Comprehensive Retake 2020 NR 504

23 August 2024

Comprehensive Retake 2020 NR 504

  1. Question: A nurse is assessing a client who has received an antibiotic. The nurse should identify which of the following findings as an indication of a possible allergic reaction to the medication?
    • Answer: Hypotension (Correct Answer)
  2. Question: A nurse on a mental health unit is caring for a client who has schizophrenia and is experiencing auditory hallucinations telling them to hurt others. The client is refusing to take antipsychotic medication. Which of the following responses should the nurse make?
    • Answer: “This medication will help you stop the voices you are hearing.” (Correct Answer)
  3. Question: A nurse is providing care for a patient who has depression and is to have electroconvulsive therapy. Which of the following conditions should the nurse identify as increasing the client’s risk for complications?
    • Answer: Cardiac dysrhythmias (Correct Answer)
  4. Question: A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis. Which of the following findings should the nurse report to the provider?
    • Answer: Erythrocyte sedimentation rate 75 mm/hr (Correct Answer)
  5. Question: A nurse is suctioning the airway of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following findings should the nurse identify as an indication that suctioning has been effective?
    • Answer: Decreased peak inspiratory pressure (Correct Answer)
  6. Question: A nurse is caring for a client who is in a seclusion room following violent behavior. The client continues to display aggressive behavior. Which of the following actions should the nurse take?
    • Answer: Speak assertively to the client. (Correct Answer)
  7. Question: A nurse is caring for a client who is immediately postoperative following an adrenalectomy to treat Cushing’s disease. Which of the following actions is the nurse’s priority?
    • Answer: Monitor the client’s fluid and electrolyte status. (Correct Answer)
  8. Question: A nurse is caring for a client who is scheduled for a surgical procedure and states, “I don’t want to have this surgery anymore.” Which of the following responses should the nurse make?
    • Answer: “You have the right to refuse the procedure.” (Correct Answer)
  9. Question: A nurse is evaluating a client who has borderline personality disorder. Which of the following behaviors indicates an improvement in the client’s condition?
    • Answer: Decreased clinging behavior (Correct Answer)
  10. Question: A nurse is teaching a group of school-age children about healthy snack options. Which of the following snacks should the nurse include?
    • Answer: Air-popped popcorn (Correct Answer)
  11. Question: A nurse is providing teaching to a client who has a new prescription for enoxaparin. Which of the following medications for pain relief should the nurse include in the teaching that can be taken concurrently with enoxaparin?
    • Answer: Acetaminophen (Correct Answer)
  12. Question: A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse plan to administer?
    • Answer: Pregabalin (Correct Answer)
  13. Question: A nurse is caring for a client who has congestive heart failure and is receiving furosemide and digoxin. Which of the following laboratory values indicates that the client is at risk for developing digoxin toxicity?
    • Answer: Potassium 3.1 mEq/L (Correct Answer)
  14. Question: A nurse is caring for a client who had an embolic stroke and has a prescription for alteplase. Which of the following in the client’s history should the nurse identify as a contraindication for receiving alteplase?
    • Answer: Hip arthroplasty 1 week ago (Correct Answer)
  15. Question: A nurse is providing discharge teaching for a client who has a new implantable cardioverter defibrillator (ICD). Which of the following client statements demonstrates understanding of the teaching?
    • Answer: “I will wear loose clothing over my ICD.” (Correct Answer)
  16. Question: A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25ml/hr. Which of the following interventions should the nurse anticipate?
    • Answer: Administer a fluid bolus (Correct Answer)
  17. Question: A nurse is caring for a client who has experienced a stillbirth. Which of the following actions should the nurse take during the initial grieving process?
    • Answer: Offer to take pictures of the newborn for the client (Correct Answer)
  18. Question: A nurse is caring for a client who has a major burn injury. Which of the following actions is the nurse’s priority to prevent wound infection?
    • Answer: Maintain consistent hand washing by staff. (Correct Answer)
  19. Question: A nurse is speaking with the caregiver of a client who has Alzheimer’s disease. The caregiver states, “Providing constant care is very stressful and is affecting all areas of my life.” Which of the following actions should the nurse take?
    • Answer: Assist the caregiver to arrange a daycare program for the client. (Correct Answer)
  20. Question: A nurse is caring for a client who is 1 hr postpartum and unable to urinate. Which of the following actions should the nurse take?
    • Answer: Place an ice pack on the client’s perineum. (Correct Answer
  21. Question: A nurse on a medical-surgical unit is performing medication reconciliation for a newly admitted client. Which of the following actions should the nurse take?
    • Answer: Compare the client’s list of home medications to the admission prescriptions written for the client. (Correct Answer)
  22. Question: A nurse is preparing to administer betamethasone to a client who is 25 weeks of gestation and has preterm labor. Which of the following findings should the nurse identify as an adverse effect of this medication?
    • Answer: Hyperglycemia (Correct Answer)
  23. Question: A nurse is preparing to obtain a blood sample from a client who has a central venous catheter. Which of the following actions should the nurse take? (Select all that apply)
    • Answer:
      • Aspirate for blood return to assess catheter patency. (Correct Answer)
      • Flush the catheter with 0.9% sodium chloride. (Correct Answer)
  24. Question: A nurse is preparing to perform a dressing change on a preschooler. Which of the following actions should the nurse take to prepare the child for the procedure?
    • Answer: Explain in simple terms how the procedure will affect the child. (Correct Answer)
  25. Question: A nurse is performing wound care for a client who has an abdominal incision. Which of the following techniques should the nurse implement?
    • Answer: Irrigate the wound with a low-pressure flow of solution. (Correct Answer)
  26. Question: A nurse on an antepartum unit is prioritizing care for multiple clients. Which of the following clients should the nurse see first?
    • Answer: A client who has preeclampsia and reports a persistent headache. (Correct Answer)
  27. Question: A nurse is caring for a client who is recovering from an amputation of her right arm above the elbow. Which of the following information should the nurse report to the occupational therapist?
    • Answer: The client has two small children at home. (Correct Answer)
  28. Question: A nurse is caring for a client who has major depressive disorder. The client tells the nurse, “No one cares about me. I’m completely alone.” Which of the following responses should the nurse make?
    • Answer: “Can you give me an example of how others are making you feel this way?” (Correct Answer)
  29. Question: A nurse is caring for a client who has sustained a severe head trauma and has significant bleeding from the nose. Which of the following actions should the nurse take first?
    • Answer: Establish a patent airway. (Correct Answer)
  30. Question: A nurse is reviewing the rhythm strip of a client who is experiencing sinus arrhythmia. Which of the following findings should the nurse expect?
    • Answer: P to QRS ratio 1:1 (Correct Answer)
  31. Question: A nurse is admitting a client who has dementia to a long-term care facility. The client tells the nurse that she lived in this facility years ago and took care of all the residents by herself. The nurse should document this as which of the following findings?
    • Answer: Confabulation (Correct Answer)
  32. Question: A nurse is reviewing home recommendations with a client who is postoperative following knee surgery. Which of the following recommendations should the nurse make?
    • Answer: Ensure that all area rugs are rubber-backed. (Correct Answer)
  33. Question: A nurse is caring for a client who is postoperative following total hip arthroplasty. Which of the following actions should the nurse take to prevent dislocation of the prosthesis?
    • Answer: Keep an abduction pillow between the client’s legs. (Correct Answer)
  34. Question: A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella zoster virus. Which of the following information should the nurse include?
    • Answer: Children who have varicella are contagious until the vesicles are crusted. (Correct Answer)
  35. Question: A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?
    • Answer: Sit with the client to provide a sense of security. (Correct Answer)
  36. Question: A nurse is teaching a newly licensed nurse about ergonomic principles. Which of the following actions by the newly licensed nurse indicates an understanding of the teaching?
    • Answer: Uses a mechanical lift device to move a client from the bed to the chair. (Correct Answer)
  37. Question: A nurse is teaching a client about condom use. Which of the following client statements should the nurse identify as an understanding of the teaching?
    • Answer: “I can store the condoms in the drawer of my night-stand.” (Correct Answer)
  38. Question: A nurse is planning care for a client who has a chest tube. Which of the following interventions should the nurse include in the plan? (Select all that apply)
    • Answer:
      • Mark the drainage output on the collection chamber hourly. (Correct Answer)
      • Add water to the water seal chamber as it evaporates. (Correct Answer)
  39. Question: The nurse is reviewing a medical record of a client who has a prescription for intermittent heat therapy for a foot injury. Which of the following findings should the nurse identify as a contraindication to heat therapy?
    • Answer: Peripheral neuropathy (Correct Answer)
  40. Question: A charge nurse is recommending postpartum clients for discharge following a local disaster. Which of the following client’s should the nurse recommend for discharge first?
    • Answer: A client who delivered precipitously and has a second-degree perineal laceration (Correct Answer)
  41. Question: A nurse is providing teaching about crutch safety to a client. Which of the following client actions indicates an understanding of the teaching?
    • Answer: The client keeps her axillae free of pressure. (Correct Answer)
  42. Question: A nurse is preparing the body of a client who has died for the family to view. Which of the following actions should the nurse take?
    • Answer: Place a pillow under the client’s head. (Correct Answer)
  43. Question: A nurse is reviewing annual education requirements for fire safety. Identify the sequence that the nurse should use when operating a fire extinguisher.
    • Answer:
      1. Unlock the handle by pulling on the pin.
      2. Point the hose at the base of the fire.
      3. Squeeze the handles together.
      4. Sweep the extinguisher from side to side. (Correct Sequence)
  44. Question: A nurse is reviewing legal issues in health care with a group of newly licensed nurses. Which of the following recommendations should the nurse make?
    • Answer: Obtain personal professional liability insurance coverage. (Correct Answer)
  45. Question: A nurse is caring for a client who speaks a language different than the nurse. Which of the following actions should the nurse make?
    • Answer: Review the facility policy about the use of an interpreter. (Correct Answer)
  46. Question: A nurse in the emergency department is caring for a client following a motor-vehicle crash. Which of the following findings should the nurse identify as a manifestation of hypovolemic shock?
    • Answer: Change in level of consciousness (Correct Answer)
  47. Question: A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first?
    • Answer: Palpate the pulse distal to the cast. (Correct Answer)
  48. Question: A nurse is performing a gait assessment on a client to evaluate the client’s ability to perform ADLs. Which of the following findings indicates a standard gait?
    • Answer: The client’s heels touch the ground before their toes. (Correct Answer)
  49. Question: A nurse on a mental health unit is caring for a client who has suicidal ideation. Which of the following actions should the nurse take?
    • Answer: Establish a no-suicide contract with the client. (Correct Answer)
  50. Question: A nurse is providing teaching about nutrition therapy to a client who is experiencing anorexia due to chemotherapy treatment. Which of the following statements should the nurse make?
    • Answer: “Add grated cheese to vegetable dishes.” (Correct Answer)
  51. Question: A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus about administering NPH and regular insulin together in one injection. Which of the following instructions should the nurse include?
    • Answer: Draw up the regular insulin prior to NPH. (Correct Answer)
  52. Question: A nurse is caring for a client who has a calcium level of 8 mg/dL. Which of the following actions should the nurse take?
    • Answer: Place the client on seizure precautions. (Correct Answer)
  53. Question: A nurse is caring for a client who has schizophrenia and is experiencing delusions. Which of the following actions should the nurse take?
    • Answer: Direct long conversations about the delusions toward reality-based topics. (Correct Answer)
  54. Question: A nurse is conducting a health promotion class about the use of oral contraceptives. Which of the following disorders is a contraindication for oral contraceptive use?
    • Answer: Hypertension (Correct Answer)
  55. Question: A nurse in the emergency department is triaging victims of a house fire. Which of the following clients should the nurse prioritize as emergent?
    • Answer: Client who has hypertension and reports chest pain (Correct Answer)
  56. Question: A nurse is planning care for a group of clients. Which of the following methods should the nurse use to manage time effectively?
    • Answer: Gather supplies prior to completing a dressing change. (Correct Answer)
  57. Question: A nurse on a mental health unit is planning room assignments for four clients. Which of the following clients should the nurse assign to a room near the nurse’s station?
    • Answer: A client who has bipolar disorder and impaired social interactions. (Correct Answer)
  58. Question: A nurse is assessing coping strategies of a client whose partner has alcohol use disorder. Which of the following findings indicates that the client is coping effectively?
    • Answer: The client attends regular counseling sessions. (Correct Answer)
  59. Question: A nurse is caring for a client who has Graves’ disease and is experiencing a thyroid storm. Which of the following actions is the nurse’s priority?
    • Answer: Monitor the client’s cardiac rhythm. (Correct Answer)
  60. Question: A nurse is providing preoperative teaching to a client about promoting circulation during the postoperative period. Which of the following instructions should the nurse include?
    • Answer: “Participate in range-of-motion exercises.” (Correct Answer)
  61. Question: A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?
    • Answer: Hold the bottle in the center of the sterile field when pouring the solution. (Correct Answer)
  62. Question: A nurse is conducting a home visit for a family who has two young children. The nurse notes several welts across the back of the legs of one of the children. Which of the following actions should the nurse take first?
    • Answer: Contact child protective services. (Correct Answer)
  63. Question: A nurse is teaching a client who is to undergo placement of a non-tunneled percutaneous central venous access device. Which of the following statements should the nurse include in the teaching?
    • Answer: “The provider will wear a mask while performing the procedure.” (Correct Answer)
  64. Question: A nurse in a clinic is reviewing the health history of a client during her first prenatal visit. Which of the following findings indicates a risk for gestational diabetes mellitus?
    • Answer: BMI of 31 (Correct Answer)
  65. Question: A nurse is caring for a client who is incontinent and has a stage II pressure injury on their coccyx. Which of the following interventions should the nurse implement?
    • Answer: Position the client laterally at 30 degrees. (Correct Answer)
  66. Question: A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as the clinic staff. Which of the following instructions should the nurse include?
    • Answer: Direct questions to a medical interpreter. (Correct Answer)
  67. Question: A nurse is caring for an infant who is in contact isolation and received a blood transfusion. Which of the following actions is appropriate for the nurse to provide cost-effective care?
    • Answer: Return unopened equipment to the supply center. (Correct Answer)
  68. Question: A nurse is caring for a client who has acute exacerbation of multiple sclerosis. Which of the following prescriptions should the nurse expect the provider to prescribe?
    • Answer: Interferon beta-1a (Correct Answer)
  69. Question: A nurse is speaking with the partner of a client who is in the early stage of Alzheimer’s disease. The partner tells the nurse that she is able to manage the client’s physical care, but she doesn’t want to leave him home alone while she travels for work. Which of the following referrals should the nurse make?
    • Answer: Respite care (Correct Answer)
  70. Question: A nurse is assessing a school-age child who has moderate dehydration due to diarrhea and vomiting. Which of the following manifestations should the nurse expect?
    • Answer: Orthostatic hypotension (Correct Answer)
  71. Question: A nurse is caring for a client who is at 14 weeks of gestation and reports feelings of ambivalence about being pregnant. Which of the following responses should the nurse make?
    • Answer: “Describe your feelings to me about being pregnant.” (Correct Answer)
  72. Question: A nurse manager is planning to promote client advocacy among staff on a medical unit. Which of the following actions should the nurse plan to take?
    • Answer: Develop a system for staff members to report safety concerns in the client care environment. (Correct Answer)
  73. Question: A nurse received a telephone call from a parent reporting that their school-age child has a nosebleed and that they cannot stop the bleeding. Which of the following instructions should the nurse provide for the parent?
    • Answer: “Use your thumb and forefinger to apply pressure to the sides of your child’s nose.” (Correct Answer)
  74. Question: A nurse is assessing a client who has a stage IV pressure ulcer and is undergoing treatment prescribed by a wound care consultant. For which of the following findings should the nurse contact the consultant to revise the plan of care?
    • Answer: Weight loss of 5% in 10 days. (Correct Answer)
  75. Question: A nurse is performing an abdominal assessment as part of a client’s comprehensive physical examination. Which of the following is the final step the nurse should perform?
    • Answer: Percussion (Correct Answer)
  76. Question: A nurse is caring for a client who has an NG tube in place for gastric decompression and notes that the tube is not draining. Which of the following steps should the nurse take first?
    • Answer: Check the functioning of the suction equipment. (Correct Answer)
  77. Question: A nurse is caring for a client who has major depressive disorder. Which of the following findings should indicate to the nurse that the client’s condition is improving?
    • Answer: The client participates in self-care. (Correct Answer)
  78. Question: A nurse is supervising an assistive personnel (AP) who is feeding a client. The nurse observes that the client coughs after each bite. After asking the AP to stop feeding the client, which of the following actions should the nurse take next?
    • Answer: Ask a speech therapist to evaluate the client’s ability to swallow. (Correct Answer)
  79. Question: A nurse in an acute mental health facility is prioritizing care for multiple clients. Which of the following clients should the nurse see first?
    • Answer: A client who is taking clozapine to treat schizophrenia and reports a sore throat. (Correct Answer)
  80. Question: A charge nurse is educating a group of unit nurses about delegating client tasks to assistive personnel (AP). Which of the following statements should the nurse include in the teaching?
    • Answer: “The RN is legally responsible for the actions of the AP.” (Correct Answer)
  81. Question: A nurse in an emergency department is caring for a client who reports cocaine use 1 hr ago. Which of the following findings should the nurse expect?
    • Answer: Elevated temperature (Correct Answer)
  82. Question: A nurse administered 400mg of ibuprofen to a client 2 hr ago to treat pain following a biopsy. The client is crying and states, “It really still hurts a lot.” Which of the following actions should the nurse take?
    • Answer: Ask the client to rate their pain on a scale of 0 to 10. (Correct Answer)
  83. Question: A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (Select all that apply)
    • Answer:
      • Establish eye contact when communicating with the client. (Correct Answer)
      • Reinforce orientation to time, place, and person. (Correct Answer)
      • Give the client one simple direction at a time. (Correct Answer)
  84. Question: A nurse is providing nutritional teaching to a client who is experiencing severe nausea. Which of the following responses by the client indicates an understanding of the teaching?
    • Answer: “I should sip on clear carbonated beverages that have gone flat.” (Correct Answer)
  85. Question: A nurse is providing teaching about disulfiram to a client who has alcohol use disorder. Which of the following statements should the nurse make?
    • Answer: “Wait at least 12 hr after your last drink to take this medication.” (Correct Answer)
  86. Question: A nurse is assessing a client following an ischemic stroke. Which of the following findings is the priority for the nurse to report to the provider?
    • Answer: The client coughs after swallowing. (Correct Answer)
  87. Question: A nurse is creating a plan of care for a client who has paranoid personality disorder and refuses to take their medication. Which of the following interventions should the nurse include in the plan?
    • Answer: Speak in a neutral tone when addressing the client. (Correct Answer)
  88. Question: A nurse is assessing a client immediately following a cardiac catheterization. The nurse should notify the provider for which of the following findings?
    • Answer: Hematoma over the insertion site. (Correct Answer)
  89. Question: A home care nurse is making a follow-up visit with a client who has COPD and is using a compressed oxygen system in his home. Which of the following actions should the nurse take?
    • Answer: Place the oxygen tank away from curtains or drapes. (Correct Answer)
  90. Question: A nurse is providing discharge teaching to a client following a total hip arthroplasty. Which of the following statements by the client indicates an understanding of the teaching?
    • Answer: “I won’t cross my legs when sitting in a chair.” (Correct Answer)
  91. Question: A nurse is teaching a client about the oral administration of chlorpromazine. Which of the following information should the nurse include?
    • Answer: Move slowly when standing from a sitting position. (Correct Answer)
  92. Question: A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. The client reports that she is experiencing difficulty breathing. Which of the following actions should the nurse take first?
    • Answer: Discontinue the infusion. (Correct Answer)
  93. Question: A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a kidney transplant. Which of the following findings should the nurse report to the provider?
    • Answer: Serum creatinine 1.6 mg/dL (Correct Answer)
  94. Question: A nurse is caring for a client who is on fall precautions. Which of the following actions should the nurse take?
    • Answer: Establish an elimination schedule for the client. (Correct Answer)
  95. Question: A nurse on a medical-surgical unit is caring for a client who states that she plans to leave the facility against medical advice. For which of the following actions by the nurse should the charge nurse intervene?
    • Answer: Asks security to detain the client until the provider is notified. (Correct Answer)
  96. Question: A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following nursing interventions should the nurse include in the plan of care for this client?
    • Answer: Perform neurologic checks. (Correct Answer)
  97. Question: A nurse is using an IV pump for a newly admitted client. Which of the following actions should the nurse take?
    • Answer: Check the cords of the IV pump for fraying. (Correct Answer)
  98. Question: A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse plan to include?
    • Answer: Critical pathways should reduce health care costs. (Correct Answer)
  99. Question: A nurse is providing teaching to a client who has otitis media and is 1 hr postoperative following a myringotomy. Which of the following statements should the nurse include in the teaching?
    • Answer: “You should not drink through a straw for 2 weeks.” (Correct Answer)
  100. Question: A nurse is teaching a newly licensed nurse about incident reports. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? - Answer: “They assist with unit quality improvement.” (Correct Answer)
  101. Question: A nurse is caring for a client who has experienced a stroke and is moving in with their adult child. Which of the following actions should the nurse encourage the client and family to take as they adjust to their new roles? - Answer: Implement firm but flexible boundaries in their relationship. (Correct Answer)
  102. Question: A nurse is planning care for a client who has an L4 spinal cord injury. Which of the following interventions to prevent skin breakdown should the nurse include in the plan of care? - Answer: Ask the client to shift his weight every 20 min while sitting in a chair. (Correct Answer)
  103. Question: A nurse in a provider’s office is reviewing the laboratory results of a group of clients. The nurse should identify that which of the following sexually transmitted infections is a nationally notifiable infectious disease that should be reported to the state health department? - Answer: Chlamydia (Correct Answer)
  104. Question: A nurse is caring for a client who is postpartum and requests information about contraception. Which of the following instructions should the nurse include? - Answer: “Place the transdermal birth control patch on your upper outer arm.” (Correct Answer)
  105. Question: A nurse is caring for a client who is 12 hr postoperative following a transurethral resection of the prostate. Which of the following findings should the nurse report to the provider? - Answer: Burgundy-colored urine (Correct Answer)
  106. Question: A nurse is caring for a client who is receiving enteral feedings through a nasoenteric tube and has aspirated fluid prior to feeding. Which of the following findings should indicate to the nurse that the tube is positioned in the client’s lung? - Answer: Residual fluid with a pH of 8 (Correct Answer)
  107. Question: A nurse is caring for a client who is postoperative following a liver biopsy. In which of the following positions should the nurse place the client immediately following the procedure? - Answer: Right lateral (Correct Answer)
  108. Question: A nurse is caring for a client who is receiving brachytherapy for endometrial cancer. Which of the following actions should the nurse take? - Answer: Keep visitors at least 6 feet (1.8 m) away from the client. (Correct Answer)
  109. Question: A nurse is updating the plan of care for a client who has amyotrophic lateral sclerosis with dysphagia. Which of the following interprofessional team members should the nurse identify as the priority consult? - Answer: Speech-language pathologist (Correct Answer)
  110. Question: A nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the entries should the nurse make in the medical record? - Answer: “Morphine 3 mg subcutaneous every 4 hr PRN for pain.” (Correct Answer)
  111. Question: A nurse is collecting a sputum specimen from a client who has tuberculosis. Which of the following actions should the nurse take? - Answer: Obtain the specimen immediately upon the client waking up. (Correct Answer)
  112. Question: A home health nurse is teaching a new parent about caring for his 1-week-old infant. Which of the following statements by the client indicates an understanding of the teaching? - Answer: “I will place a ticking clock nearby to soothe my baby throughout the day.” (Correct Answer)
  113. Question: A nurse is planning care for a client who has COPD and weight loss. Which of the following interventions should the nurse include in the plan? - Answer: Provide high-protein nutritional supplements. (Correct Answer)
  114. Question: A nurse is providing teaching to an older client who has a seizure disorder and a new prescription for phenytoin. Which of the following instructions should the nurse include? - Answer: “Plan to take this medication with food.” (Correct Answer)
  115. Question: A nurse is reviewing the facility’s safety protocols concerning newborn abduction with the parent of a newborn. Which of the following client statements indicates an understanding of the teaching? - Answer: “I will not publish a public announcement about my baby’s birth.” (Correct Answer)
  116. Question: A nurse is providing prenatal teaching to a client who is at 12 weeks of gestation. The nurse should tell the client that she will undergo which the following screening tests at 16 weeks of gestation? - Answer: Maternal serum alpha-fetoprotein (Correct Answer)
  117. Question: A nurse is providing nutritional teaching about appropriate food choices to a client who has a new diagnosis of uric acid calculi. Which of the following foods should the nurse include in the teaching? - Answer: Chicken (Correct Answer)
  118. Question: A nurse in a mental health facility is caring for a client who is experiencing a panic level of anxiety. Which of the following actions should the nurse take? - Answer: Use short sentences when communicating with the client. (Correct Answer)
  119. Question: A nurse is teaching a client about advance directives. Which of the following statements should the nurse make? - Answer: “Advance directives can include a do-not-resuscitate order signed by the provider.” (Correct Answer)
  120. Question: A nurse is caring for an adolescent who has sickle-cell anemia. Which of the following manifestations indicates acute chest syndrome and should be immediately reported to the provider? - Answer: Substernal retractions (Correct Answer)
  121. Question: A nurse is caring for a client who has a tension pneumothorax. Which of the following manifestations should the nurse expect? - Answer: Asymmetry of the chest (Correct Answer)
  122. Question: A nurse is caring for a client who is at 11 weeks of gestation. Which of the following immunizations should the nurse recommend? - Answer: Influenza (Correct Answer)
  123. Question: A nurse is performing triage in the emergency department. Which of the following clients should the nurse classify as emergent? - Answer: A client who has a head injury and is experiencing confusion. (Correct Answer)
  124. Question: A nurse is assessing a client who is receiving mechanical ventilation. Which of the following findings should the nurse identify as an indication of pneumonia? - Answer: Positive sputum culture (Correct Answer)
  125. Question: A nurse is preparing to administer a blood transfusion to a client who is in a semi-private room. Which of the following actions should the nurse take? - Answer: Confirm the blood type compatibility with another nurse. (Correct Answer)
  126. Question: A nurse in an acute care setting is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse implement? - Answer: Elevate the head of the bed to 30°. (Correct Answer)
  127. Question: A nurse is reviewing laboratory values for a client who has heart failure and is receiving furosemide. The nurse notes that the client has a potassium level of 3.1 mEq/L. Which of the following actions should the nurse take? - Answer: Monitor the client for dysrhythmias. (Correct Answer)
  128. Question: A nurse is caring for a client who has a stage III pressure ulcer. Which of the following findings indicates wound healing? - Answer: Appearance of red granulation tissue (Correct Answer)
  129. Question: A nurse is caring for a child who has a new prescription for IV gentamicin. Which of the following laboratory values should the nurse review prior to administering the dose? - Answer: Serum creatinine (Correct Answer)
  130. Question: A nurse is assessing a newborn who was just delivered. Which of the following respiratory rates is within the expected reference range for a newborn? - Answer: 48/min (Correct Answer)
  131. Question: A nurse is providing teaching to the partner of an older adult client who is in the late stages of Alzheimer’s disease. Which of the following instructions should the nurse include in the teaching? - Answer: Reorient the client when they are disoriented. (Correct Answer)
  132. Question: A nurse is caring for a child who has Kawasaki disease. Which of the following actions should the nurse take? - Answer: Monitor the client’s cardiac status. (Correct Answer)
  133. Question: A nurse is assessing a client who has deep-vein thrombosis in the left calf. Which of the following findings should the nurse expect? - Answer: Cool skin on the affected leg. (Correct Answer)
  134. Question: A nurse is teaching a client who is in early labor about pattern-paced breathing techniques. Which of the following instructions should the nurse include? - Answer: “Take a cleansing breath at the end of each contraction.” (Correct Answer)
  135. Question: A nurse is caring for a client who has a seizure disorder and requires continuous pulse oximetry. Which of the following actions should the nurse take to ensure an accurate reading? - Answer: Apply the sensor to a finger. (Correct Answer)
  136. Question: A nurse is preparing to administer a feeding via a nasoenteric tube to a client who is at risk for aspiration. Which of the following actions should the nurse take? - Answer: Elevate the head of the client’s bed 30° to 45°. (Correct Answer)
  137. Question: A nurse is caring for a client who is 4 hr postoperative following an open reduction and internal fixation of a fractured femur. Which of the following assessments should the nurse perform first? - Answer: Neurovascular status (Correct Answer)
  138. Question: A nurse is providing teaching to a client who has primary hypertension and a new prescription for propranolol. Which of the following statements by the client indicates an understanding of the teaching? - Answer: “I will sit on the side of my bed for a few minutes before standing up in the morning.” (Correct Answer)
  139. Question: A nurse is caring for a client who is experiencing a prolonged labor. The nurse observes late decelerations on the fetal monitor strip. Which of the following actions should the nurse take first? - Answer: Turn the client to a side-lying position. (Correct Answer)
  140. Question: A nurse is assessing a client who is receiving parenteral nutrition. Which of the following findings should the nurse identify as an adverse effect? - Answer: Hyperglycemia (Correct Answer)
  141. Question: A nurse is planning care for a client who has multiple sclerosis and is experiencing diplopia. Which of the following interventions should the nurse include in the plan of care? - Answer: Apply an eye patch to the affected eye. (Correct Answer)
  142. Question: A nurse is assessing a client who is 12 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following findings should the nurse report to the provider? - Answer: Decreased urine output (Correct Answer)
  143. Question: A nurse is caring for a client who has been prescribed lithium carbonate. The nurse should recognize that which of the following conditions is a contraindication for taking this medication? - Answer: Heart failure (Correct Answer)
  144. Question: A nurse is caring for a client who has COPD and is receiving oxygen at 2 L/min via nasal cannula. The client is dyspneic, and reports shortness of breath. Which of the following actions should the nurse take first? - Answer: Assist the client to a high-Fowler’s position. (Correct Answer)
  145. Question: A nurse is providing teaching to a client who has a new prescription for ciprofloxacin. Which of the following instructions should the nurse include? - Answer: “Avoid taking antacids with this medication.” (Correct Answer)
  146. Question: A nurse is teaching a client who has Crohn’s disease about dietary recommendations. Which of the following statements by the client indicates an understanding of the teaching? - Answer: “I will avoid drinking beverages with meals.” (Correct Answer)
  147. Question: A nurse is providing teaching about phototherapy to the parent of a newborn who has jaundice. Which of the following statements by the parent indicates an understanding of the teaching? - Answer: “I will remove my baby from the lights for feeding.” (Correct Answer)
  148. Question: A nurse is planning care for a client who has a new prescription for enoxaparin. Which of the following actions should the nurse include in the plan? - Answer: Inject the medication deep into the client’s subcutaneous tissue. (Correct Answer)
  149. Question: A nurse in an outpatient facility is assessing a client who has a new diagnosis of Raynaud’s disease. Which of the following manifestations should the nurse expect? - Answer: Blanching of the fingers and toes (Correct Answer)
  150. Question: A nurse is planning care for a client who has developed deep-vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care? - Answer: Elevate the affected leg. (Correct Answer)
  151. Question: A nurse is planning care for a client who has rheumatoid arthritis and is experiencing difficulty feeding herself. Which of the following interventions should the nurse plan to include? - Answer: Provide an adaptive feeding device for the client. (Correct Answer)
  152. Question: A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? - Answer: Frothy sputum (Correct Answer)
  153. Question: A nurse is preparing a sterile field to perform a sterile dressing change for a client. Which of the following actions should the nurse take first? - Answer: Perform hand hygiene. (Correct Answer)
  154. Question: A nurse is preparing to discharge a client who has heart failure and is to start therapy with digoxin. Which of the following instructions should the nurse include in the teaching? - Answer: “Eat a diet high in potassium.” (Correct Answer)
  155. Question: A nurse is assessing a client who has pernicious anemia. Which of the following findings should the nurse expect? - Answer: Glossitis (Correct Answer)
  156. Question: A nurse is caring for a client who has a pressure ulcer. Which of the following interventions should the nurse include in the plan of care? - Answer: Reposition the client at least every 2 hr. (Correct Answer)
  157. Question: A nurse is assessing a client who has a traumatic brain injury and increased intracranial pressure (ICP). Which of the following findings should the nurse expect? - Answer: Lethargy (Correct Answer)
  158. Question: A nurse is teaching a client about the use of crutches. Which of the following instructions should the nurse include in the teaching? - Answer: Place the crutches about 12 inches in front of your feet when walking. (Correct Answer)
  159. Question: A nurse is preparing to administer a controlled substance to a client for pain. The nurse should perform which of the following actions to safely administer this medication? - Answer: Count the available doses of medication before administration. (Correct Answer)
  160. Question: A nurse is caring for a client who is postoperative following a thyroidectomy and reports severe muscle spasms in his lower extremities. Which of the following actions should the nurse take? - Answer: Request a stat calcium level. (Correct Answer)
  161. Question: A nurse is caring for a client who is receiving enteral nutrition via a gastrostomy tube. The client is to receive 400 mL of formula over 6 hr. Using an IV pump, at which of the following rates should the nurse set the pump to administer the formula? - Answer: 67 mL/hr (Correct Answer)
  162. Question: A nurse is providing dietary teaching to a client who has a new prescription for levothyroxine. Which of the following instructions should the nurse include? - Answer: Avoid drinking coffee within 1 hr of taking this medication. (Correct Answer)
  163. Question: A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings should the nurse identify as a manifestation of a febrile transfusion reaction? - Answer: Chills (Correct Answer)
  164. Question: A nurse is assessing a client who has alcohol use disorder. Which of the following questions should the nurse ask to assess the client’s level of alcohol consumption? - Answer: “How many alcohol-containing drinks do you have per day?” (Correct Answer)
  165. Question: A nurse is providing teaching to the parent of a child who has autism spectrum disorder. Which of the following instructions should the nurse include? - Answer: Implement a daily schedule for the child. (Correct Answer)
  166. Question: A nurse is caring for a client who has an AV fistula in the left arm. Which of the following actions should the nurse take to assess the AV fistula? - Answer: Auscultate for a bruit over the fistula. (Correct Answer)
  167. Question: A nurse is planning care for a client who is in the oliguric phase of acute kidney injury. The nurse should plan to monitor the client for which of the following manifestations? - Answer: Hyperkalemia (Correct Answer)
  168. Question: A nurse is teaching a newly licensed nurse about caring for a client who is receiving chemotherapy. Which of the following client laboratory values should the nurse include as the priority for monitoring? - Answer: Absolute neutrophil count (Correct Answer)
  169. Question: A nurse is assessing a client who has a radial fracture. Which of the following findings should the nurse expect? - Answer: Crepitus (Correct Answer)
  170. Question: A nurse is reviewing the medical record of a client who is receiving hydromorphone for pain management. Which of the following findings should the nurse identify as a contraindication to administering this medication? - Answer: The client’s respiratory rate is 8/min. (Correct Answer)
  171. Question: A nurse is teaching a client who has a new prescription for atorvastatin. Which of the following instructions should the nurse include? - Answer: “Notify your provider if you experience muscle pain.” (Correct Answer)
  172. Question: A nurse is providing discharge teaching to a client who has a new prescription for warfarin. Which of the following statements should the nurse include in the teaching? - Answer: “You should use an electric razor when shaving.” (Correct Answer)
  173. Question: A nurse is providing teaching to a client who has a new prescription for nitroglycerin sublingual tablets. Which of the following statements should the nurse include in the teaching? - Answer: “Place the tablet under your tongue and let it dissolve.” (Correct Answer)
  174. Question: A nurse is caring for a client who is receiving parenteral nutrition (PN). Which of the following actions should the nurse take to prevent complications? - Answer: Monitor the client’s blood glucose level every 6 hr. (Correct Answer)
  175. Question: A nurse is providing teaching to a client who has a new prescription for albuterol. Which of the following instructions should the nurse include? - Answer: “Rinse your mouth after using this inhaler.” (Correct Answer)
  176. Question: A nurse is planning care for a client who is receiving opioid analgesics for pain management. Which of the following interventions should the nurse include in the plan? - Answer: Encourage the client to increase fiber intake. (Correct Answer)
  177. Question: A nurse is providing teaching to a client who has a new prescription for ranitidine. Which of the following statements should the nurse include? - Answer: “You should report yellowing of your skin to your provider.” (Correct Answer)
  178. Question: A nurse is caring for a client who is receiving IV fluid therapy. Which of the following findings should the nurse identify as a manifestation of fluid overload? - Answer: Distended neck veins (Correct Answer)
  179. Question: A nurse is teaching a client about a new prescription for hydrochlorothiazide. Which of the following instructions should the nurse include in the teaching? - Answer: “Take this medication in the morning.” (Correct Answer)
  180. Question: A nurse is preparing to administer medications to a client who has dysphagia. Which of the following actions should the nurse take? - Answer: Administer one medication at a time. (Correct Answer)
  181. Question: A nurse is assessing a client who has cirrhosis. Which of the following findings should the nurse report to the provider? - Answer: Bloody stools (Correct Answer)
  182. Question: A nurse is teaching a client who has a new prescription for furosemide. Which of the following foods should the nurse recommend to help the client prevent potassium loss? - Answer: Bananas (Correct Answer)
  183. Question: A nurse is planning care for a client who has a prescription for total parenteral nutrition (TPN). Which of the following actions should the nurse plan to take? - Answer: Monitor the client’s blood glucose level. (Correct Answer)
  184. Question: A nurse is teaching a client who has a new diagnosis of hypertension about dietary management. Which of the following statements should the nurse include in the teaching? - Answer: “You should reduce your intake of foods high in sodium.” (Correct Answer)
  185. Question: A nurse is providing teaching to a client who has chronic kidney disease. Which of the following statements by the client indicates an understanding of the teaching? - Answer: “I will avoid using salt substitutes.” (Correct Answer)
  186. Question: A nurse is planning care for a client who has a pressure ulcer. Which of the following interventions should the nurse include to prevent the development of a pressure ulcer? - Answer: Use a moisture barrier ointment on the client’s skin. (Correct Answer)
  187. Question: A nurse is assessing a client who is 1 day postoperative following a thyroidectomy. Which of the following findings should the nurse report to the provider? - Answer: Tachycardia (Correct Answer)
  188. Question: A nurse is planning care for a client who is in labor and has a positive group B streptococcus culture. Which of the following actions should the nurse include in the plan? - Answer: Administer prophylactic antibiotics. (Correct Answer)
  189. Question: A nurse is providing teaching to a client who has a new prescription for metformin. Which of the following instructions should the nurse include in the teaching? - Answer: “Take the medication with meals.” (Correct Answer)
  190. Question: A nurse is assessing a client who has diabetes mellitus. Which of the following findings should the nurse identify as a manifestation of hypoglycemia? - Answer: Diaphoresis (Correct Answer)
  191. Question: A nurse is caring for a client who has schizophrenia. The client states, “The voices are telling me to kill myself.” Which of the following actions should the nurse take first? - Answer: Ensure the client’s environment is safe. (Correct Answer)
  192. Question: A nurse is assessing a client who has an arteriovenous (AV) fistula in the left arm. Which of the following findings should the nurse report to the provider? - Answer: Absence of a bruit (Correct Answer)
  193. Question: A nurse is teaching a client who has a new prescription for warfarin. Which of the following statements should the nurse include in the teaching? - Answer: “You should have your INR checked regularly.” (Correct Answer)
  194. Question: A nurse is providing discharge teaching to a client who is postoperative following a total knee arthroplasty. Which of the following statements by the client indicates an understanding of the teaching? - Answer: “I should wear elastic stockings on both of my legs.” (Correct Answer)
  195. Question: A nurse is caring for a client who has tuberculosis (TB). Which of the following actions should the nurse take? - Answer: Wear a N95 respirator mask. (Correct Answer)
  196. Question: A nurse is assessing a client who has pancreatitis. Which of the following findings should the nurse expect? - Answer: Epigastric pain (Correct Answer)
  197. Question: A nurse is assessing a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to report to the provider? - Answer: Neutropenia (Correct Answer)
  198. Question: A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan? - Answer: Provide high-calorie finger foods. (Correct Answer)
  199. Question: A nurse is teaching a client who has a new prescription for levothyroxine. Which of the following instructions should the nurse include in the teaching? - Answer: “Take this medication on an empty stomach.” (Correct Answer)
  200. Question: A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings should the nurse identify as an indication of hypocalcemia? - Answer: Numbness and tingling of the extremities (Correct Answer
  201. Question: A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse identify as a complication of TPN? - Answer: Hyperglycemia (Correct Answer)
  202. Question: A nurse is caring for a client who has acute pancreatitis. Which of the following laboratory findings should the nurse expect? - Answer: Elevated serum amylase (Correct Answer)
  203. Question: A nurse is providing discharge teaching to a client who is newly diagnosed with type 2 diabetes mellitus. Which of the following instructions should the nurse include in the teaching? - Answer: “Take your blood glucose level before each meal.” (Correct Answer)
  204. Question: A nurse is assessing a client who has end-stage renal disease (ESRD). Which of the following findings should the nurse expect? - Answer: Pruritus (Correct Answer)
  205. Question: A nurse is teaching a client who has a new prescription for alendronate. Which of the following instructions should the nurse include? - Answer: “Sit upright for 30 minutes after taking this medication.” (Correct Answer)
  206. Question: A nurse is caring for a client who is receiving chemotherapy and is immunosuppressed. Which of the following precautions should the nurse include in the plan of care? - Answer: Avoid fresh flowers in the client’s room. (Correct Answer)
  207. Question: A nurse is caring for a client who has a prescription for amoxicillin to treat a respiratory infection. Which of the following instructions should the nurse include in the teaching? - Answer: “Take the medication with food.” (Correct Answer)
  208. Question: A nurse is planning care for a client who is receiving hemodialysis. Which of the following actions should the nurse take? - Answer: Check the access site for a thrill. (Correct Answer)
  209. Question: A nurse is providing teaching to a client who has a new diagnosis of systemic lupus erythematosus (SLE). Which of the following instructions should the nurse include? - Answer: “Wear protective clothing when out in the sun.” (Correct Answer)
  210. Question: A nurse is caring for a client who is receiving palliative care. The client states, “I am ready to die.” Which of the following responses should the nurse make? - Answer: “Tell me more about how you are feeling.” (Correct Answer)
  211. Question: A nurse is teaching a client who has a new prescription for risperidone. Which of the following instructions should the nurse include? - Answer: “Notify your provider if you develop a fever.” (Correct Answer)
  212. Question: A nurse is assessing a client who is receiving methotrexate for the treatment of rheumatoid arthritis. Which of the following findings is the priority for the nurse to report to the provider? - Answer: Fever (Correct Answer)
  213. Question: A nurse is caring for a client who has increased intracranial pressure (ICP). Which of the following actions should the nurse take to decrease the potential for raising the client’s ICP? - Answer: Maintain the head of the bed at 30 degrees. (Correct Answer)
  214. Question: A nurse is providing teaching to a client who has a new prescription for clopidogrel. Which of the following instructions should the nurse include? - Answer: “Avoid taking over-the-counter NSAIDs.” (Correct Answer)
  215. Question: A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following findings should the nurse expect? - Answer: Muscle weakness (Correct Answer)
  216. Question: A nurse is teaching a client who has a new prescription for insulin glargine. Which of the following instructions should the nurse include? - Answer: “Inject this insulin at the same time each day.” (Correct Answer)
  217. Question: A nurse is planning care for a client who has a deep vein thrombosis (DVT) in the left leg. Which of the following interventions should the nurse include? - Answer: Elevate the affected leg. (Correct Answer)
  218. Question: A nurse is assessing a client who has a new prescription for digoxin. Which of the following findings should the nurse identify as a manifestation of digoxin toxicity? - Answer: Nausea (Correct Answer)
  219. Question: A nurse is caring for a client who is at 38 weeks of gestation and reports no fetal movement for 24 hours. Which of the following actions should the nurse take? - Answer: Auscultate for a fetal heart rate. (Correct Answer)
  220. Question: A nurse is assessing a client who is postoperative following a colon resection. Which of the following findings should the nurse report to the provider? - Answer: Absent bowel sounds (Correct Answer)
  221. Question: A nurse is providing teaching to a client who has a new prescription for sucralfate. Which of the following instructions should the nurse include? - Answer: “Take this medication on an empty stomach.” (Correct Answer)
  222. Question: A nurse is caring for a client who has a prescription for a transfusion of packed red blood cells (PRBCs). Which of the following actions should the nurse take? - Answer: Remain with the client during the first 15 minutes of the transfusion. (Correct Answer)
  223. Question: A nurse is assessing a client who has hypokalemia. Which of the following findings should the nurse expect? - Answer: Weak, irregular pulse (Correct Answer)
  224. Question: A nurse is providing teaching to a client who has a new prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include? - Answer: “Place the tablet under your tongue and let it dissolve.” (Correct Answer)
  225. Question: A nurse is caring for a client who has type 1 diabetes mellitus and is not adhering to the prescribed regimen of insulin administration. Which of the following findings should the nurse expect? - Answer: Ketonuria (Correct Answer)
  226. Question: A nurse is teaching a client who has a new prescription for digoxin. Which of the following instructions should the nurse include? - Answer: “Call your provider if your pulse is below 60/min.” (Correct Answer)
  227. Question: A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? - Answer: Frothy sputum (Correct Answer)
  228. Question: A nurse is assessing a client who has Cushing’s syndrome. Which of the following findings should the nurse expect? - Answer: Moon face (Correct Answer)
  229. Question: A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? - Answer: Apply an alarm to the client’s bed. (Correct Answer)
  230. Question: A nurse is assessing a client who has dehydration. Which of the following findings should the nurse expect? - Answer: Hypotension (Correct Answer)
  231. Question: A nurse is assessing a client who is at 34 weeks of gestation and reports epigastric pain. Which of the following actions should the nurse take? - Answer: Obtain a blood pressure reading. (Correct Answer)
  232. Question: A nurse is planning care for a client who is receiving continuous tube feedings via a gastrostomy tube. Which of the following interventions should the nurse include in the plan of care? - Answer: Flush the tube with 30 mL of water every 4 hours. (Correct Answer)
  233. Question: A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following medications should the nurse expect the provider to prescribe? - Answer: Diazepam (Correct Answer)
  234. Question: A nurse is teaching a client who has a new prescription for digoxin. Which of the following instructions should the nurse include in the teaching? - Answer: “Call your provider if you experience blurred vision.” (Correct Answer)
  235. Question: A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse report to the provider? - Answer: Crackles in the lungs (Correct Answer)
  236. Question: A nurse is providing teaching to a client who has a new prescription for insulin glargine. Which of the following instructions should the nurse include in the teaching? - Answer: “This insulin is absorbed over 24 hours.” (Correct Answer)
  237. Question: A nurse is teaching a client who has a new diagnosis of pernicious anemia about the treatment plan. Which of the following statements by the client indicates an understanding of the teaching? - Answer: “I will need to take vitamin B12 for the rest of my life.” (Correct Answer)
  238. Question: A nurse is providing discharge teaching to a client who has a new prescription for prednisone. Which of the following instructions should the nurse include? - Answer: “You might notice some swelling in your face.” (Correct Answer)
  239. Question: A nurse is caring for a client who has a prescription for metformin. The nurse should recognize that which of the following conditions is a contraindication for taking this medication? - Answer: Renal insufficiency (Correct Answer)
  240. Question: A nurse is assessing a client who has fluid volume overload. Which of the following findings should the nurse expect? - Answer: Crackles in the lungs (Correct Answer)
  241. Question: A nurse is providing teaching to a client who has a new prescription for levothyroxine. Which of the following statements should the nurse include in the teaching? - Answer: “Take this medication on an empty stomach.” (Correct Answer)
  242. Question: A nurse is assessing a client who is at 28 weeks of gestation and has gestational diabetes mellitus. Which of the following findings should the nurse expect? - Answer: Polyuria (Correct Answer)
  243. Question: A nurse is caring for a client who is receiving chemotherapy and has a platelet count of 25,000/mm³. Which of the following actions should the nurse take? - Answer: Avoid administering intramuscular injections. (Correct Answer)
  244. Question: A nurse is teaching a client who has a new prescription for enoxaparin. Which of the following instructions should the nurse include? - Answer: “Administer this medication subcutaneously.” (Correct Answer)
  245. Question: A nurse is providing teaching to a client who has a new prescription for nitroglycerin patches. Which of the following instructions should the nurse include? - Answer: “Remove the patch each evening.” (Correct Answer)
  246. Question: A nurse is assessing a client who has a new prescription for morphine. Which of the following findings should the nurse report to the provider? - Answer: Respiratory rate 10/min (Correct Answer)
  247. Question: A nurse is assessing a client who has a new diagnosis of hyperthyroidism. Which of the following findings should the nurse expect? - Answer: Weight loss (Correct Answer)
  248. Question: A nurse is teaching a client who has a new prescription for atenolol. Which of the following instructions should the nurse include? - Answer: “Take your pulse daily.” (Correct Answer)
  249. Question: A nurse is teaching a client who has a new prescription for levodopa/carbidopa. Which of the following instructions should the nurse include? - Answer: “Change positions slowly.” (Correct Answer)
  250. Question: A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect? - Answer: Peripheral edema (Correct Answer)
  251. Question: A nurse is assessing a client who has a new diagnosis of diabetes insipidus. Which of the following findings should the nurse expect? - Answer: Polyuria (Correct Answer)
  252. Question: A nurse is providing discharge teaching to a client who has a new prescription for spironolactone. Which of the following instructions should the nurse include? - Answer: “Avoid salt substitutes.” (Correct Answer)
  253. Question: A nurse is assessing a client who is 3 days postoperative following an abdominal surgery. The client reports feeling their incision “pop” while coughing. Which of the following actions should the nurse take? - Answer: Cover the wound with a sterile, moist dressing. (Correct Answer)
  254. Question: A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? - Answer: Orthopnea (Correct Answer)
  255. Question: A nurse is caring for a client who is receiving a continuous IV infusion. Which of the following findings should the nurse report to the provider? - Answer: Phlebitis at the IV site (Correct Answer)
  256. Question: A nurse is teaching a client who has a new prescription for metoprolol. Which of the following instructions should the nurse include? - Answer: “Take this medication with food.” (Correct Answer)
  257. Question: A nurse is providing discharge teaching to a client who has a new prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include? - Answer: “Place the tablet under your tongue and let it dissolve.” (Correct Answer)
  258. Question: A nurse is assessing a client who has a new prescription for enalapril. Which of the following findings should the nurse report to the provider? - Answer: Elevated potassium level (Correct Answer)
  259. Question: A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following statements should the nurse include? - Answer: “You should have your INR checked regularly.” (Correct Answer)
  260. Question: A nurse is providing discharge teaching to a client who has a new prescription for lisinopril. Which of the following instructions should the nurse include? - Answer: “Monitor your blood pressure regularly.” (Correct Answer)