A 4-year-old child who has been ill for 4 hours is admitted to the hospital with difficulty swallowing, a sore throat, and severe substernal retractions. The child's temperature is 104°F (40°C), and the apical pulse is 140 bpm. The white blood cell count is 16,000/mm3. Which of the following would the nurse identify as the immediate priority nursing diagnosis?
Anxiety related to need for immediate and unplanned hospitalization.
Risk for Injury (airway obstruction) related to epiglottal edema.
Impaired Gas Exchange related to excessive respiratory effort.
Ineffective Airway Clearance related to aspiration.
Pulmonary function studies have been ordered for a client with emphysema. The nurse would anticipate that the test would demonstrate which of the following results?
The nurse who is caring for a client with diabetes realizes that the client has a higher risk for development of cataracts and
background retinopathy.
proliferative retinopathy.
neuropathy.
diabetic retinopathy.
The nurse assesses the assigned clients for the shift. Of the following assigned clients, which client is at greatest risk for falling?
A 22-year-old man with three fractured ribs and a fractured left arm.
A 70-year-old woman with episodes of syncope.
A 50-year-old man with angina.
A 30-year-old woman with a fractured ankle
Which of the following baseline laboratory data should be established before a client is started on tissue plasminogen activator (t-PA) or alteplase recombinant (Activase)?
Potassium level.
Lee-White clotting time.
Hemoglobin, hematocrit, and platelet count
Blood glucose level.
The nurse is developing an education plan for clients with hypertension. Which of the following long-term goals would it be most appropriate for the nurse to emphasize to the clients?
Develop a plan to limit stress.
Participate in a weight reduction program.
Commit to lifelong therapy.
Monitor blood pressure regularly.
The nurse should consider which of the following principles when developing a care plan to manage a client's pain from cancer?
Individualize the pain medication regimen for the client.
Select medications that are least likely to lead to addiction.
Administer pain medication as soon as the client requests it.
Change pain medications periodically to avoid drug tolerance.
After explaining to a multigravid client at 36 weeks' gestation who is diagnosed with severe hydramnios about the possible complications of this condition, which of the following client statements indicates that the client needs further instruction?
"Because I have hydramnios, I may have an increased weight gain."
"Hydramnios has been associated with gastrointestinal disorders in the fetus."
"I should continue to eat high-fiber foods and avoid constipation."
"I can continue to work at my job at the automobile factory until labor starts."
An obese diabetic client complains of bilateral leg aching. His physician has referred him to cardiac rehabilitation to start an exercise program. Which of the following activities would be most helpful for the client?
Interval training on the stationary bicycle.
Interval training on the treadmill.
Interval training on a commercial ski machine.
Interval training on the stair climber.
The nurse is assigned to a client with jaundice and collects the following data: poor appetite, complaints of nausea and two episodes of emesis in the past 2 hours. Which of the following diagnoses best acknowledges the client's problems?
Imbalanced Nutrition: Less Than Body Requirements.
Pain related to abdominal muscle spasms.
Adult Failure to Thrive.
Ineffective Health Maintenance.
Which of the following interventions is recommended protocol for all clients who are at risk for pressure sore development?
Identify at-risk clients on admission to the health care facility.
Place at-risk clients on an every-2-hour turning schedule.
Automatically place clients in specialty beds.
Provide at-risk clients with a high-protein, high-carbohydrate diet.
A client has been prescribed digoxin (Lanoxin). Which of the following symptoms should the nurse tell the client to report as a potential indication of digitalis toxicity?
Urticaria.
Shortness of breath.
Visual disturbances.
Hypertension.
The nurse is instructing a client on how to care for skin that has become dry after radiation therapy. Which of the following statements by the client indicates that the client understands the teaching?
"I should take antihistamines to decrease the itching I am experiencing."
"It is safe to apply a nonperfumed lotion to my skin."
"A heating pad, set on the lowest setting, will help decrease my discomfort."
"I can apply an over-the-counter cortisone ointment to relieve the dryness."
The appetite-suppressing neurotransmitter that is made from tryptophan is
epinephrine.
norepinephrine.
serotonin.
phenylalanine.
When administering atropine sulfate preoperatively to a client scheduled for lung surgery, the nurse should tell the client which of the following?
"This medicine will make you drowsy."
"This medicine will help you relax."
"This medicine will make your mouth feel dry."
"This medicine will reduce the risk of postoperative infection."
The nurse is preparing a client for a thoracentesis. How should the nurse position the client for the procedure?
Supine with arms over head.
Sims' position.
Prone position without a pillow
Sitting forward with arms supported on bedside table.
The antidote for heparin is
vitamin K.
warfarin (Coumadin).
thrombin.
protamine sulfate.
Which of the following actions would be most appropriate when dealing with a client who is expressing anger verbally, is pacing, and is irritable?
Conveying empathy and encouraging ventilation.
Using calm, firm directions to get the client to a quiet room.
Putting the client in restraints.
Discussing alternative strategies for when the client is angry in the future.
client with myasthenia gravis is seen in the emergency department for epistaxis. A priority nursing diagnosis would be
Ineffective Breathing Pattern.
Risk for Aspiration.
Risk for Injury.
Self-Care Deficit.
Which of the following measures should be implemented promptly after a client's nasogastric tube has been removed?
Provide the client with oral hygiene.
Offer the client liquids to drink.
Encourage the client to cough and deep breathe.
Auscultate the client's bowel sounds.
The nurse prepares a warm compress to apply to a client's leg. The nurse understands that the reason for applying a heat treatment is to
reduce tissue metabolism.
decrease mobility of leukocytes.
promote circulation to the area.
prevent swelling in the area.
While assisting the physician with an amniocentesis on a multigravid client at 38 weeks' gestation, the nurse observes that the fluid is very cloudy and thick. The nurse interprets this finding as indicating which of the following?
Intrauterine infection.
Fetal meconium staining.
Erythroblastosis fetalis.
Normal amniotic fluid.
The nurse instructs the UAP on how to collect a 24-hour urine specimen. Which of the following instructions is correct for a collection that is scheduled to start at 7 am Monday and end at 7 am Tuesday?
Collect and save the urine voided at 7 am on Monday.
Send first voided urine specimen on Monday to the laboratory for culture.
Collect and save the urine voided at 7 am on Tuesday.
Keep each day's urine collection in separate containers.
Which of the following abnormal serum chemistry values would be present in a client with cirrhosis who has developed ascites?
Decreased aspartate aminotransferase (AST).
Hypoalbuminemia.
Hyperkalemia.
Decreased alanine aminotransferase (ALT).
An infant is brought to the clinic for a regular checkup and the diphtheria, tetanus, and acellular pertussis (DTaP) and inactivated polio vaccine (IPV) immunizations. The child is recovering from a cold and is afebrile. The child's sibling has cancer and is receiving chemotherapy. Which of the following actions would be most appropriate?
Giving the DTaP and withholding the IPV.
Administering the DTaP and IPV immunizations.
Postponing both immunizations until the sibling is in remission.
Withholding both immunizations until the infant is well.
When creating a program to decrease the primary cause of disability and death in children, which of the following would be most effective for the community health nurse to do?
Encourage state legislators to draft legislation to promote prenatal care.
Recommend that the health department make immunizations available at no cost to all children.
Perform teaching of health and safety practices to children and their parents.
Have a nurse practitioner hired for each of the schools in the community.
A client has had an incisional cholecystectomy. Which of the following nursing interventions would have the highest priority in postoperative care for this patient?
A client has had an incisional cholecystectomy. Which of the following nursing interventions would have the highest priority in postoperative care for this patient?
Performing leg exercises every shift.
Maintaining a weight-reduction diet.
Promoting incisional healing.
During a home visit, the nurse is evaluating an infant for auditory ability. Which of the following would be the expected response in an infant with normal hearing?
Stoppage of body movements when sound is introduced.
Evidence of shy and withdrawn behaviors.
Saying "da-da" by 5 months of age.
Absence of squealing by 4 months of age.
A client who had a transurethral resection of the prostate (TURP) 1 day earlier has a three-way Foley catheter inserted for continuous bladder irrigation. Which of the following statements best explains why continuous irrigation is used after a TURP?
To control bleeding in the bladder
To instill antibiotics into the bladder.
To keep the catheter free from clot obstruction.
To prevent bladder distention.
Which of the following sounds would the nurse expect to hear when percussing a distended bladder?
Hyperresonance
Tympany.
Dullness.
Flatness.
A tour bus has overturned on an exit ramp. Many passengers are injured, but there were no fatalities. While the emergency department nurse prepares for treating the injured, the nurse also calls the crisis nurse based on the understanding about which of the following?
The accident victims will be experiencing grief and mourning.
Many of the passengers may be experiencing feelings of victimization.
There is a need for someone to coordinate calls from relatives about the passengers.
Some of the passengers will need psychiatric hospitalization
A postoperative nursing goal for the infant who has had surgery to correct imperforate anus is to prevent tension on the perineum. To achieve this goal, the nurse should avoid placing the neonate
on the abdomen, with legs pulled up under the body.
on the back, with legs suspended at a 90-degree angle.
on the left side, with hips elevated.
on the right side, with hips elevated.
A child with meningococcal meningitis seen in the emergency department is to be admitted to the pediatric unit. In preparation for the child's arrival, the nurse would expect to do which of the following first?
Institute droplet precautions
Obtain the child's vital signs.
Ask the parent about medication allergies.
Inquire about the health of siblings at home.
When developing the plan of care for a 14-year-old boy with a nursing diagnosis of Deficient Diversional Activity related to immobility, which of the following activities would be most appropriate?
Playing a card game with a boy the same age.
Putting together a puzzle with his mother.
Playing video games with a 9-year-old.
Watching a movie with his younger brother.
An adolescent is being prepared for an emergency appendectomy. Which of the following should the nurse include in the teaching plan? Select all that apply.
Friends can visit whenever they want.
The scar will be small.
The teen will be back in school in a week.
Antibiotics will be given to prevent an infection.
A client receives morphine for postoperative pain. Considering the effects of morphine, which of the following assessments should the nurse include in the client's care plan?
Take apical heart rate after each dose of morphine.
Assess urinary output every shift.
Assess mental status every shift.
Check for pedal edema every shift.
A client who is complaining of back and left flank pain is diagnosed with renal calculi. The client is experiencing periods of complete comfort alternating with periods of excruciating pain, accompanied by nausea and difficulty walking. Based on these data, what would be the priority nursing diagnosis for this client?
Activity Intolerance.
Acute Pain.
Deficient Fluid Volume.
Imbalanced Nutrition: Less than Body Requirements.
When infusing total parenteral nutrition (TPN), the nurse should assess the client for which of the following complications?
Essential amino acid deficiency.
Essential fatty acid deficiency.
Hyperglycemia.
Infection.
When assessing for signs of a blood transfusion reaction in a client with dark skin, the nurse should assess for which of the following?
Hypertension.
Diaphoresis.
Polyuria.
Warm skin.
After surgery for the creation of a urinary diversion, the client is at risk for a urinary tract infection. The nurse should plan to incorporate which of the following interventions into the client's care?
Clamp the urinary appliance at night.
Empty the urinary appliance when one-third full.
Administer prophylactic antibiotics.
Change urinary appliance daily.
When suctioning a client's tracheostomy tube, the nurse should incorporate which of the following steps into the procedure?
Oxygenate the client before suctioning.
Insert the suction catheter about 2 inches into the cannula.
Use a bolus of sterile water to stimulate cough.
Use clean gloves during the procedure.
When making a home visit, the nurse notices that the 14-month-old has a severe diaper rash. Which of the following recommendations should the nurse provide to the toddler's parents?
Continue to use the baby wipes.
Change the diaper every 4 to 6 hours.
Wash the buttocks using mild soap.
Apply powder to the diaper area.
On entering a toddler's room, the nurse finds the mother sitting about 8 feet from the child and watching television while the toddler is screaming. Which of the following would be the most appropriate response by the nurse?
"What happened between you and your child?"
"Why is your child screaming?"
"Did something cause your child to be upset?"
"Have you tried to calm down your child?"
A client has a total hip replacement. Which of the following client statements indicates a need for further teaching before discharge?
"I will implement my exercise program as soon as I get home."
"I will be careful not to cross my legs."
"I will need an elevated toilet seat."
"I can't wait to take a tub bath when I get home."
An adolescent tells the school nurse she thinks she has infectious mononucleosis. Which of the following would the nurse expect the student to exhibit most frequently?
Sore throat and malaise.
Fatigue and weight loss.
Cold-like symptoms and fever.
Skin rash and abdominal pain.
While assessing the fundus of a multiparous client on the first postpartum day, the nurse performs handwashing and dons clean gloves. Which of the following would the nurse do next?
Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus.
Ask the client to assume a side-lying position with the knees flexed.
Perform massage vigorously at the level of the umbilicus if the fundus feels "boggy."
Place the client on a bedpan in case the uterine palpation stimulates the client to void.
A nulligravid client with gestational diabetes tells the nurse that she had a reactive nonstress test 3 days ago and asks, "What does that mean?" The nurse explains that a reactive nonstress test indicates which of the following about the fetus?
Evidence of some compromise that will require delivery soon.
Fetal well-being at this point in the pregnancy.
Evidence of late decelerations occurring during the test.
No accelerations demonstrated within a 20-minute period.
A client has been diagnosed with right-sided heart failure. Which of the following clinical manifestations would the nurse expect to find in the client?
Intermittent claudication.
Dyspnea.
Dependent edema.
Crackles.
To help prevent hip flexion deformities associated with rheumatoid arthritis, the nurse should help the client assume which of the following positions in bed several times a day?
Prone.
Very low Fowler's.
Modified Trendelenburg.
Side-lying.
Which of the following would be the nurse's priority assessment after an epidural anesthetic has been given to a nulligravid client in active labor?
Level of consciousness.
Blood pressure.
Cognitive function.
Contraction pattern.
Assessment of a nulligravid client in active labor reveals the following: complaints of moderate discomfort; cervix dilated 3 cm, 0 station and completely effaced; fetal heart rate of 136 bpm. Which of the following would the nurse plan to do next?
Assist the client with comfort measures and breathing techniques.
Turn the client from the left side-lying position to the right side-lying position.
Prepare the client for epidural anesthesia to relieve the pain
Instruct the client that internal fetal monitoring will be necessary.
The nurse monitors the serum electrolyte levels of a client who is taking digoxin (Lanoxin). Which of the following electrolyte imbalances is a common cause of digitalis toxicity?
Hyponatremia
Hypomagnesemia.
Hypocalcemia.
Hypokalemia.
After abdominal surgery, a client has an order for meperidine (Demerol) IM 100 mg every 3 to 4 hours and acetaminophen (Tylenol) with codeine 30 mg. The client has been taking meperidine every 4 hours for the past 48 hours, but she tells the nurse that the meperidine is no longer lasting 4 hours and she needs to have it every 3 hours. Which of the following nursing actions is most appropriate?
Realizing that the client is developing tolerance to the meperidine, the nurse administers the meperidine every 3 hours.
The nurse urges the client to take the acetaminophen with codeine to prevent addiction to the meperidine.
The nurse requests an order from the physician to change the dose to an equianalgesic dose of morphine.
The nurse encourages the client to do relaxation exercises to provide distraction from the pain.
The nurse assesses a 7-month-old infant's growth and development. Which behavior would the nurse consider unusual?
Drinking from a cup and spilling little of the liquid.
Raising the chest and upper abdomen off the bed with the hands.
Imitating sounds that the nurse makes.
Crying loudly in protest when the mother leaves the room.
A 13-year-old client is dying of cancer and struggling with the emotional aspects of this. When providing care for this client, the nurse would incorporate the developmental tasks for this age. According to Erickson's developmental model, the child normally would be expected to be working on which of the following psychosocial issues?
Lifetime vocation.
Social conscience.
Personal values.
Sense of competence.
The physician has prescribed amiodarone (Cordarone) for a client with cardiomyopathy. The nurse understands that the client's rhythm should be monitored to determine the effectiveness of the medication in controlling
sinus node dysfunction.
heart block.
severe bradycardia.
life-threatening ventricular dysrhythmias.
An 18-year-old female client who is sexually active with her boyfriend visits the clinic complaining of a purulent vaginal discharge that is sometimes "frothy." The nurse interprets this as suggesting which of the following?
STD.
Normal variations in vaginal discharge.
Use of nylon panties and pantyhose.
Wearing of tight-fitting garments, such as jeans.
An elderly client has been bedridden since a cerebral vascular accident that resulted in total right-sided paralysis. The client has become increasingly confused, is occasionally incontinent of urine, and is refusing to eat. In planning the client's care, which of the following factors will the nurse consider as most critical in contributing to skin breakdown in this client?
Nutritional status.
Urinary incontinence
Episodes of confusion.
Right-sided paralysis.
Assessment of a client who has just been admitted to the inpatient psychiatric unit reveals an unshaven face, noticeable body odor, visible spots on the shirt and pants, slow movements, gazing at the floor, and a flat affect. Which of the following would the nurse interpret as indicating psychomotor retardation?
Slow movements
Flat affect
Unkempt appearance.
Avoidance of eye contact.
A nurse working in the newborn nursery notices that an infant has a swelling in the scrotal area. The nurse interprets this swelling as indicative of hydrocele if which of the following occurs?
The swollen bulge can be reduced.
The increase in scrotal size is bilateral.
The scrotal sac can be transilluminated.
The bulge appears during crying.
When cleaning the skin around an incision and drain site, which of the following procedures should the nurse follow?
Clean the incision and drain site separately.
Clean from the incision to the drain site.
Clean from the drain site to the incision.
Clean the incision and drain site simultaneously.
An Hispanic mother, who does not speak English and is very upset, brings her child to the clinic with bleeding from the mouth. Which of the following would be the most appropriate action by the nurse who does not speak Spanish?
Call for the Spanish interpreter.
Grab the child and take the child to the treatment room
Immediately apply ice to the child's mouth.
Give the ice to the mother and demonstrate what to do.
The nurse is instructing a UAP on prevention of postoperative pulmonary complications. Which of the following statements indicates that the assistant has understood the nurse's instructions?
"I will turn the client every 4 hours."
"I will keep the client's head elevated."
"I should suction the client every 2 hours."
"I will have the client take 5 to 10 deep breaths every hour."
Which of the following outcomes would be most appropriate for a nursing diagnosis of Ineffective Tissue Perfusion related to interruption of arterial flow? Select all that apply.
Extremities warm to touch.
Improved respiratory status.
Decreased muscle pain with activity.
Participation in self-care measures.
The infusion rate of TPN is tapered before being discontinued. This is done to prevent which of the following complications?
Essential fatty acid deficiency.
Dehydration.
Rebound hypoglycemia.
Malnutrition.
While assessing the psychosocial aspects of a primigravid client at 30 weeks' gestation, the nurse can anticipate that the client will most likely have feelings of which of the following?
Vulnerability.
Confirmation.
Ambivalence.
Body image disturbance.
The nurse teaches a client scheduled for an intravenous pyelogram (IVP) what to expect when the dye is injected. The nurse would know that the client has correctly understood what was taught when he states that he may experience which of the following sensations when the dye is injected?
A metallic taste.
Flushing of the face.
Cold chills.
Chest pain.
To prevent development of peripheral neuropathies associated with isoniazid administration, the nurse should teach the client to
avoid excessive sun exposure.
follow a low-cholesterol diet.
obtain extra rest.
supplement the diet with pyridoxine (vitamin B6).
A usually reliable interpreter called by the nurse to help communicate with a mother of a child who does not speak English and has brought her child in for a routine visit has yet to arrive in the clinic. The nurse has paged the interpreter several times. Which of the following would the nurse do next?
Allow the pediatric nurse practitioner to examine the infant.
Reschedule the infant's appointment for later in the week.
Ask the mother to stay longer in the hope that the interpreter arrives.
Try to page the interpreter one more time.
Oxygen toxicity results from oxygen concentrations greater than
21%.
28%.
40%.
60%.
Before discharge from the hospital after a myocardial infarction, a client is taught to exercise by gradually increasing the distance walked. Which vital sign should the nurse teach the client to monitor to determine whether to increase or decrease the exercise level?
Pulse rate.
Blood pressure
Body temperature.
Respiratory rate.
During an appointment with the nurse, a client says, "I could hate God for that flood." The nurse responds, "Oh, don't feel that way. We're making progress in these sessions." The nurse's statement demonstrates a failure to do which of the following?
Look for meaning in what the client says.
Explain to the client why he may think as he does.
Add to the strength of the client's support system.
Give the client credit for solving his own problems
The nurse has just received the change of shift report on the following clients on the labor, delivery, recovery, and postpartum unit. Which of these clients would the nurse assess first?
An 18-year-old single primigravid client, in labor for 9 hours, with cervical dilation at 6 cm, 0 station, contractions occurring every 5 minutes, and receiving epidural anesthesia.
A 24-year-old primiparous client who delivered a 7-pound, 3-ounce boy vaginally 1 hour ago, has a firm fundus and scant lochia rubra, and is attempting to breast-feed.
A 26-year-old multigravid client, in labor for 8 hours, with cervical dilation at 8 cm, 1+ station, contractions every 3 to 4 minutes, and receiving no anesthesia.
A 30-year-old multipara who delivered a 6 pound 5 ounce girl by cesarean section owing to fetal distress 3 hours ago, has a firm fundus and scant lochia rubra, and is receiving patient-controlled morphine analgesia.
A client who is an insulin-dependent diabetic is scheduled to have surgery. The client has been NPO since midnight in preparation for the surgery. In the morning before sending the client to the operating room, the nurse notices that the client's daily insulin has not been ordered. Which of the following interventions would be most appropriate for the nurse at this time?
Obtain the client's blood glucose values and evaluate the client's need for insulin.
Contact the physician for further orders regarding insulin administration.
Give the client's usual morning dose of insulin.
Notify the recovery room staff to obtain an order for the insulin after surgery.
A client's chest tube is to be removed by the physician. Which of the following items should the nurse have ready to be placed directly over the wound when the chest tube is removed?
Butterfly dressing.
Montgomery strap.
Fine mesh gauze dressing.
Petrolatum gauze dressing.
While visiting a client with multiple sclerosis, the community health nurse observes that the client looks untidy and sad. The client suddenly says, "I can't even find the strength to comb my hair," and bursts into tears. Which of the following responses by the nurse would be best?
"It must be frustrating not to be able to care for yourself."
"How many days have you been unable to comb your hair?"
"Why hasn't your husband been helping you?"
"Tell me more about how you're feeling."
A client newly diagnosed with bulimia is attending a nurse-led group at the mental health center. She tells the group that she only came because her husband said he would divorce her if she didn't get help. Which of the following responses by the nurse would be most appropriate?
"You sound angry with your husband. Is that correct?"
"You will find that you like coming to group. These people are a lot of fun."
"Tell me more about why you are here and how you feel about that."
"Tell me something about what has caused you to be bulimic."
A client has tried without success to modify her lifestyle to lower her blood pressure. Which of the following will most likely be added to the program of continued lifestyle modification?
Starting an antihypertensive medication.
Beginning an exercise program.
Quitting smoking.
Losing weight.
A diabetic client has been diagnosed with hypertension and the physician has prescribed atenolol (Tenormin), a -blocker. When performing discharge teaching, it is important for the client to recognize that the addition of Tenormin can cause
a decrease in the hypoglycemic effects of insulin.
an increase in the hypoglycemic effects of insulin.
an increase in the incidence of ketoacidosis.
a decrease in the incidence of ketoacidosis.
The parent of a child who is taking an antibiotic for bilateral otitis media tells the nurse that he has stopped the medicine since his child is better, saving the rest of the medication to use the next time the child gets sick. Which of the following would be the nurse's best response?
"It is important to give the medicine as ordered."
"How do you know your child's ears are cured?"
"Your child needs all of the medicine so that the infection clears."
"Stopping the medicine is not what's best for your child!"
The nurse is preparing to administer digoxin (Lanoxin) 0.125 mg. Scored 0.25-mg tablets are available. How many tablets should the nurse administer?
0.5
1
5.0
1.5
A 19-year-old client just finding out that she is approximately 8 weeks pregnant says, "I can't believe I'm pregnant. I just started college full-time!" The nurse interprets the client's statement as indicating which of the following?
Ambivalence about the pregnancy.
Disappointment about the pregnancy.
Abortion is a likely option.
Bonding may be difficult after delivery.
A mother visits the clinic with her 11-year-old daughter for a routine physical examination. The mother tells the nurse that her daughter is beginning to have slight breast enlargement. When teaching the mother and daughter about pubertal changes, the nurse would explain that breast enlargement is caused by the rise in which of the following?
Prolactin.
Estrogen.
Progesterone.
Testosterone.
The nurse monitors a client who is receiving mechanical ventilation for which of the following complications?
Gastrointestinal hemorrhage.
Immunosuppression.
Increased cardiac output.
Pulmonary emboli.
A client is going home with a prescription for nitroglycerin for his anginal symptoms. Which of the following statements accurately conveys information the client must understand to safely self-medicate?
Store the nitroglycerin in the refrigerator.
Take one tablet every 15 minutes.
Sit down or lie down before taking the nitroglycerin.
Swallow the nitroglycerin tablet.
Which of the following nursing interventions would most likely be beneficial initially in helping the parents of an adolescent hospitalized for appendicitis deal with the hospitalization?
Reassure the parents that their adolescent will be fine.
Assess the parents' current knowledge level before providing information.
Encourage the parents to participate in the client's physical care.
Interact with the parents when they ask for information.
The nurse instructs a female client about contraceptive options. The nurse explains that the intrauterine device (IUD) is a good contraceptive option for women who
desire short-term use of a contraceptive.
are in a monogamous relationship.
have a history of STDs.
have had a history of ectopic pregnancies.
Before the parents of a 3-month-old child who died from sudden infant death syndrome (SIDS) leave the hospital, the nurse asks the parents what they understand about the cause of SIDS. The nurse evaluates their understanding as correct when the parents state,
"The cause is unknown."
"The cause is apnea."
"The cause is infection."
"The cause is cardiac dysrhythmias."
A client has been diagnosed with peripheral arterial occlusive disease. Which of the following instructions would be appropriate for the nurse to give the client for promoting circulation to the extremities?
Keep the extremities elevated slightly.
Participate in a regular walking program.
Use a heating pad to promote warmth.
Massage the calf muscles if pain occurs.
A primigravid client at 16 weeks' gestation visits the clinic for a routine examination. The client tells the nurse that she knows someone whose baby was born with congenital toxoplasmosis. Which of the following would the nurse instruct the client to do to prevent transmission of the toxoplasmosis protozoan?
Avoid contact with anyone diagnosed with this disease.
Consider a course of prophylactic penicillin as prevention.
Plan to be vaccinated for this condition at the next visit.
Cook all meats such as beef and pork thoroughly.
Which of the following medications would the nurse anticipate administering in the event of a heparin overdose?
Warfarin sodium.
Protamine sulfate.
Acetylsalicylic acid.
Atropine sulfate.
Chloral hydrate 1,000 mg has been ordered. It is available in a syrup containing 0.5 g/5 mL. How many milliliters should the nurse give?
1 ml
10 ml
0.1 ml
5 ml
The client is supposed to receive 500 mL of 5% dextrose on 0.45% normal saline (D5/0.45 NS) with 20 mEq of potassium chloride (KCl) over the next 6 hours. The infusion set administers 10 gtt/mL. To what flow rate should the nurse adjust the intravenous flow?
10 gtt/minute
12 gtt/minute
20 gtt/minute
14 gtt/minute
What is the primary purpose of administering aminophylline to a client with emphysema?
To relieve spasms of the diaphragm.
To relax smooth muscles in the bronchioles.
To promote efficient pulmonary circulation.
To stimulate the medullary respiratory center.
Diuretic therapy with torsemide (Demadex) is started for a client with heart failure. When calling the client 2 days after the drug therapy is started, the nurse evaluates the torsemide as effective when the client says she has experienced which of the following outcomes?
She has an improved appetite and is eating better.
She weighs 6 pounds less than she did 2 days ago.
She is less thirsty than she was before the drug therapy.
She has clearer urine since starting the torsemide.
Which of the following techniques is correct for the nurse to use when inserting a rectal suppository for an adult client?
Insert the suppository while the client bears down.
Place the client in a supine position.
Position the suppository along the rectal wall.
Insert the suppository 2 inches into the rectum.
A client receiving digoxin (Lanoxin) for congestive heart failure undergoes cardiac catheterization to evaluate his condition further. The procedure reveals a cardiac output of 2.2 L/minute. How would the nurse evaluate this cardiac output?
High, because of the effects of digoxin.
Within normal limits, because of the effects of digoxin.
Within normal limits, but not adequate to support strenuous activity.
Low, requiring further medical intervention.
Clients who are receiving total parenteral nutrition (TPN) are at risk for development of which of the following complications?
Hypostatic pneumonia.
Pulmonary hypertension.
Postural hypotension.
Fluid imbalances.
The client is receiving propantheline bromide (Pro-Banthine) to treat cholecystitis. The nurse would evaluate the client's response to the medication by observing for which of the following side effects?
Urinary retention.
Diarrhea.
Hypertension.
Diaphoresis.
The nurse is preparing to start an intravenous infusion. Before inserting the needle into a vein, the nurse would apply a tourniquet to the client's arm to accomplish which of the following?