A client with HIV and AIDS confides that he is homosexual and his employer does not know his HIV status. The nurse's best response to him is

The mother of a child with bronchial asthma tells the nurse that the child wants a pet. Which of the following pets should the nurse tell the mother is most appropriate?

An elderly client is being admitted to same-day surgery for cataract extraction. The client has several diamond rings. The nurse should explain to the client that

When an infant resumes taking oral feedings after surgery to correct intussusception, the parents comment that the child seems to suck on the pacifier more since the surgery. The nurse explains that sucking on a pacifier

A 22-year-old client is brought to the emergency department with his fiancée after being involved in a serious motor vehicle accident. His Glasgow Coma Scale score is 7 and he demonstrates evidence of decorticate posturing. Which of the following would be appropriate for obtaining permission to place a catheter for intracranial pressure (ICP) monitoring?

A 68-year-old client's daughter is asking about the follow-up evaluation for her father after his pneumonectomy for primary lung cancer. The nurse's best response is which of the following?

The nurse is preparing to administer blood to an otherwise healthy client who requires postoperative blood replacement. The nurse is aware that the blood administration set must include

Under which circumstance may a nurse communicate medical information without the client's consent?

During the health history interview, which of the following strategies is the most effective for the nurse to use to help clients feel that they have an active role in their health care?

A client with severe major depression states, "My heart has stopped and my blood is black ash." The nurse interprets this statement to be evidence of which of the following?

When a client wants to read his chart, the nurse should

A client who has a fractured leg has been instructed to ambulate without weight bearing on the affected leg. The nurse evaluates that the client is ambulating correctly if she uses which of the following crutch-walking gaits?

A client with major depression states, "Life isn't worth living anymore. Nothing matters." Which of the following responses by the nurse would be best?

A client with bipolar 1 disorder has been prescribed olanzapine (Zyprexa) 5 mg two times a day and lamotrigine (Lamictal) 25 mg two times a day. Which of the following adverse effects would the nurse report to the physician immediately? Select all that apply.

A client is prescribed atropine, 0.4 mg IM. The atropine vial is labeled 0.5 mg/mL. How many milliliters should the nurse plan to administer?

A multiparous client tells the nurse that she is using medroxyprogesterone (Depo-Provera) for contraception. The nurse instructs the client to increase her intake of which of the following?

Which of the following statements made by a woman in the first trimester are consistent with this stage of pregnancy? Select all that apply.

The nurse is teaching a client about topical gentamicin sulfate (Garamycin). Which of the following comments by the client indicates the need for additional teaching?

A client has been taking imipramine (Tofranil) for his depression for 2 days. His sister asks the nurse, "Why is he still so depressed?" Which of the following responses by the nurse would be most appropriate?

Which interventions would the nurse use to assist the client with grandiose delusions? Select all that apply.

multigravid client visiting the prenatal clinic at 16 weeks' gestation exhibits facial swelling, a brownish vaginal discharge, and fundal height of 22 cm. The client's blood pressure is 160/90 mm Hg and her pulse is 80 bpm. The nurse interprets these findings as suggestive of which of the following?

Which of the following responses would be most helpful for a client who is euphoric, intrusive, and interrupts other clients engaged in conversations to the point where they get up and leave or walk away?

The nurse coordinates with the laboratory staff to have the gentamicin trough serum level drawn. At what time should the blood be drawn in relation to the administration of the intravenous dose of gentamicin sulfate (Garamycin)?

Older adults with known cardiovascular disease must balance which of the following measures for optimum health?

A 4-year-old is brought to the emergency department with sudden onset of a temperature of 103°F (39.5°C), sore throat, and refusal to drink. The child will not lie down and prefers to lean forward while sitting up. Which of the following would the nurse do next?

Assessment of a client taking lithium reveals dry mouth, nausea, thirst, and mild hand tremor. Based on an analysis of these findings, which of the following would the nurse do next?

A client asks the nurse how long she will have to take her medicine for hypothyroidism. The nurse's response is based on the knowledge that

Assessment of which of the following clients would lead the nurse to expect the physician to order an adjustment in lithium dosage?

A client admitted with a gastric ulcer has been vomiting bright red blood. His hemoglobin is 5.11 g/dL, and his blood pressure is 100/50 mm Hg. The client and the family state that their religious beliefs do not support the use of blood products and refuse blood transfusions as a treatment for the bleeding. The nurse would expect that the next step in the treatment plan would be to

The parents of a child with cystic fibrosis express concern about how the disease was transmitted to their child. The nurse would explain that

A client with angina shows the nurse her nitroglycerin (Nitrostat) that she is carrying in a plastic bag in her pocket. The nurse instructs the client that nitroglycerin should be kept

The nurse caring for client on the telemetry unit is able to determine that the client is in sinus bradycardia by recognizing which characteristics? Select all that apply.

When teaching a client with bipolar disorder, mania, who has started to take valproic acid (Depakene) about possible side effects of this medication, the nurse would include which of the following in the teaching plan?

An infant is born with facial abnormalities, growth retardation, mental retardation, and vision abnormalities. These abnormalities are probably caused by maternal

Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently used in the treatment of musculoskeletal conditions. It is important for the nurse to remind the client to

The nurse would suspect that the client taking disulfiram (Antabuse) therapy has ingested alcohol when the client exhibits which of the following symptoms?

The nurse holds the gauze pledget against an intramuscular injection site while removing the needle from the muscle. This technique helps to

A client whose condition remains stable after a myocardial infarction gradually increases his activity. Which the following conditions should the nurse assess to determine whether the activity is appropriate for the client?

When a client with alcohol dependency begins to talk about not having a problem with alcohol, the nurse would use which of the following approaches?

Which of the following correctly describes Medicaid?

The nurse is preparing a teaching plan for a 45-year-old client recently diagnosed with type 2 diabetes mellitus. What is the first step in this process?

A loading dose of digoxin (Lanoxin) is given to a client newly diagnosed with atrial fibrillation. The nurse begins instructing the client about the medication and the importance of monitoring the heart rate. An expected outcome of the education program will be

A multigravid client is scheduled for a percutaneous umbilical blood sampling (PUBS) procedure. The nurse instructs the client that this procedure is useful for diagnosing which of the following?

Which of the following is a side effect of vancomycin (Vancocin) and needs to be reported promptly?

Which of the following statements indicates that the client with a peptic ulcer understands the dietary modifications he will need to follow at home?

The client with a nasogastric tube begins to complain of abdominal distention. Which of the following measures should the nurse implement first?

A male client has been diagnosed as having a low sperm count during infertility studies. After instructions by the nurse about some causes of low sperm counts, the nurse determines that the client needs further instructions when he says low sperm counts may be caused by which of the following?

The nurse assesses a client and notes puffy eyelids, swollen ankles, and crackles at both lung bases. The nurse understands that these clinical findings are most specifically associated with fluid excess in which of the following compartments?

An expected physiologic response to a low potassium level is

When teaching unlicensed assistive personnel (UAP) about the importance of handwashing in preventing disease, the nurse makes which of the following statements?

The nurse is performing Leopold maneuvers on a woman who is in her eighth month of pregnancy. The nurse is palpating the uterus at the symphysis pubis area. Which of the following maneuvers is the nurse performing?

A client in a cardiac rehabilitation program states that he would like to make sure he is eating the right foods to ensure adequate endurance on the treadmill. Which of the following nutrients is most helpful for promoting endurance during sustained activity?

A client's chest tube is connected to a chest tube drainage system with a water seal. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. The fluctuation means that

A client with diabetes is explaining to the nurse how she will care for her feet at home. Which statement indicates that the client understands proper foot care?

The nurse assesses a client with diverticulitis and suspects peritonitis when which of the following symptoms is noted?

When assessing a client, which risk factors would lead the nurse to suspect that the client has pancreatitis? Select all that apply.

When performing chest percussion on a child, which of the following techniques would the nurse use?

The nurse walks into the room of a client who has a "Do Not Resuscitate" order and finds the client without a pulse, respirations, or blood pressure. What is the most appropriate action?

A client is trying to lose weight at a moderate pace. If the client eliminates 1000 calories per day from his normal intake, how many pounds would he lose in 1 week?

A nulliparous client calls the clinic and tells the nurse that she forgot to take her oral contraceptive this morning. Which of the following would the nurse instruct the client to do?

The nurse recognizes that a client with pain disorder is improving when the client states which of the following?

A client admitted in an acute psychotic state says that she hears "terrible voices in the head" and thinks her neighbor is "out to get her." Which of the following would be the nurse's best response?

The nurse would assess the client with severe diarrhea for which acid–base imbalance?

Which of the following outcome criteria would be appropriate for a client with excess fluid volume?

A 7-year-old child is admitted to the hospital with the medical diagnosis of acute rheumatic fever. Which of the following laboratory blood findings would confirm that the child probably has had a streptococcal infection?

A client is scheduled for hip replacement surgery and is interviewed by the nurse in the preadmission testing unit. The client states that he wishes to receive his own blood for the upcoming surgery. What is the nurse's most appropriate response?

A client needs surgery to relieve an intestinal obstruction. The day before the surgery, the nurse receives the following set of orders for the client. Which of the following orders should the nurse question before performing?

After teaching a client about collecting a stool sample for occult testing, which client statement indicates effective teaching? Select all that apply.

A client who is NPO is constantly asking for a drink. Which of the following would be the most appropriate nursing intervention?

A female client is admitted with complaints of fatigue, cold intolerance, weight gain, and muscle weakness. The initial nursing assessment reveals brittle nails, dry hair, constipation, and possible goiter. The client is most likely experiencing signs and symptoms of

A mother visiting the clinic for a routine visit with her 10-year-old daughter reports that her daughter has an increase in hair growth and breast enlargement. The nurse explains to the mother and daughter that after the symptoms of puberty are noticed, menstruation most typically occurs within which of the following time frames?

While a mother is feeding her full-term neonate 1 hour after birth, she asks the nurse, "What are these white dots in my baby's mouth? I tried to wash them out, but they're still there." After assessing the neonate's mouth, the nurse explains that these spots are which of the following?

The nurse would suspect esophageal atresia (EA) and tracheoesophageal fistula (TEF) in a newborn exhibiting which of the following initially? Select all that apply.

Which one of the following factors is most important for healing an infected decubitus ulcer?

A client is receiving digoxin (Lanoxin). His pulse range is normally 70 to 76 bpm. After assessing the apical pulse for 1 minute and finding it to be 60 bpm, the nurse should initially

While shopping at a local mall, the nurse hears a pregnant client yell "Oh my! The baby's coming!" After placing the client in a supine position and trying to maintain some privacy, the nurse sees that the neonate's head is delivering. Which of the following would the nurse do first?

The nurse is preparing a discharge plan for a 16-year-old who has fractured her femur and ulna. The client asks the nurse how quickly her fractures will heal so she can return to her normal activities. Which of the following responses would be most appropriate for the nurse to make?

A client with delirium becomes very anxious and says, "I can't stop what is happening to me. Make it stop, please!" Which of the following would be the nurse's most appropriate response?

After teaching a primigravid client at 10 weeks' gestation about the recommendations for exercise during pregnancy, which of the following client statements indicates successful teaching?

The nurse is caring for a client who has had a myocardial infarction involving a large section of the heart muscle. The nurse anticipates that the client is at risk for

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

The physician has ordered a chemotherapy drug to be administered to a client every day for the next week. The client is on an adult medical–surgical floor but the nurse assigned to the client has not been trained to handle chemotherapy agents. What is the nurse's most appropriate response?

Which of the following nursing diagnoses would the nurse identify as a priority after surgical repair of a cleft lip?

Which of the following would be an appropriate outcome for a client with rheumatoid arthritis? The client will

A client's burn wounds are being cleaned twice a day in a hydrotherapy tub. Which of the following interventions should be included in the plan of care before a hydrotherapy treatment is initiated?

A health care provider has been exposed to hepatitis B through a needlestick. Which of the following drugs would the nurse anticipate administering as postexposure prophylaxis?

When performing an otoscopic examination of the tympanic membrane of a 2-year-old child, the nurse would pull the pinna in which of the following directions?

Which of the following findings would the nurse most likely note in the client who is in the compensatory stage of shock?

A client has been prescribed hydrochlorothiazide (HydroDIURIL) for treatment of heart failure. For which of the following symptoms should the nurse monitor the client?

The son of a client with Alzheimer's disease excitedly tells the nurse, "Mom was singing one of her favorite old songs. I think she's getting her memory back!" Which of the following responses by the nurse is most appropriate?

The nurse collects a urine specimen from a client for a culture and sensitivity analysis. Which of the following is the correct care of the specimen?

A 16-year-old client is in the emergency department for treatment of minor injuries from a car accident. A crisis nurse is with her because she became hysterical and was saying, "It's my fault. My Mom is going to kill me. I don't even have a way home." Which of the following would be the nurse's initial intervention?

The nurse is developing a community health education program about STDs. Which information about women who acquire gonorrhea should be included?

A client has his leg immobilized in a long leg cast. Which of the following assessments would indicate the early beginning of circulatory impairment?

While feeding a term neonate at 2 hours of age, the nurse observes that the neonate has a drooping appearance on the left side of the face. The nurse notifies the physician based on the understanding that this is associated with which of the following?

A client tells the nurse that she has had sexual contact with someone whom she suspects has genital herpes. Which of the following instructions should the nurse give the client in response to this information?

The nurse is assigned to a client with irreversible shock. The nurse realizes that the negative outcomes of irreversible shock include severe hypoperfusion to all vital organs and failure of vital functions. Therefore, the nurse will monitor the client for

The nurse is caring for a client who has been diagnosed with deep vein thrombosis. When assessing the client's vital signs, the nurse notes an apical pulse of 150 bpm, a respiration rate of 46 breaths/minute and a blood pressure of 100/60 mm Hg. The client appears anxious and restless. What should be the nurse's first course of action?

The charge nurse should give a new graduate nurse who made an insulin medication error the following advice:

A client who has Ménière's disease is trying to cope with the chronic tinnitus that she is experiencing. Which of the following interventions would be most appropriate for the nurse to suggest for coping with the tinnitus?