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A 4-year old child is brought by her grandmother in the emergency room due to fever, chills, and difficulty walking. The nurse tries to remove the excessive clothing of the child but is reluctant. After a thorough assessment, the nurse also noted bruises around the genital area. Which of the following interventions should the nurse do first?
A client receiving hydrochlorothiazide is instructed to increase her dietary intake of potassium. The best snack for the client requiring increased potassium is:
The nurse is caring for a client following the removal of the thyroid. Immediately post-op, the nurse should:
A client hospitalized with chronic dyspepsia is diagnosed with gastric cancer. Which of the following is associated with an increased incidence of gastric cancer?
A client is sent to the psychiatric unit for forensic evaluation after he is accused of arson. His tentative diagnosis is antisocial personality disorder. In reviewing the client’s record, the nurse would expect to find:
The licensed vocational nurse may not assume the primary care for a client:
The physician has ordered dressings with Sulfamylon cream for a client with full-thickness burns of the hands and arms. Before dressing changes, the nurse should give priority to:
The nurse is teaching a group of parents about gross motor development of the toddler. Which behavior is an example of the normal gross motor skill of a toddler?
A client hospitalized with a fractured mandible is to be discharged. Which piece of equipment should be kept on the client with a fractured mandible?
The nurse is to administer digoxin elixir to a 6-month-old with a congenital heart defect. The nurse auscultates an apical pulse rate of 100 beats per minute. The nurse should:
A mother of a 3-year-old hospitalized with lead poisoning asks the nurse to explain the treatment for her daughter. The nurse’s explanation is based on the knowledge that lead poisoning is treated with:
An 18-month-old is scheduled for a cleft palate repair. The usual type of restraints for the child with a cleft palate repair are:
A client with glaucoma has been prescribed Timoptic (timolol) eye drops. Timolol should be used with caution in the client with a history of:
An elderly client who experiences nighttime confusion wanders from his room into the room of another client. The nurse can best help decrease the client’s confusion by:
Which of the following is a common complaint of the client with end-stage renal failure?
Which of the following medication orders needs further clarification?
Angela has been experiencing tinnitus, vertigo and ear stuffiness caused by Meniere’s disease. The following food items she is discouraged to eat, except:
Which of the following findings is associated with right-sided heart failure?
An 8-year-old admitted with an upper-respiratory infection has an order for O2 saturation via pulse oximeter. To ensure an accurate reading, the nurse should:
An infant with Tetralogy of Fallot is discharged with a prescription of lanoxin elixir 0.5 mL once a day PO. The nurse should instruct the mother to:
The client scheduled for electroconvulsive therapy tells the nurse, “I’m so afraid. What will happen to me during the treatment?” Which of the following statements is most therapeutic for the nurse to make?
Which of the following skin lesions is associated with Lyme’s disease?
Which of the following snacks would be suitable for the child with gluten-induced enteropathy?
A client with schizophrenia is receiving Thorazine (chlorpromazine) 400mg twice a day. An adverse side effect of the medication is:
Which information should be given to the client taking Dilantin (phenytoin)?
A client with a history of emboli is receiving Lovenox (enoxaparin). Which drug is given to counteract the effects of enoxaparin?
The nurse is formulating a plan of care for a client with a cognitive disorder. Which activity is most appropriate for the client with confusion and a short attention span?
The mother of a child with hemophilia asks the nurse which over-the-counter medication is suitable for her child’s joint discomfort. The nurse should tell the mother to purchase:
Which home remedy is suitable to relieve the itching associated with varicella?
A newborn male has been diagnosed with hypospadias with chordee. The nurse understands that the infant will have altered patterns of urination because:
Jeremiah, a clinical instructor, is discussing the list of controlled substances schedules. The following are considered to be under Schedule I controlled substances, except:
Which statement best describes the difference between the pain of angina and the pain of myocardial infarction?
The nurse is developing a bowel-retraining plan for a client with multiple sclerosis. Which measure is likely to be least helpful to the client:
The nurse is providing dietary teaching for a client with Meniere’s disease. Which statement indicates that the client understands the role of diet in triggering her symptoms?
The nurse is assessing a multigravida, 36 weeks gestation for symptoms of pregnancy-induced hypertension and preeclampsia. The nurse should give priority to assessing the client for:
An adolescent with borderline personality is hospitalized with suicidal ideation and self-mutilation. Which goal is both therapeutic and realistic for this client?
A client with angina has an order for nitroglycerin ointment. Before applying the medication, the nurse should:
The nurse is caring for a client who is unconscious following a fall. Which comment by the nurse will help the client become reoriented when he regains consciousness?
Following a generalized seizure, the nurse can expect the client to:
A client with oxalate renal calculi should be taught to avoid eating:
A 6-year-old is diagnosed with Legg-Calve Perthes disease. An important part of the child’s care includes instructing the parents:
The nurse is assessing an infant with Hirschsprung’s disease. The nurse can expect the infant to:
The physician has prescribed supplemental iron for a prenatal client. The nurse should tell the client to take the medication with:
The nurse is teaching a client with a history of obesity and hypertension regarding dietary requirements during pregnancy. Which statement indicates that the client needs further teaching?
An elderly client with dementia is admitted to the psychiatric unit from the nursing home. Transfer information indicates that the client has become confused and disoriented, with behavioral problems. The client will also likely show a loss of ability in:
The physician has ordered an external monitor for a laboring client. If the fetus is in the left occipital posterior (LOP) position, the nurse knows that the ultrasound transducer will be located:
A client develops tremors while withdrawing from alcohol. Which medication is routinely administered to lessen physiological effects of alcohol withdrawal?
A client with Type II diabetes has an order for regular insulin 10 units SC each morning. The client’s breakfast should be served within:
A nurse is caring for a 5th month old boy who suffered physical injuries from fall. Which of the following is the most appropriate pain assessment that the nurse will use?
Which antibiotic is contraindicated for the treatment of infections in infants and young children?
The nurse is caring for a client with systemic lupus erythematosus (SLE). The major complication associated with systemic lupus erythematosus is:
Which diet is associated with an increased risk of colorectal cancer?
The nurse is caring for an infant following a cleft lip repair. While comforting the infant, the nurse should avoid:
The physician has ordered Amoxil (amoxicillin) 500 mg capsules for a client with esophageal varices. The nurse can best care for the client’s needs by:
The nurse is providing dietary instructions for a client with hemochromatosis. Which food items should the client consume, except?
The nurse is teaching a client with Parkinson’s disease ways to prevent curvatures of the spine associated with the disease. The nurse should tell the client to:
The nurse is planning dietary changes for a client following an episode of pancreatitis. Which diet is suitable for the client?
A client with hypothyroidism frequently complains of feeling cold. The nurse should tell the client that she will be more comfortable if she:
A client has been hospitalized with a diagnosis of laryngeal cancer. Which factor is most significant in the development of laryngeal cancer?
The nurse is completing an assessment history of a client with pernicious anemia. Which complaint differentiates pernicious anemia from other types of anemia?
The chart of a client with schizophrenia states that the client has perseveration. The nurse can expect the client to:
Which early morning activity helps to reduce the symptoms associated with rheumatoid arthritis?
A newborn weighed 7 pounds at birth. At 6 months of age, the infant could be expected to weigh:
A client with nontropical sprue has an exacerbation of symptoms. Which meal selection is responsible for the recurrence of the client’s symptoms?
A client with congestive heart failure has been receiving Digoxin (lanoxin). Which finding indicates that the medication is having a desired effect?
Which play activity is best suited to the gross motor skills of the toddler?
The physician has ordered Basaljel (aluminum carbonate gel) for a client with recurrent indigestion. The nurse should teach the client common side effects of the medication, which include:
A client is admitted with suspected abdominal aortic aneurysm (AAA). A common complaint of the client with an abdominal aortic aneurysm is:
A client is admitted with acute adrenal crisis. During the intake assessment, the nurse can expect to find that the client has:
An elderly client is hospitalized for transurethral resection of the prostate (TURP). Which finding postoperatively should be reported to the doctor immediately?
A 9-year-old is admitted with suspected rheumatic fever. Which finding is suggestive of polymigratory arthritis?
A child with a croup is placed in a cool, high-humidity tent connected to room air. The primary purpose of the tent is to:
A client is admitted with a diagnosis of hypothyroidism. An initial assessment of the client would reveal:
Robert is diagnosed with varicella. He went to a clinic with a mild fever, loss of appetite, and rashes on the chest area. When he asked about the disease. Which statement describes the contagious stage of varicella?
A client admitted to the psychiatric unit claims to be the Son of God and insists that he will not be kept away from his followers. The most likely explanation for the client’s delusion is:
A client has returned to his room following an esophagoscopy. Before offering fluids, the nurse should give priority to assessing the client’s:
Which instruction should be included in the discharge teaching for the client with cataract surgery?
An 8-year-old is admitted with a sore throat, drooling, muffled phonation, high pitched-sound upon breathing (stridor), and a temperature of 102°F. The nurse should immediately notify the doctor because the child’s symptoms are suggestive of:
Phototherapy is ordered for a newborn with physiologic jaundice. The nurse caring for the infant should:
A teen hospitalized with anorexia nervosa is now permitted to leave her room and eat in the dining room. Which of the following nursing interventions should be included in the client’s plan of care?
According to Erikson’s stage of growth and development, the developmental task of an 8-year old child is:
The nurse should observe for side effects associated with the use of bronchodilators. A common side effect of bronchodilators is:
The 5-minute Apgar of a baby delivered by C-section is recorded as 9. The most likely reason for this score is:
A 5-month-old infant is admitted to the ER with a temperature of 106°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
A client with a bowel resection and anastomosis returns to his room with an NG tube attached to intermittent suction. Which of the following observations indicates that the nasogastric suction is working properly?
The nurse is teaching the client with insulin-dependent diabetes the signs of hypoglycemia. Which of the following signs is associated with hypoglycemia?
Which of the following symptoms is associated with relapse of multiple sclerosis?
Which of the following conditions is most likely related to the development of renal calculi?
A client with AIDS is admitted for the treatment of wasting syndrome. Which of the following dietary modifications can be used to compensate for the limited absorptive capability of the intestinal tract?
The treatment protocol for a client with acute lymphatic leukemia includes prednisone, methotrexate, and cimetidine. The purpose of the cimetidine is to:
Which of the following meal choices is suitable for a 6-month-old infant?
The LPN is preparing to administer an injection of vitamin K to the newborn. The nurse should administer the injection in the:
The physician has prescribed Cytoxan (cyclophosphamide) for a client with nephrotic syndrome. The nurse should:
The nurse is caring for a client with detoxification from alcohol. Which medication is used in the treatment of alcohol withdrawal?
A client with insulin-dependent diabetes takes 20 units of NPH insulin at 7 a.m. The nurse should observe the client for signs of hypoglycemia at:
The licensed practical nurse is assisting the charge nurse in planning care for a client with a detached retina. Which of the following nursing diagnoses should receive priority?
The primary purpose for using a continuous passive motion (CPM) machine for the client with a total knee repair is to help:
Which of the following statements reflects Kohlberg’s theory of the moral development of the preschool-age child?
A toddler with otitis media has just completed antibiotic therapy. A recheck appointment should be made to:
A factory worker is brought to the nurse’s office after a metal fragment enters his right eye. The nurse should:
The physician has ordered a low-potassium diet for a child with acute glomerulonephritis. Which fruit is suitable for the child with potassium restrictions?
The physician has ordered a blood test for H. pylori. The nurse should prepare the client by:
The nurse is preparing to give a liquid oral potassium supplement. The nurse should:
The physician has ordered cultures for cytomegalovirus (CMV). Which statement is true regarding the collection of cultures for cytomegalovirus?
A pediatric client with burns to the hands and arms has dressing changes with Sulfamylon (mafenide acetate) cream. The nurse is aware that the medication:
The physician has ordered Dilantin (phenytoin) for a client with generalized seizures. When planning the client’s care, the nurse should:
A client receiving chemotherapy for breast cancer has an order for Zofran (ondansetron) 8 mg PO to be given 30 minutes before induction of the chemotherapy. The purpose of the medication is to:
The physician has ordered chloramphenicol ear drops for a 2-year-old with otitis media. To administer the ear drops, the nurse should:
A client with schizophrenia has been taking chlorpromazine (Thorazine) 200 mg four times a day. Which finding should be reported to the doctor immediately?
A client with iron-deficiency anemia is taking an oral iron supplement. The nurse should tell the client to take the medication with:
A client is admitted with burns of the right arm, front chest, and head. According to the Rule of Nines, the percent of burn injury is:
A client who was admitted with chest pain and shortness of breath has a standing order for oxygen via mask. Standing orders for oxygen mean that the nurse can apply oxygen at:
The nurse is caring for a client with an ileostomy. The nurse should pay careful attention to care around the stoma because:
The physician has ordered aspirin therapy for a client with severe rheumatoid arthritis. A sign of acute aspirin toxicity is:
A client is admitted to the emergency room with symptoms of delirium tremens. After admitting the client to a private room, a priority nursing intervention is to:
The nurse is providing dietary teaching for a client with gout. Which dietary selection is suitable for the client with gout?
A newborn has been diagnosed with exstrophy of the bladder. The nurse should position the newborn:
The mother of a 3-month-old with esophageal reflux asks the nurse what she can do to lessen the baby’s reflux. The nurse should tell the mother to:
A child is hospitalized with a fractured femur involving the epiphysis. Epiphyseal fractures are serious because:
Before administering a nasogastric feeding to a client hospitalized following a CVA, the nurse aspirates 40mL of residual. The nurse should:
A mother brought her 5 year old child to a clinic. The nurse notes that the child’s appearance looks older than she is. After a genetic test, the doctor diagnosed the child with Hutchinson-Gilford syndrome. What is the average life expectancy of the child with this kind of disorder?
The LPN is reviewing the lab results of an elderly client when she notes a urine specific gravity of 1.006. The nurse recognizes that:
A client with pancreatitis has requested pain medication. Which pain medication is indicated for the client with pancreatitis?
A client with a hiatal hernia has been taking magnesium hydroxide for relief of heartburn. Overuse of magnesium-based antacids can cause the client to have:
When performing a newborn assessment, the nurse measures the circumference of the neonate’s head and chest. Which assessment finding is expected in the normal newborn?
The nurse is caring for an 8-year-old following a routine tonsillectomy. Which finding should be reported immediately?
The nurse is admitting a client with a suspected duodenal ulcer. The client will most likely report that his abdominal discomfort lessens when he:
Which of the following meal selections is appropriate for the client with celiac disease?
A client with hyperthyroidism is taking lithium carbonate to inhibit thyroid hormone release. Which complaint by the client should alert the nurse to a problem with the client’s medication?
A 2-month-old infant has just received her first Tetramune injection. The nurse should tell the mother that the immunization:
The nurse is caring for a client hospitalized with bipolar disorder, manic phase. Which of the following meals would be best for the client with mania?
A 3-year-old is admitted due to suspected intussusception. Which finding is associated with intussusception?
A client is being treated for cancer with linear acceleration radiation. The physician has marked the radiation site with a blue marking pen. The nurse should:
The nurse is caring for a client with acromegaly. Following a transsphenoidal hypophysectomy, the nurse should:
A client newly diagnosed with diabetes is started on Precose (acarbose). The nurse should tell the client that the medication should be taken:
A client with a deep decubitus ulcer is receiving therapy in the hyperbaric oxygen chamber. Before therapy, the nurse should:
A client with a laryngectomy returns from surgery with a nasogastric tube in place. The primary reason for the placement of the nasogastric tube is to:
The chart indicates that a client has expressive aphasia following a stroke. The nurse understands that the client will have difficulty with:
A camp nurse is applying sunscreen to a group of children enrolled in swim classes. Chemical sunscreens are most effective when applied:
A postoperative client has an order for Demerol (meperidine) 75mg and promethazine (Phenergan) 25mg IM every 3–4 hours as needed for pain. The combination of the two medications produces a/an:
Before administering a client’s morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 52. The appropriate nursing intervention is to:
What information should the nurse give a new mother regarding the introduction of solid foods for her infant?
A client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should anticipate the physician to:
A client with human immunodeficiency syndrome has gastrointestinal symptoms, including diarrhea. The nurse should teach the client to avoid:
A 5-year-old is admitted with acute leukemia. It will be most important to monitor the child for:
A 4-month-old is diagnosed with atopic dermatitis. Nursing interventions will focus on:
The nurse is caring for a client with a history of diverticulitis. The client complains of abdominal pain, fever, and diarrhea. Which food was responsible for the client’s symptoms?
The physician has scheduled a Whipple procedure for a client with pancreatic cancer. The nurse recognizes that the client’s cancer is located in:
A child with cystic fibrosis is being treated with inhalation therapy with Pulmozyme (dornase alfa). A side effect of the medication is:
The doctor has ordered Percocet (oxycodone) for a client following abdominal surgery. The primary objective of nursing care for the client receiving an opiate analgesic is to:
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