : 🧘Tension relief reduces migraines.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

112 :
In formulating the nursing care plan for a client diagnosed with Parkinson's disease, which nursing problem has the highest priority?

Impaired physical mobility relative to muscle rigidity.

Risk for aspiration relative to muscle weakness.

Risk for constipation relative to immobility.

Self-care deficit relative to motor disturbance.

Hint : 🫁Airway protection priority.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

113 :
An unresponsive male victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save his life. The client is accompanied by a close friend, but no family members are available. Which action should the nurse take first?

Carry on with surgical preparation of the client without a signed informed consent.

Ask the man's friend to sign the informed consent since the client is unresponsive.

Notify the unit manager that an emergency court order is needed to allow surgery.

Continue to provide life support until a thorough search for a guardian is completed.

Hint : 🚨Emergency = implied consent.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

114 :
The nurse is caring for a client who reports sudden right-sided numbness and weakness of the arm and leg. The nurse also observes a distinct right-sided facial droop. After reporting the findings to the healthcare provider, the nurse receives several prescriptions for the client, including a STAT Computerized tomography scan of the head. Which action should the nurse take first?

Begin continuous observation for transient episodes of neurologic dysfunction.

Start two large bore intravenous (IV) catheters and review inclusion criteria for IV fibrinolytic therapy.

Administer aspirin to prevent further clot formation and platelet clumping.

Raise the head of the bed to 30 degrees keeping head and neck in neutral alignment.

Hint : 🧠Protect brain perfusion.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

115 :
A female client who is admitted to the mental health unit for opiate dependency is receiving clonidine 0.1 mg by mouth (PO) for withdrawal symptoms. The client begins to complain of feeling nervous and tells the nurse that her bones are itching. Which finding should the nurse identify as a contraindication for administering the medication?

Hypertension.

Apical heart rate 72 beats/minute.

Muscle weakness.

Blood pressure 90/76 mm Hg.

Hint : 📉Hold if hypotensive.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

116 :
A client is admitted following a motor vehicle collision. When assessing the client's level of consciousness, the nurse notes that the client no longer responds to commands. The nurse initiates a painful stimulus and the client responds by pulling the arms inward with elbows and wrists flexed and extending the legs with the toes pointed downward. Which action should the nurse implement?

Report the finding to the healthcare provider.

Document the purposeful response to pain.

Initiate seizure precautions immediately.

Administer a prescribed PRN analgesic.

Hint : 🧠Posturing = neuro emergency.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

117 :
The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

CP is one of the most common permanent physical disabilities in children.

Brain damage with CP is not progressive but does have a variable course.

Severe motor dysfunction determines the extent of successful habilitation.

Continued development of the brain lesion determines the child's outcome.

Hint : 🧠Damage fixed, effects change.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

118 :
A client who is receiving radiation treatment for laryngeal cancer has developed xerostomia and mucositis. The nurse determines the client has an imbalanced nutritional intake and is consuming less than body requirements. Which factor is the most likely cause for this problem?

Nausea.

Fatigue.

Pain when eating.

Altered taste sensation.

Hint : 🍽️Pain hinders eating.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

119 :
Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

An adult who is one day postoperative for a laparoscopic cholecystectomy.

An older client who is one day postoperative with a colostomy for colon cancer.

An older adult who is scheduled for foot amputation due to diabetes complications.

An adult with alcoholism, cirrhosis, and hepatic encephalopathy.

Hint : 🏥Stable + predictable care.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

120 :
A client receives a prescription for 1 liter of lactated Ringer's intravenously (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.)

Hint : 💧Use IV rate formula.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

121 :
The nurse is planning discharge instructions for a client with type 2 diabetes who will be starting exenatide. Which information should be included in the discharge instructions?

Exenatide acts in the same way as insulin in lowering blood glucose.

Inject exenatide within 30 minutes before or after a meal.

There are no precautions about taking exenatide with other medications.

Notify your healthcare provider if you start having abdominal pain.

Hint : 🦴Pancreatitis risk warning.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

122 :
An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasm when taking the blood pressure using the same arm. After confirming the presence of the spasms, which action should the nurse take?

Review the client's serum calcium level.

Administer an as-needed (PRN) antianxiety medication.

Ask the UAP to take the blood pressure in the other arm.

Tell the UAP to use a different sphygmomanometer.

Hint : 🧪Trousseau = low calcium.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

123 :
A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. Which action should the nurse take first?

Ask the mother if any visitors were expected to arrive.

Match ID bands of all infants and mothers on the unit.

Determine if the newborn is in the nursery.

Activate the lockdown procedure.

Hint : 🚨Suspected abduction = lockdown.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

124 :
After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to an unlicensed assistive personnel (UAP)?

Procure platelet products from the blood bank.

Titrate oxygen to the prescribed parameters.

Monitor an intravenous infusion rate on an established schedule.

Insert a urinary catheter for an uncomplicated client.

Hint : 📌Task doesn't require judgment.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

125 :
An older male client is admitted with the medical diagnosis of a possible cerebral vascular accident (CVA). He has facial paralysis and cannot move his left side. When entering the room, the nurse finds the client's wife tearful and trying unsuccessfully to give him a drink of water. Which action should the nurse take?

Ask the wife to stop and assess the client's swallowing reflex.

Give the wife a straw to help facilitate the client's drinking.

Assist the wife and carefully give the client small sips of water.

Obtain thickening powder before providing any more fluids.

Hint : 🥤Prevent aspiration risk.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

126 :
After an increase in the number of suicides in a community, the nurse is developing a class for adolescents about mental health. Which type of activity should the nurse include in the teaching?

Assessment of tobacco use geared toward adolescents.

Exploration of stress self-management techniques.

Video with statistics showing trends in suicide rates.

Handouts for local substance abuse treatment centers.

Hint : 🧠 Focus on coping tools.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

127 :
A clinical trial is recommended for a female client with metastatic breast cancer, but she refuses to participate and tells her family that she does not wish to have further treatments. The client's son and daughter ask the nurse to try and convince their mother to reconsider this decision. How should the nurse respond?

Explain to the family that they must accept their mother's decision.

Discuss success of clinical trials and ask the client to consider participating for one month.

Explore the client's decision to refuse treatment and offer support.

Ask the client with her children present if she fully understands the decision she has made.

Hint : 🌺Respect client autonomy.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

128 :
The healthcare provider prescribes the antibiotic cefdinir 300 mg by mouth every 12 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat?

Avocados and cheese.

Fresh fruits.

Yogurt or buttermilk.

Green leafy vegetables.

Hint : 🥛Supports GI flora.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

129 :
A client tells the nurse about beginning an exercise program a month ago to lose weight and improve sleep. The client states that it still takes at least two hours to fall asleep at night. Which action should the nurse implement?

Encourage the client to exercise every day to eliminate bedtime wakefulness.

Advise the client that lifestyle changes often take several weeks to be effective.

Ask the client for a description of the exercise schedule that is being followed.

Determine the amount of weight the client has lost since increasing activity.

Hint : 🛌 Assess before advising.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

130 :
A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients?

Assign the newly hired UAP to clients who require the least complex level of care.

Ask the most experienced UAP on the team to partner with the newly hired UAP.

Review the UAP's skills checklist and experience with the person who hired the UAP.

Evaluate the newly hired UAP's level of competency by observing the UAP deliver care.

Hint : 🧽Match task to skill.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

131 :
A client receiving mechanical ventilation has a pH of 7.26, PaCO2 of 68 mm Hg, and a PaO2 of 92 mm Hg. Which intervention should the nurse implement?

Decrease expiratory flow time.

Decrease expiratory pressure.

Increase rate of ventilation.

Increase ventilator tidal volume.

Hint : 🌬️Fix respiratory acidosis.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

132 :
A client is admitted to the intensive care unit (ICU) with a spinal cord injury (SCI) following a motor vehicle collision. Which nurse should be contacted to coordinate the progression of the client's care?

Neurology unit supervisor.

Adult nurse practitioner.

Nurse case manager.

Risk management nurse.

Hint : 📝Coordinates rehab journey.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

133 :
A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. Which action should the nurse take first?

Ask the mother if any visitors were expected to arrive.

Match ID bands of all infants and mothers on the unit.

Determine if the newborn is in the nursery.

Activate the lockdown procedure.

Hint : 🚨Initiate code pink.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

134 :
After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to an unlicensed assistive personnel (UAP)?

Procure platelet products from the blood bank.

Titrate oxygen to the prescribed parameters.

Monitor an intravenous infusion rate on an established schedule.

Insert a urinary catheter for an uncomplicated client.

Hint : 💉Task within UAP scope.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

135 :
An older male client is admitted with the medical diagnosis of a possible cerebral vascular accident (CVA). He has facial paralysis and cannot move his left side. When entering the room, the nurse finds the client's wife tearful and trying unsuccessfully to give him a drink of water. Which action should the nurse take?

Ask the wife to stop and assess the client's swallowing reflex.

Give the wife a straw to help facilitate the client's drinking.

Assist the wife and carefully give the client small sips of water.

Obtain thickening powder before providing any more fluids.

Hint : 🥤Assess for dysphagia.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

136 :
After an increase in the number of suicides in a community, the nurse is developing a class for adolescents about mental health. Which type of activity should the nurse include in the teaching?

Assessment of tobacco use geared toward adolescents.

Exploration of stress self-management techniques.

Video with statistics showing trends in suicide rates.

Handouts for local substance abuse treatment centers.

Hint : 🧘Promote coping skills.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

137 :
The client is a 29-year-old female with a history of type 1 diabetes from the age of 6.

Nurses' Notes

The client is a 29-year-old female with a history of type 1 diabetes from the age of 6. She controls her blood glucose with an insulin pump and uses a continuous glucose monitor.

The client was out of town for a business trip, and her insulin pump was damaged when she accidentally dropped it on the floor.

She had forgotten her back-up long-acting insulin at home, so she decided to take the 6-hour drive home without any insulin.

By the time she arrived at home, she was having nausea and vomiting, abdominal pain, and rapid breathing.

Her blood glucose meter read over 500 mg/dL (27.8 mmol/L). She took a dose of insulin glargine and took herself to the emergency room.

What are the signs and symptoms of DKA? Select all that apply.

Answer Options

Hyperglycemia.

Ketonuria.

Metabolic acidosis.

Hypokalemia.

Dehydration.

Kussmaul respirations

Hint : 🍬DKA = insulin deficit crisis.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

138 :
The client is a 29-year-old with a history of type 1 diabetes from the age of 6.

Nurses' Notes.

The client is a 29-year-old with a history of type 1 diabetes from the age of 6. She controls her blood glucose with an insulin pump and uses a continuous glucose monitor.

The client was out of town, and her insulin pump was damaged.

She had forgotten her back-up long-acting insulin at home, so she took the 6-hour drive home.

By the time she arrived at home, she was having nausea and vomiting.

Her blood glucose meter read over 500 mg/dL (27.8 mmol/L). She took a dose of insulin glargine and took herself to the emergency room.

What are three goals of therapy for this client? Select three that apply.

Answer Options

Correct electrolytes that are out of normal range.

Promote oxygenation to tissues.

Prevent hyperventilation.

Reverse dehydration.

Replace insulin.

Provide respiratory support.

Hint : 🩸Fix insulin, fluids, electrolytes.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

139 :
The client is a 29-year-old with a history of type 1 diabetes from the age of 6.

Nurse's Notes.
Provider's Orders.

The client is a 29-year-old with a history of type 1 diabetes from the age of 6. She controls her blood glucose with an insulin pump and uses a continuous glucose monitor.

The client was out of town, and her insulin pump was damaged.

She had forgotten her back-up long-acting insulin at home, so she took the 6-hour drive home.

By the time she arrived at home, she was having nausea and vomiting.

Her blood glucose meter read over 500 mg/dL (27.8 mmol/L). She took a dose of insulin glargine and took herself to the emergency room.

0600.

Admit client to medical intensive care unit: diagnosis DKA.

Place peripheral intravenous (IV) catheter.

Blood gas every 2 hours, point of care blood glucose every hour.

Vital signs every hour.

Lactated Ringers IV at 125 mL/hr. NPO.

The nurse has called the physician and is anticipating orders. Select the actions that would help with the listed treatment goals. Select all that apply.

Answer Options

Start an insulin drip at 0.1 u/kg/hr.

Give a long-acting insulin dose.

Provide an oral medication that will enhance insulin production.

Change the intravenous fluid to 5% dextrose and 0.45% sodium chloride with 20 mEq potassium.

Have the client drink as much as they can tolerate.

Give 1 L of 0.9% sodium chloride IV

Promote removal of electrolytes with a diuretic.

Giving a multivitamin

Replacing potassium as needed

Hint : 💧Hydrate, insulin, correct K⁺.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

140 :
The client is a 29-year-old with a history of type 1 diabetes from the age of 6.

Nurses' Notes.

The client is a 29-year-old with a history of type 1 diabetes from the age of 6. She controls her blood glucose with an insulin pump and uses a continuous glucose monitor.

The client was out of town, and her insulin pump was damaged.

She had forgotten her back-up long-acting insulin at home, so she took the 6-hour drive home.

By the time she arrived at home, she was having nausea and vomiting.

Her blood glucose meter read over 500 mg/dL (27.8 mmol/L). She took a dose of insulin glargine and took herself to the emergency room.

The nurse is drawing an arterial blood gas to evaluate the client post treatment. Complete the following sentence by choosing from the lists of options. A pH level of and HCO3- level of indicate a resolution of ketoacidosis.

Hint : 🧪Normal pH + bicarbonate = resolution.

Rationale :

Rationale to be Available Soon

141 :
A nurse working on a medical-surgical unit is notified about a mass casualty event that recently took place in the community. Which of the assignments should the nurse anticipate?

Assist in discharging stable clients to home.

Determine the acuity and number of casualties arriving at the facility.

Delegate tasks to emergency health care specialists.

Provide informational updates to members of the media.

Hint : 🏥Discharge stable patients.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

142 :
A client is a 51-year-old male with pneumonia.

Nurses' Notes.
Provider Prescriptions.

The client is a 51-year-old male with pneumonia.

The client has a history of hypertension and takes enalapril and a multivitamin daily.

His surgical history includes adenoid removal at age 4-years and a surgical repair of a fractured tibia at age 20.

0800 Admit to the medical floor.

Vital signs every 4 hours.

Continuous pulse oximetry.

Supplemental oxygen 10 L/min via nasal cannula.

Enalapril 10 mg by mouth every morning.

Ibuprofen 400 mg by mouth every 4 to 6 hours as needed for temperature greater than 100.5 °F (38 °C). Send blood for a complete blood count, electrolytes.

Chest X-ray now.

What is the rationale for the order of supplemental oxygen 10 L/min via nasal cannula? Select the best answer.

Answer Options

To prevent hypoxia and tissue damage due to pneumonia.

To lower the blood pressure and reduce the workload of the heart.

To increase the oxygen saturation and improve the respiratory function.

To dilate the bronchioles and decrease the inflammation of the lungs.

Hint : 🫁Improves oxygenation during infection.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

143 :
A client is a 51-year-old male with pneumonia.

Nurses' Notes.
Provider Prescriptions.

The client is a 51-year-old male with pneumonia.

The client has a history of hypertension and takes enalapril and a multivitamin daily.

His surgical history includes adenoid removal at age 4-years and a surgical repair of a fractured tibia at age 20.

0800
Admit to the medical floor.

Vital signs every 4 hours.

Continuous pulse oximetry.

Supplemental oxygen 10 L/min via nasal cannula.

Enalapril 10 mg by mouth every morning.

Ibuprofen 400 mg by mouth every 4 to 6 hours as needed for temperature greater than 100.5 °F (38 °C). Send blood for a complete blood count, electrolytes.

Chest X-ray now.

The nurse notes that the client’s oxygen saturation is 88% on room air. What is the priority action by the nurse?

Answer Options

Increase the supplemental oxygen to 15 L/min via nasal cannula.

Notify the health care provider of the client’s condition.

Administer ibuprofen as ordered for fever.

Obtain a sputum culture from the client.

Hint : 🧑‍⚕️Notify provider promptly.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

144 :
A client is a 51-year-old male who was admitted to the hospital with pneumonia.

Nurses' Notes.
Provider Orders.

The client is a 51-year-old male who was admitted to the hospital with pneumonia.

He has been experiencing fever, cough, shortness of breath, and chest pain for the past three days.

The client has a history of hypertension and takes enalapril 10 mg by mouth every morning and a multivitamin daily.

His surgical history includes adenoid removal at age 4-years and a surgical repair of a fractured tibia at age 20. He has no known allergies.

His current vital signs are: temperature 101.2 °F (38.4 °C), pulse 110 beats/min, respirations 24 breaths/min, blood pressure 160/90 mmHg, and oxygen saturation 88% on room air.

0800

Admit to the medical floor.

Vital signs every 4 hours.

Continuous pulse oximetry.

Supplemental oxygen 10 L/min via nasal cannula.

Enalapril 10 mg by mouth every morning.

Ibuprofen 400 mg by mouth every 4 to 6 hours as needed for temperature greater than 100.5 °F (38 °C). Send blood for a complete blood count, electrolytes, blood cultures, and procalcitonin.

Chest X-ray now.

Sputum culture and sensitivity.

Levofloxacin 500 mg intravenously every 24 hours.

Which order would the nurse question? Select all that apply.

Answer Options

Ibuprofen 400 mg every 4 to 6 hours as needed for temperature greater than 100.5 °F (38 °C).

Enalapril 10 mg every morning.

Supplemental oxygen 10 L/min via nasal cannula.

Continuous pulse oximetry.

Send blood for a complete blood count, electrolytes, blood cultures, and procalcitonin.

Admit to the medical floor.

Vital signs every 4 hours.

Hint : 💊Hold ACE inhibitors during illness.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

145 :
A 70-year-old female presents to the emergency department 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. The triage nurse does a rapid assessment of the client. 1915: Client arrives via personal car to emergency department with facial drooping and garbled speech. Click to highlight the data that indicate the client is in need of immediate health interventions.

A 70-year-old female presents to the emergency department 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.

Client arrives via personal car to emergency department with facial drooping and garbled speech.

Hint : 📝Classic stroke signs.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

146 :
The triage nurse does a rapid assessment of the client.

Assessment.

1915:
Client arrives via personal car to emergency department with facial drooping and garbled speech.

1920:
Vital Signs:. Temperature: 98.2°F (36.8° C).

Heart rate: 92 beats/minute.

Respirations: 24 breaths/minute.

Blood pressure: 210/98 mm Hg.

Oxygen saturation: 95% on room air.

The nurse performs an initial rapid assessment of the client and observes facial drooping and garbled speech. A 70-year-old female presents to the emergency department 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. Select 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 as evidenced by ,

Hint : 🧠 Stroke → speech & droop.

Rationale :

Rationale to be Available Soon

147 :
The triage nurse does a rapid assessment of the client.

1915:

Client arrives via personal car to emergency department with facial drooping and garbled speech.

1920:

Temperature: 98.2°F (36.8° C).

Heart rate: 92 beats/minute.

Respirations: 24 breaths/minute.

Blood pressure: 210/98 mm Hg.

Oxygen saturation: 95% on room air.

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.

A 70-year-old female presents to the emergency department 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.

The nurse begins to plan care for the client’s recovery and identifies interdisciplinary team members who can assist with the client’s recovery. Select the interdisciplinary team members who should assist the client in recovery. Select all that apply.

Answer Options

Speech Therapist .

Case Manager .

Physical Therapist .

Pharmacy Technician.

Chief Nursing Officer .

Respiratory Therapist.

Medical Assistant.

An Occupational Therapist.

Hint : 🧑‍🤝‍🧑Rehab team support stroke recovery.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

148 :
A parent asked the nurse how to care for their 4-year-old child after receiving the Haemophilus influenzae Type b (Hib) conjugate vaccine .Which instruction should the nurse provide?

Any level of fever is serious and should be reported right away.

Keep the child home from daycare for the next two days.

Apply a cool pack to the injection site to reduce discomfort.

Chewable children’s aspirin will help prevent inflammation.

Hint : 💉Cold relieves vaccine site pain.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

Total Questions: 148

Choose Different Exam !

PN HESI Exit-2023 Exam 1

No.

1 : A male preoperative client who has already signed the informed consent for a surgical procedure confides in the practical nurse (PN) that he is really frightened and unsure about undergoing the surgery. Which priority action should the PN take?

2 : The parents of a one-year-old child with the diagnosis of hypospadias informed the practical nurse (PN) that they plan to delay corrective surgery to see if the child will outgrow the problem. Which information should the PN provide to these parents?

3 : Before administering an antibiotic that can cause nephrotoxicity, which laboratory value is most important for the practical nurse (PN) to review?

4 : The practical nurse (PN) is assessing an older client with left-sided heart failure (HF). What intervention is most important for the PN to implement?

5 : The practical nurse (PN) receives a report of a stable client who experienced partial-thickness burns over 30% of the body surface area (BSA) 3 days ago. Which complication is most important for the PN to anticipate?

6 : The practical nurse (PN) is providing care for a client who is receiving an aminoglycoside to treat a bacterial infection. To assess for signs of ototoxicity, which action should the PN take?

7 : A client who is reaching saturation with medication reports the onset of muscle soreness and fatigue, and the practical nurse (PN) notes that the client's skin is warm to the touch. Which action by the PN is a priority?

8 : A college student brings his roommate to the clinic because the roommate has been talking to someone who is not present. The student tells the practical nurse (PN) that his roommate is acting strange. Which question should the PN ask the client next?

9 : The practical nurse (PN) notices that one of the unlicensed assistive personnel (UAP) working in the long- term care facility consistently records subnormal temperatures when using the thermometer. Which action should the PN take first?

10 : At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best?

11 : The practical nurse (PN) is auscultating a client's lung sounds. Which description should the PN use to document this sound? (Please listen to the audio clip provided). Audio: [Wheezing sound]

12 : The medication aide at a long-term care facility is sick and requests to go home before all medications are administered. Which action should the practical nurse (PN) take in this situation?

13 : The medication aide at a long-term care facility is sick and requests to go home before all medications are administered. Which action should the practical nurse (PN) in charge take?

14 : A male client tells the practical nurse (PN) that the pill he has been taking at home is a diﬀerent color and size than the one the PN is trying to give him now.How should the PN respond?

15 : The practical nurse (PN) learns that a client who is receiving chemotherapy has developed stomatitis. Which information should the PN obtain from the client during a focused assessment?

17 : The unlicensed assistive personnel (UAP) tells the practical nurse (PN) that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times. Which action should the PN implement first?

19 : Which information should the practical nurse (PN) collect during the admission assessment of a terminally ill client to an acute care facility?

20 : When performing a focused gastrointestinal system assessment, the practical nurse (PN) asks a male client when his last bowel movement occurred. The client answers, "Three days ago." Which action should the PN implement first?

21 : The practical nurse (PN) observes a newly hired unlicensed assistive personnel (UAP) who is counting a client's radial pulse as seen in the picture. Which action should the PN take?

22 : When the practical nurse (PN) attempts to assist an 18-year-old client with a mild mental disability to ambulate on the first postoperative day after an appendectomy, she becomes angry and says, "PN, 'Get out of here! I'll get up when I'm ready!" Which response is best for the PN to make?

24 : A nurse is teaching a client with hypertension about antihypertensive drugs. Which of the following statements by the client indicates an understanding of the teaching?

25 : A nurse is teaching a group of older adults about the effects of aging on the neurological system. Which of the following statements should the nurse include as correct? (Select all that apply.).

26 : A client with renal calculi is experiencing hematuria and reports severe flank pain. Which intervention should the nurse implement first?

27 : A nurse is providing education to a client prescribed an antidepressant for their phobia. Which statement by the client indicates a need for further teaching?

28 : A nurse is planning care for a client with a phobia. Which nursing intervention is appropriate for this client?

29 : A nurse is caring for a client with a specific phobia. Which statement by the nurse is accurate regarding phobias?

30 : After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home.Which intervention(s) should the nurse take to prepare the body before the family enters the room? (Select all that apply.).

32 : A client with bleeding esophageal varices receives vasopressin intravenously (IV). Which adverse effect should the nurse monitor for during the IV infusion of this medication?

33 : When assessing a client, the nurse should establish which finding(s) as objective? (Select all that apply.).

34 : A client asks a nurse about the differences between major depressive disorder (MDD) and dysthymia. Which of the following responses by the nurse is accurate?

35 : A nurse is providing education to a group of healthcare professionals about suicide and suicidal ideation. Which of the following statements accurately describes suicidal ideation?

37 : Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

38 : A client has been diagnosed with depression and has a history of suicide attempts. What intervention is essential for the nurse to implement?

39 : What is the most common type of shock in children?

40 : A nurse is establishing a therapeutic relationship with a client with anxiety disorder. What is the primary goal of this intervention?

41 : The nurse is caring for a client who receives a prescription for valproic acid in which the maximum safe dosage is 60 mg/kg/day. How many mg/day is the maximum safe dosage for a client who weighs 176 pounds? (Enter numerical value only.).

42 : A client with diabetic peripheral neuropathy has been taking pregabalin for 4 days. Which finding indicates to the nurse that the medication is effective?

43 : The nurse observes a client with amyotrophic lateral sclerosis (ALS) is excessively drooling and prepares to suction the client's oral cavity. Which action should the nurse include?

44 : A nurse is providing interventions for a client with panic disorder. Which interventions should the nurse include in the plan of care? (Select all that apply).

45 : A nurse is assessing a client with panic disorder. Which statement by the nurse would be appropriate during the assessment?

46 : After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

47 : A client is admitted with an exacerbation of heart failure secondary to chronic obstructive pulmonary disease (COPD). Which observation(s) by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply.).

48 : An adolescent who is brought to the emergency department (ED) with a fever and persistent lower right quadrant abdominal pain is anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid-base imbalance?

49 : While caring for a client with a full-thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

50 : The nurse is preparing a community outreach program on primary disease prevention. Which topic should the nurse plan to include in this event?

51 : A client who weighs 176 pounds receives a prescription for norepinephrine 2 mcg/min intravenously (IV). The IV bag is labeled, "Norepinephrine 4 mg in dextrose 5% in water (D;W) 1,000 mL." How many mL/hour should the nurse program the infusion pump? (Enter numerical value only.).

52 : A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely?

53 : 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?

54 : When conducting diet teaching for a client who was diagnosed with hypertension, which food(s) should the nurse encourage the client to eat? (Select all that apply.)

55 : A nurse is teaching a client who has a fungal infection about fluconazole. Which of the following statements by the client indicates an understanding of the teaching?

57 : 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?

58 : Which is the best approach for the nurse to use when interviewing a client about intimate partner violence?

61 : A client arrives at the emergency department with chest pain after taking sildenafil. Based on the client's history, which medication should the nurse withhold?

62 : A client with delusions tells the nurse, "You aren't doing your job. Go get those people over there and shoot them before they get me." Which statement is the nurse's best response?

63 : When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?

64 : The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu item(s) should the nurse request for this client? (Select all that apply).

65 : A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? (Select all that apply.)

66 : When caring for an older male client with urinary frequency, which measure is most important for the nurse to implement to help the client prepare to go to bed for the night?

67 : A nurse is caring for a client who has variant angina and is prescribed verapamil. Which of the following are expected outcomes of this medication? (Select all that apply.)

68 : A client who has been prescribed propranolol for the treatment of arrhythmias reports experiencing shortness of breath and difficulty breathing while lying down at night. Which of the following should the nurse instruct the client to do?

69 : A nurse is caring for a client who has hypertension and is prescribed metoprolol, a beta blocker. The nurse should monitor the client for which of the following adverse effects?

70 : A client with chronic kidney disease receives a prescription for darbepoetin alfa 40 mcg subcutaneous every 7 days.The darbepoetin alfa vial is labeled, "60 mcg/mL." How many mL should the nurse administer? round to the nearest tenth.

71 : The nurse is assessing an adolescent female diagnosed with anorexia nervosa who is admitted to the unit with severe malnutrition and electrolyte imbalance. Which pathological process results from the adolescent's consistent maladaptive behavior?

72 : A 5-year-old child with a history of a waddling gait and frequent falls is brought into the hospital for diagnostic testing. When explaining the diagnostic testing to the parents, the nurse should provide information based on which understanding of the underlying disease pathology?

73 : The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the educational materials include which characteristics? (Select all that apply.).

74 : A client is diagnosed with influenza A and is prescribed oseltamivir. Which of the following statements by the client indicates a need for further education?

75 : A nurse is caring for a client who has meningitis caused by Streptococcus pneumoniae. The provider orders penicillin G IV for this client. Before administering the medication, which of the following actions should the nurse take?

76 : A nurse is teaching a client who has a urinary tract infection (UTI) about trimethoprim/sulfamethoxazole. The client asks why he needs to take two antibiotics together. What should the nurse say?

77 : A nurse is administering tetracycline to a client who has acne vulgaris. The client tells the nurse that he usually takes calcium supplements with his meals.How should the nurse respond?

78 : A nurse is reviewing laboratory results for a client who has been taking amoxicillin-clavulanate (Augmentin) for a bacterial respiratory tract infection. Which of the following findings should alert the nurse to a possible adverse effect of this medication? (Select all that apply.).

79 : An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies. Which is the best response by the nurse?

81 : The nurse is providing education to a client who receives a prescription for zolpidem. Which information about the medication should the nurse include?

82 : Which computer documentation indicates that activities to prevent postoperative venous stasis were performed correctly?

83 : The nurse is planning care for a client who has a fourth-degree midline laceration that occurred during vaginal delivery of an 8-pound 10-ounce (3674 grams) infant. Which intervention has the highest priority for this client?

84 : A client at 42-weeks gestation arrives at the labor and delivery unit for a scheduled induction but refuses the prescribed oxytocin infusion because she wants to have a "natural" delivery. Which action is most important for the nurse to implement?

85 : A woman at 12 weeks' gestation comes to the clinic for her first prenatal visit. After completing a health history, the nurse should discuss which topic about pregnancy at this initial visit?

86 : After a client receives a dose of albuterol, the nurse evaluates the medication's effects by auscultating the client's lung fields. Which action should the nurse take next based on the assessment?

87 : A client who has atrial fibrillation is prescribed warfarin therapy. Which of the following statements by the client indicates an understanding of the medication?

1 :
A male preoperative client who has already signed the informed consent for a surgical procedure confides in the practical nurse (PN) that he is really frightened and unsure about undergoing the surgery. Which priority action should the PN take?

2 :
The parents of a one-year-old child with the diagnosis of hypospadias informed the practical nurse (PN) that they plan to delay corrective surgery to see if the child will outgrow the problem. Which information should the PN provide to these parents?

3 :
Before administering an antibiotic that can cause nephrotoxicity, which laboratory value is most important for the practical nurse (PN) to review?

4 :
The practical nurse (PN) is assessing an older client with left-sided heart failure (HF). What intervention is most important for the PN to implement?

5 :
The practical nurse (PN) receives a report of a stable client who experienced partial-thickness burns over 30% of the body surface area (BSA) 3 days ago. Which complication is most important for the PN to anticipate?

6 :
The practical nurse (PN) is providing care for a client who is receiving an aminoglycoside to treat a bacterial infection. To assess for signs of ototoxicity, which action should the PN take?

7 :
A client who is reaching saturation with medication reports the onset of muscle soreness and fatigue, and the practical nurse (PN) notes that the client's skin is warm to the touch. Which action by the PN is a priority?

8 :
A college student brings his roommate to the clinic because the roommate has been talking to someone who is not present. The student tells the practical nurse (PN) that his roommate is acting strange. Which question should the PN ask the client next?

9 :
The practical nurse (PN) notices that one of the unlicensed assistive personnel (UAP) working in the long- term care facility consistently records subnormal temperatures when using the thermometer. Which action should the PN take first?

10 :
At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best?

11 :
The practical nurse (PN) is auscultating a client's lung sounds. Which description should the PN use to document this sound? (Please listen to the audio clip provided). Audio: [Wheezing sound]

12 :
The medication aide at a long-term care facility is sick and requests to go home before all medications are administered. Which action should the practical nurse (PN) take in this situation?

13 :
The medication aide at a long-term care facility is sick and requests to go home before all medications are administered. Which action should the practical nurse (PN) in charge take?

14 :
A male client tells the practical nurse (PN) that the pill he has been taking at home is a diﬀerent color and size than the one the PN is trying to give him now.
How should the PN respond?

15 :
The practical nurse (PN) learns that a client who is receiving chemotherapy has developed stomatitis. Which information should the PN obtain from the client during a focused assessment?

17 :
The unlicensed assistive personnel (UAP) tells the practical nurse (PN) that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times. Which action should the PN implement first?

19 :
Which information should the practical nurse (PN) collect during the admission assessment of a terminally ill client to an acute care facility?

20 :
When performing a focused gastrointestinal system assessment, the practical nurse (PN) asks a male client when his last bowel movement occurred. The client answers, "Three days ago." Which action should the PN implement first?

21 :
The practical nurse (PN) observes a newly hired unlicensed assistive personnel (UAP) who is counting a client's radial pulse as seen in the picture. Which action should the PN take?

22 :
When the practical nurse (PN) attempts to assist an 18-year-old client with a mild mental disability to ambulate on the first postoperative day after an appendectomy, she becomes angry and says, "PN, 'Get out of here! I'll get up when I'm ready!" Which response is best for the PN to make?

24 :
A nurse is teaching a client with hypertension about antihypertensive drugs. Which of the following statements by the client indicates an understanding of the teaching?

25 :
A nurse is teaching a group of older adults about the effects of aging on the neurological system. Which of the following statements should the nurse include as correct? (Select all that apply.).

26 :
A client with renal calculi is experiencing hematuria and reports severe flank pain. Which intervention should the nurse implement first?

27 :
A nurse is providing education to a client prescribed an antidepressant for their phobia. Which statement by the client indicates a need for further teaching?

28 :
A nurse is planning care for a client with a phobia. Which nursing intervention is appropriate for this client?

29 :
A nurse is caring for a client with a specific phobia. Which statement by the nurse is accurate regarding phobias?

30 :
After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home.
Which intervention(s) should the nurse take to prepare the body before the family enters the room? (Select all that apply.).

32 :
A client with bleeding esophageal varices receives vasopressin intravenously (IV). Which adverse effect should the nurse monitor for during the IV infusion of this medication?

33 :
When assessing a client, the nurse should establish which finding(s) as objective? (Select all that apply.).

34 :
A client asks a nurse about the differences between major depressive disorder (MDD) and dysthymia. Which of the following responses by the nurse is accurate?

35 :
A nurse is providing education to a group of healthcare professionals about suicide and suicidal ideation. Which of the following statements accurately describes suicidal ideation?

37 :
Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

38 :
A client has been diagnosed with depression and has a history of suicide attempts. What intervention is essential for the nurse to implement?

39 :
What is the most common type of shock in children?

40 :
A nurse is establishing a therapeutic relationship with a client with anxiety disorder. What is the primary goal of this intervention?

41 :
The nurse is caring for a client who receives a prescription for valproic acid in which the maximum safe dosage is 60 mg/kg/day. How many mg/day is the maximum safe dosage for a client who weighs 176 pounds? (Enter numerical value only.).

42 :
A client with diabetic peripheral neuropathy has been taking pregabalin for 4 days. Which finding indicates to the nurse that the medication is effective?

43 :
The nurse observes a client with amyotrophic lateral sclerosis (ALS) is excessively drooling and prepares to suction the client's oral cavity. Which action should the nurse include?

44 :
A nurse is providing interventions for a client with panic disorder. Which interventions should the nurse include in the plan of care? (Select all that apply).

45 :
A nurse is assessing a client with panic disorder. Which statement by the nurse would be appropriate during the assessment?

46 :
After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

47 :
A client is admitted with an exacerbation of heart failure secondary to chronic obstructive pulmonary disease (COPD). Which observation(s) by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply.).

48 :
An adolescent who is brought to the emergency department (ED) with a fever and persistent lower right quadrant abdominal pain is anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid-base imbalance?

49 :
While caring for a client with a full-thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

50 :
The nurse is preparing a community outreach program on primary disease prevention. Which topic should the nurse plan to include in this event?

51 :
A client who weighs 176 pounds receives a prescription for norepinephrine 2 mcg/min intravenously (IV). The IV bag is labeled, "Norepinephrine 4 mg in dextrose 5% in water (D;W) 1,000 mL." How many mL/hour should the nurse program the infusion pump? (Enter numerical value only.).

52 :
A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely?

53 :
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?

54 :
When conducting diet teaching for a client who was diagnosed with hypertension, which food(s) should the nurse encourage the client to eat? (Select all that apply.)

55 :
A nurse is teaching a client who has a fungal infection about fluconazole. Which of the following statements by the client indicates an understanding of the teaching?

57 :
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?

58 :
Which is the best approach for the nurse to use when interviewing a client about intimate partner violence?

61 :
A client arrives at the emergency department with chest pain after taking sildenafil. Based on the client's history, which medication should the nurse withhold?

62 :
A client with delusions tells the nurse, "You aren't doing your job. Go get those people over there and shoot them before they get me." Which statement is the nurse's best response?

63 :
When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?

64 :
The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu item(s) should the nurse request for this client? (Select all that apply).

65 :
A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? (Select all that apply.)

66 :
When caring for an older male client with urinary frequency, which measure is most important for the nurse to implement to help the client prepare to go to bed for the night?

67 :
A nurse is caring for a client who has variant angina and is prescribed verapamil. Which of the following are expected outcomes of this medication? (Select all that apply.)

68 :
A client who has been prescribed propranolol for the treatment of arrhythmias reports experiencing shortness of breath and difficulty breathing while lying down at night. Which of the following should the nurse instruct the client to do?

69 :
A nurse is caring for a client who has hypertension and is prescribed metoprolol, a beta blocker. The nurse should monitor the client for which of the following adverse effects?

70 :
A client with chronic kidney disease receives a prescription for darbepoetin alfa 40 mcg subcutaneous every 7 days.The darbepoetin alfa vial is labeled, "60 mcg/mL." How many mL should the nurse administer? round to the nearest tenth.

71 :
The nurse is assessing an adolescent female diagnosed with anorexia nervosa who is admitted to the unit with severe malnutrition and electrolyte imbalance. Which pathological process results from the adolescent's consistent maladaptive behavior?

72 :
A 5-year-old child with a history of a waddling gait and frequent falls is brought into the hospital for diagnostic testing. When explaining the diagnostic testing to the parents, the nurse should provide information based on which understanding of the underlying disease pathology?

73 :
The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the educational materials include which characteristics? (Select all that apply.).

74 :
A client is diagnosed with influenza A and is prescribed oseltamivir. Which of the following statements by the client indicates a need for further education?

75 :
A nurse is caring for a client who has meningitis caused by Streptococcus pneumoniae. The provider orders penicillin G IV for this client. Before administering the medication, which of the following actions should the nurse take?

76 :
A nurse is teaching a client who has a urinary tract infection (UTI) about trimethoprim/sulfamethoxazole. The client asks why he needs to take two antibiotics together. What should the nurse say?

77 :
A nurse is administering tetracycline to a client who has acne vulgaris. The client tells the nurse that he usually takes calcium supplements with his meals.
How should the nurse respond?

78 :
A nurse is reviewing laboratory results for a client who has been taking amoxicillin-clavulanate (Augmentin) for a bacterial respiratory tract infection. Which of the following findings should alert the nurse to a possible adverse effect of this medication? (Select all that apply.).

79 :
An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies. Which is the best response by the nurse?

81 :
The nurse is providing education to a client who receives a prescription for zolpidem. Which information about the medication should the nurse include?

82 :
Which computer documentation indicates that activities to prevent postoperative venous stasis were performed correctly?

83 :
The nurse is planning care for a client who has a fourth-degree midline laceration that occurred during vaginal delivery of an 8-pound 10-ounce (3674 grams) infant. Which intervention has the highest priority for this client?

84 :
A client at 42-weeks gestation arrives at the labor and delivery unit for a scheduled induction but refuses the prescribed oxytocin infusion because she wants to have a "natural" delivery. Which action is most important for the nurse to implement?

85 :
A woman at 12 weeks' gestation comes to the clinic for her first prenatal visit. After completing a health history, the nurse should discuss which topic about pregnancy at this initial visit?

86 :
After a client receives a dose of albuterol, the nurse evaluates the medication's effects by auscultating the client's lung fields. Which action should the nurse take next based on the assessment?

87 :
A client who has atrial fibrillation is prescribed warfarin therapy. Which of the following statements by the client indicates an understanding of the medication?

88 :
A nurse is reviewing the laboratory results of a client who is receiving intravenous unfractionated heparin. The nurse notes that the client’s activated partial thromboplastin time (aPTT) is 120 seconds. What are the appropriate nursing actions in this situation? Select all that apply.

89 :
What are some important nursing considerations for this medication?