A client hospitalized with severe depression and suicidal ideation refuses to talk with the nurse. The nurse recognizes that the suicidal client has difficulty: Show
A client receiving HydroDIURIL (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 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 could expect to find:
The licensed vocational nurse may not assume the primary care for a client:
The physician has ordered dressings with mafenide acetate (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 (Lanoxin) elixir to a 6-month-old with a congenital heart defect. The nurse auscultates an apical pulse rate of 100. 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) eyedrops. Timoptic 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?
The best diet for the client with Meniere’s syndrome is one that is:
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 for lanoxin elixir. 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 chlorpromazine (Thorazine) 400mg twice a day. An adverse side effect of the medication is:
Which information should be given to the client taking phenytoin (Dilantin)?
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 drooling, muffled phonation, 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 Erickson’s stage of growth and development, the developmental task associated with middle childhood 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 103.6°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 anastamosis 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 exacerbation 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 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 lymphocytic leukemia includes prednisone, methotrexate, and cimetadine. The purpose of the cimetadine 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 nephotic 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 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 nurse is caring for a client with systemic lupus erythematosis (SLE). The major complication associated with systemic lupus erythematosis 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) 500mg 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 iron-deficiency anemia. Which food is a poor source of iron?
The nurse is teaching a client with Parkinson’s disease ways to prevent curvatures of the spine associated with the disease. To prevent spinal flexion, 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 echolalia. 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 Basalgel (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 a transurethral prostatectomy. Which finding 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 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:
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:
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 Tetraimmune 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 snacks would be best for the client with mania?
A 2-year-old is hospitalized with 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 transphenoidal 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 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 post-operative client has an order for Demerol (meperidine) 75mg and Phenergan (promethazine) 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 54. 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 give priority to:
A client with human immunodeficiency syndrome has gastrointestinal symptoms, including diarrhea. The nurse should teach the client to avoid:
A 4-year-old is admitted with acute leukemia. It will be most important to monitor the child for:
A 5-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:
Which finding is the best indication that a client with ineffective airway clearance needs suctioning?
A client with tuberculosis has a prescription for Myambutol (ethambutol HCl). The nurse should tell the client to notify the doctor immediately if he notices:
The primary cause of anemia in a client with chronic renal failure is:
Which of the following nursing interventions has the highest priority for the client scheduled for an intravenous pyelogram?
The doctor has prescribed aspirin 325mg daily for a client with transient ischemic attacks. The nurse knows that aspirin was prescribed to:
A client with tuberculosis who has been receiving combined therapy with INH and Rifampin asks the nurse how long he will have to take medication. The nurse should tell the client that:
Which development milestone puts the 4-month-old infant at greatest risk for injury?
A client taking Dilantin (phenytoin) for tonic-clonic seizures is preparing for discharge. Which information should be included in the client’s discharge care plan?
Assessment of a newborn male reveals that the infant has hypospadias. The nurse knows that:
The nurse is providing dietary teaching for a client with elevated cholesterol levels. Which cooking oil is not suggested for the client on a low-cholesterol diet?
The nurse is caring for a client with stage III Alzheimer’s disease. A characteristic of this stage is:
The doctor has prescribed Cortone (cortisone) for a client with systemic lupus erythematosis. Which instruction should be given to the client?
The nurse is caring for a client with an above-the-knee amputation (AKA). To prevent contractures, the nurse should:
The mother of a 6-month-old asks when her child will have all his baby teeth. The nurse knows that most children have all their primary teeth by age:
While caring for a client with cervical cancer, the nurse notes that the radioactive implant is lying in the bed. The nurse should:
The nurse is preparing to discharge a client following a laparoscopic cholecystectomy. The nurse should:
A high school student returns to school following a 3-week absence due to mononucleosis. The school nurse knows it will be important for the client:
A 6-year-old with cystic fibrosis has an order for pancreatic replacement. The nurse knows that the medication will be given:
The doctor has prescribed a diet high in vitamin B12 for a client with pernicious anemia. Which foods are highest in B12?
A client with hypertension has begun an aerobic exercise program. The nurse should tell the client that the recommended exercise regimen should begin slowly and build up to:
A client with breast cancer is returned to the room following a right total mastectomy. The nurse should:
A neurological consult has been ordered for a pediatric client with suspected absence seizures. The client with absence seizures can be expected to have:
A client with schizoaffective disorder is exhibiting Parkinsonian symptoms. Which medication is responsible for the development of Parkinsonian symptoms?
Which activity is best suited to the 12-year-old with juvenile rheumatoid arthritis?
The glycosylated hemoglobin of a 40-year-old client with diabetes mellitus is 2.5%. The nurse understands that:
The physician has ordered Stadol (butorphanol) for a post-operative client. The nurse knows that the medication is having its intended effect if the client:
The mother of a child with cystic fibrosis tells the nurse that her child makes “snoring” sounds when breathing. The nurse is aware that many children with cystic fibrosis have:
A client is hospitalized with hepatitis A. Which of the client’s regular medications is contraindicated due to the current illness?
The nurse has been teaching the role of diet in regulating blood pressure to a client with hypertension. Which meal selection indicates that the client understands his new diet?
An 18-month-old is being discharged following hypospadias repair. Which instruction should be included in the nurse’s discharge teaching?
An obstetrical client calls the clinic with complaints of morning sickness. The nurse should tell the client to:
The nurse has taken the blood pressure of a client hospitalized with methicillin-resistant staphylococcus aureus. Which action by the nurse indicates an understanding regarding the care of clients with MRSA?
The physician has discussed the need for medication with the parents of an infant with congenital hypothyroidism. The nurse can reinforce the physician’s teaching by telling the parents that:
A client with diabetes mellitus has a prescription for Glucotrol XL (glipizide). The client should be instructed to take the medication:
The nurse is caring for a client admitted with suspected myasthenia gravis. Which finding is usually associated with a diagnosis of myasthenia gravis?
The nurse is teaching the parents of an infant with osteogenesis imperfecta. The nurse should tell the parents:
Physician’s orders for a client with acute pancreatitis include the following: strict NPO, NG tube to low intermittent suction. The nurse recognizes that these interventions will:
A client with diverticulitis is admitted with nausea, vomiting, and dehydration. Which finding suggests a complication of diverticulitis?
The diagnostic work-up of a client hospitalized with complaints of progressive weakness and fatigue confirms a diagnosis of myasthenia gravis. The medication used to treat myasthenia gravis is:
A client with AIDS complains of a weight loss of 20 pounds in the past month. Which diet is suggested for the client with AIDS?
The nurse is caring for a 4-year-old with cerebral palsy. Which nursing intervention will help ready the child for rehabilitative services?
At the 6-week check-up, the mother asks when she can expect the baby to sleep all night. The nurse should tell the mother that most infants begin to sleep all night by age:
Which of the following pediatric clients is at greatest risk for latex allergy?
The nurse is teaching the mother of a child with cystic fibrosis how to do chest percussion. The nurse should tell the mother to:
The nurse calculates the amount of an antibiotic for injection to be given to an infant. The amount of medication to be administered is 1.25mL. The nurse should:
A client with schizophrenia is receiving depot injections of Haldol Deconate (haloperidol decanoate). The client should be told to return for his next injection in:
A 3-year-old is immobilized in a hip spica cast. Which discharge instruction should be given to the parents?
The nurse is caring for a client following the reimplantation of the thumb and index finger. Which finding should be reported to the physician immediately?
When assessing the urinary output of a client who has had extracorporeal lithotripsy, the nurse can expect to find:
The physician has prescribed Cognex (tacrine) for a client with dementia. The nurse should monitor the client for adverse reactions, which include:
The physician has ordered a low-potassium diet for a child with acute glomerulonephritis. Which snack 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 an oral potassium supplement. The nurse should:
The physician has ordered cultures for cytomegalovirus (CMV). Which statement is true regarding 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) to be given IV 30 minutes before induction of the chemotherapy. The purpose of the medication is to:
The physician has ordered Cortisporin ear drops for a 2-year-old. To administer the ear drops, the nurse should:
A client with schizophrenia has been taking Thorazine (chlorpromazine) 200mg 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, 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, the 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 client has an order for Dilantin (phenytoin) .2g orally twice a day. The medication is available in 100mg capsules. For the morning medication, the nurse should administer:
The LPN is reviewing the lab results of an elderly client when she notes a specific gravity of 1.025. The nurse recognizes that:
A client with acute pancreatitis has requested pain medication. Which pain medication is indicated for the client with acute 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?
A client with a history of clots 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 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?
The nurse is caring for a newborn with hypospadias. Which statement describes hypospadias?
The recommended time for daily administration of Tagamet (cimetidine) is:
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 disorders 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 oxylate renal calculi should be taught to limit his intake of foods such as:
A 6-year-old is diagnosed with Legg-Calve Perthes disease of the right femur. 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 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 10-year-old has an order for Demerol (meperidine) 35mg IM for pain. The medication is available as Demerol 50mg per mL. How much should the nurse administer?
Which antibiotic is contraindicated for the treatment of infections in infants and young children?
Can phenytoin cause seizures?The neurotoxic effects are concentration dependent and can range from mild nystagmus to ataxia, slurred speech, vomiting, lethargy and eventually coma and death. Paradoxically, at very high concentrations, phenytoin can lead to seizures.
What are some of the gastrointestinal adverse reactions associated with phenytoin?Nausea and vomiting were significantly higher in patients receiving monotherapy with carbamazepine and valproic acid, respectively. When phenytoin, gabapentine, or valproic acid was added to the other AEDs, the risk of the occurrence of diarrhea, dysphagia, or heartburn was significantly increased, respectively.
Which cautions are associated with intravenous phenytoin?Intravenous phenytoin should be used with caution in patients with hypotension and severe myocardial insufficiency. Antiepileptic drugs should not be abruptly discontinued because of the possibility of increased seizure frequency, including status epilepticus.
What happens at the molecular target level of phenytoin?Phenytoin potentially acts by promoting sodium efflux from neurons located in the motor cortex reducing post-tetanic potentiation at synapses. The reduction of potentiation prevents cortical seizure foci spreading to adjacent areas, stabilizing the threshold against hyperexcitability.
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A nurse suspects that a client is experiencing phenytoin toxicity based on assessment of which sign
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