Predictive exam XI RN

A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction will aid in the prevention of pooling of blood in the lower extremities?

The client is prescribed a fentanyl patch for persistent severe pain. Which client behavior most urgently requires correction?

The nurse calls a client who is 4 days postpartum to follow up about her transition with her newborn son at home. The woman tells the nurse, “I don’t know what is wrong. I love my son, but I feel so let down. I seem to cry for no reason!” Which adjustment phase should the nurse determine the client is experiencing?

A patient with a family history of coronary artery disease (CAD) has the following laboratory results: total cholesterol, 250 mg/dL; high-density lipoprotein, 35 mg/dL; low-density lipoprotein, 160 mg/dL; and triglycerides, 240 mg/dL. Which interventions should the nurse anticipate? (Select all that apply.)

A client who delivered a healthy infant 5 days ago calls the clinic nurse and reports that her lochia is getting lighter in color. Which action should the nurse take?

The nurse caring for a patient with a temporary transvenous pacemaker notes on the monitor a pacing spike (artifact) that is not followed by a QRS. Which action should the nurse take first?

The charge nurse has just received a report on the patients in the cardiac intervention recovery unit. Which patient should be seen first?

After a coronary artery bypass graft (CABG), the nurse notes the patient has muffled heart tones, jugular vein distention, and decreased blood pressure. There is no drainage from the chest tube for the last 2 hours. The nurse suspects the patient has developed which complication?

Which patients are candidates for fibrinolytic therapy? (Select all that apply.)

The nurse would include which intervention when planning care for the client who is taking hawthorn?

The nurse performs an assessment on a client with heart failure. Which finding(s) is(are) consistent with the diagnosis of left-sided heart failure? (Select all that apply.)

Which assessment is most important for the nurse to implement when seeing a client with multiple myeloma?

The client tells the nurse that a neighbor recommends the use of bilberry in treating simple diarrhea. The nurse supports the client’s use based on knowledge of which action of bilberry?

Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time?

A mother expresses fear about changing the infant’s diaper after circumcision. What information should the nurse include in the teaching plan?

A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor. Contractions are firm and occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate increases with each contraction and returns to baseline after the contraction. Which action should the nurse implement?

In conducting a routine assessment, which question should the nurse ask to determine a client’s risk for open-angle glaucoma?

A client who is on the outpatient surgical unit is preparing for discharge after a myringotomy with placement of ventilating tubes. Which response by the client indicates that further teaching is necessary?

A client has been receiving levofloxacin, 500 mg IV piggyback q24h for 7 days. The UAP reports to the nurse that the client has had three loose foul-smelling stools this morning. Which intervention is most important for the nurse to implement?

The nurse is teaching the parents of a 10-year-old child with rheumatoid arthritis measures to help reduce the pain associated with the disease. Which instruction should the nurse provide to these parents?

The antigout medication allopurinol is prescribed for a client newly diagnosed with gout. Which comment by the client warrants intervention by the nurse?

An older client who resides in a long-term care facility is hearing-impaired. How should the nurse modify interventions for this client?

A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide PO and 40 mg of furosemide PO daily. Today, at a routine clinic visit, the client’s serum potassium level is 4 mEq/L. What is the most likely cause of this client’s potassium level?

Which intervention(s) is(are) most helpful in evaluating the effectiveness of nursing and medical treat-ments for dehydration in a 36-month-old child? (Select all that apply.)

A very busy hospital unit has had several discharges and the census is unusually low. What is the best way for the charge nurse to use the time of the nursing staff?

A patient with diarrhea has been prescribed loperamide 2 mg orally after each unformed stool. Which laboratory value will be most important for the nurse to monitor for this patient?

A critical care nurse is planning an interdisciplinary team conference regarding placement for a long-term ventilator patient. Team members include representatives from nursing, respiratory therapy, case management, physical therapy, dietary, and pharmacy. Which QSEN competencies are reflected by this team? (Select all that apply.)

A comatose client is admitted to the critical care unit, and a central venous catheter is inserted by the health care provider. What is the priority nursing assessment before initiating IV fluids?

A client reports experiencing dysuria and urinary frequency. Which client teaching should the nurse provide?

When caring for a postpartum client, which intervention is best for the nurse to implement to promote increased peripheral vascular activity?

The nurse assesses a client while the UAP measures the client’s vital signs. The client’s vital signs change suddenly, and the nurse determines that the client’s condition is worsening. The nurse is unsure of the client’s resuscitative status and needs to check the client’s medical record for any advanced directives. Which action should the nurse implement?

A client is admitted to the mental health unit with a chief complaint of crying, depressed mood, and sleeping difficulties. While talking about the death of a friend, the client states, “I can’t believe this happened.” Which statement by the nurse is most therapeutic?

The nurse assists the health care provider with an amniocentesis during the third trimester of pregnancy. Which intervention(s) would the nurse expect to implement after the procedure? (Select all that apply.)

A 40-year-old office worker who is at 36 weeks’ gestation presents to the occupational health clinic complaining of a pounding headache, blurry vision, and swollen ankles. Which intervention should the nurse implement first?

According to Erikson, which client should the nurse identify as having difficulty completing the developmental stage of older adults?

A client with glomerulonephritis is scheduled for a creatinine clearance test to determine the need for dialysis. Which information should the nurse provide the client prior to the test?

A nurse is planning client care and wants to verify the steps for a specific client procedure. Which action should the nurse take?

The RN is preparing to administer drugs to a group of patients with gastrointestinal disorders. Which drug is most important to discuss with the health care provider before administration?

What instruction(s) related to foot care is(are) appropriate for the client with type 1 diabetes mellitus? (Select all that apply.)

A client with small cell carcinoma of the lung has also developed syndrome of inappropriate antidiuretic hormone (SIADH). Which outcome finding is the priority for this client?

A client with acute renal failure (ARF) starts to void 4 L/day 2 weeks after treatment is initiated. Which complication is important for the nurse to monitor the client for at this time?

A five year old is in Bryant’s traction for intervention for a fractured femur. Which finding by the nurse would require intervention?

The charge nurse overhears a staff member asking for a doughnut from a client’s meal tray. Which action should the charge nurse implement?

The nurse is obtaining a client’s sexual history. Which finding requires additional follow-up regarding the client’s self-image?

The nurse is leveling and reserving the patient’s hemodynamic line upon returning from the radiology department. The patient asks the nurse, “Why are you doing that?” What is an appropriate response? (Select all that apply.)

A nurse-manager of a long-term care facility learns that the nursing administrator plans to remove the television from the residents’ day room because night shift staff members are sitting around watching television. How should the nurse-manager respond to this situation?

The nurse is teaching a client newly diagnosed with diabetes mellitus about the subcutaneous administration of regular and NPH insulin. Which statement indicates that the client needs further instruction?

A 77-year-old female client states that she has never been so large around the waist and that she has frequent periods of constipation. Colon disease has been ruled out with a flexible sigmoidoscopy. Which information should the nurse provide to this client?

Until the census on the obstetrics (OB) unit increases, an unlicensed assistive personnel (UAP) who usually works in labor and delivery and the newborn nursery is assigned to work on the postoperative unit. Which client would be best for the charge nurse to assign to this UAP?

The nurse formulates a nursing diagnosis of pain related to muscle spasms for a client with extreme lower back pain associated with acute lumbosacral strain. Which is the best intervention for the nurse to implement?

Upon assessing a newborn male, the nurse finds the urethral meatus opens on ventral side of penis behind the glans. The nurse would recognize this finding is consistent with which finding?

Which pathophysiologic response supports the contraindication for opioids, such as morphine, in clients with increased intracranial pressure (ICP)?

A child is having a generalized tonic-clonic seizure. Which action should the nurse take?

The client with which fasting plasma glucose level needs the most immediate intervention by the nurse?

A 2-day postpartum mother who is breastfeeding asks, “Why do I feel this tingling in my breasts after the baby sucks for a few minutes?” Which information should the nurse provide?

A mother of a 12-year-old boy states that her son is short and she fears that he will always be shorter than his peers. She tells the nurse that her grown daughter only grew 2 inches after she was 12 years of age. To provide health teaching, which question is most important for the nurse to ask this mother?

A patient is admitted with syncope, exertional dyspnea, and a systolic murmur. Cardiac catheterization reveals significantly increased left ventricular end-diastolic pressure (LVEDP). The nurse suspects the patient may be experiencing which problem?

The nurse administers levothyroxine to a client with hypothyroidism. Which data indicate(s) that the drug is effective? (Select all that apply.)

The health care provider prescribes 1000 mL of a D₅W solution to infuse over 8 hours for a client who has had an appendectomy. The IV tubing being used delivers 15 gtt/mL. The nurse should set the flow rate at how many gtt/min? (If rounding is necessary, round to the nearest whole drop.)

The nurse instructs the client taking St. John’s wort that which food preferred by the client may be safely consumed while taking this herb?

After administration of a 0730 dose of Humalog 50/50 insulin to a client with diabetes mellitus, which nursing action has the highest priority?

The nurse is assisting a father to change the diaper of his 2-day-old infant. The father notices several bluish-black pigmented areas on the infant’s buttocks and asks the nurse, “What did you do to my baby?” Which response is best for the nurse to provide?

A client with hemiparesis needs assistance transferring from the bed to the wheelchair. The nurse assists the client to a sitting position on the side of the bed. Which action should the nurse implement next?

A client with human immunodeficiency virus (HIV) infection has white lesions in the oral cavity that resemble milk curds. Nystatin preparation is prescribed as a swish and swallow. Which information is most important for the nurse to provide the client?

A client with rhabdomyolysis tells the nurse about falling while going to the bathroom and lying on the floor for 24 hours before being found. Which current client finding is indicative of renal complications?

Which client would benefit from the therapeutic effects of garlic? Select all that apply.

The RN is caring for a client who is in skeletal traction. Which activity should the RN assign to the PN?

A client with acquired immunodeficiency syndrome (AIDS) is hospitalized after a recent discharge. Which nursing intervention is most important in reducing the client’s stress associated with repeated hospitalization?

Which situation demonstrates proper application of client confidentiality requirements for the Health Insurance Portability and Accountability Act (HIPAA)?

A client hospitalized for meningitis is demonstrating nuchal rigidity. Which symptom is this client likely to be exhibiting?

The nurse would be correct in withholding a dose of digoxin in a client with congestive heart failure without specific instruction from the health care provider if which finding was documented?

The nurse is developing a health risk assessment protocol for use in a well-baby clinic in a low-income neighborhood. Which information is most important for the nurse to include in the assessment?

The nurse is preparing assignments for the day shift. Which client should be assigned to the staff RN rather than a PN?

Which care management tools can be modified by the nurse to individualize patient care? (Select all that apply.)

Which question is most relevant to ask the parents when obtaining the history of a 2-year-old child recently diagnosed with otitis externa?