What should the nurse do to assess the neurovascular status of an extremity casted from the ankle to the thigh?
A client who has breast cancer had post lumpectomy chemotherapy and is now scheduled for radiation on an outpatient basis. What is an important nursing intervention while the client is receiving radiation?
A client’s problem with ineffective control of type 1 diabetes is identified when a sudden decrease in blood glucose level is followed by rebound hyperglycemia. What should the nurse do when this event occurs?
A client with the diagnosis of personality disorder with antisocial behaviour is hospitalized. The client is openly discussing interpersonal difficulties with family members and the boss at work from whom money has been stolen. The client presently is facing criminal charges. Which behaviour indicates that the client is meeting treatment goals?
A client with severe preeclampsia is hospitalized. What should a nurse do first to ensure her physical safety?
Which statement by a client with type 2 diabetes indicates to the nurse that additional teaching about the diet is needed?
A child is found to be allergic to dust. The nurse is preparing a teaching plan for the parents. What should the nurse include in the plan?
A client who has just started on a regimen of haloperidol (Haldol) is observed pacing and shifting weight from one foot to another. What side effect does the nurse document in the client’s chart?
A client who has been on a psychiatric unit for several weeks continually talks about delusional material. What response by the nurse is most therapeutic?
A client has a tonic-clonic seizure. What is the priority nursing intervention during the tonic-clonic stage of the seizure?
A nurse admits an adolescent to the psychiatric unit with the diagnosis of anorexia nervosa. What is the primary gain a client with anorexia achieves from this disorder?
A nurse is caring for a newborn with a myelomeningocele. What should immediate nursing care for this infant include?
The cervix of a client in labor is dilated 8 cm. She tells a nurse that she has a desire to push and is becoming increasingly uncomfortable. She requests pain medication. How should the nurse respond?
A nurse administers an intramuscular injection of vitamin K to a newborn. What is the purpose of the injection?
A child with acute poststreptococcal glomerulonephritis requests a snack. Which is the most therapeutic selection of food the nurse can provide?
A client reports experiencing nausea, dyspnea, and right upper quadrant pain unrelieved by antacids.The pain occurs most often after eating in fast-food restaurants.Which diet should the nurse instruct the client to follow?
A person sustains deep partial-thickness burns while working on a boat in a town marina and seeks advice from the nurse in the first aid station. The nurse encourages the client to seek medical attention, but the client refuses. The nurse advises the person to go to a health care provider if:
A client with a history of gambling has legal difficulties for embezzling money and is required to obtain counseling. During an intake interview, the client says, “I never would have done this if I had been paid what I am worth.” What factor will create the greatest difficulty when assisting this client to develop insight?
A client has a urinary retention catheter in place after surgery. What should the nurse do when planning for the client’s safety needs in relation to this device?
What is the most important test the nurse should check to determine whether a transplanted kidney is functioning?
A pregnant adolescent at 10 weeks’ gestation visits the prenatal clinic for the first time. The nutrition interview indicates that her dietary intake consists mainly of soft drinks, candy, French fries, and potato chips. Why does the nurse consider this diet inadequate?
A nurse in the prenatal clinic is assessing a woman at 34 weeks’ gestation. The client’s blood pressure is 166/100 mm Hg and her urine is +3 for protein. She states that she has a severe headache and occasional blurred vision. Her baseline blood pressure was 100/62 mm Hg. What is the priority nursing action?
A child has cystic fibrosis. Which statement by the parents about their plan for the child’s dietary regimen provides evidence that they understand the nurse’s instructions?
A nurse is caring for a client with glaucoma. What rationale associated with the need for treatment of this condition should the nurse include in a teaching program?
A nurse is caring for a client with a below-the-knee amputation. What should the nurse encourage the client to do to prepare the residual limb for a prosthesis?
A client is admitted to the hospital with a diagnosis of an exacerbation of asthma. What should the nurse plan to do to best help this client
A health care provider orders daily sputum specimens to be collected from a client. When is the most appropriate time for the nurse to collect these specimens?
Which factor is essential to consider when a nurse evaluates whether a unit environment is conducive to psychologic safety for a confused client with dementia?
A client is extubated in the postanesthesia care unit after surgery. For which common response should the nurse be alert when monitoring the client for acute respiratory distress?
An IV infusion of magnesium sulfate is prescribed for a client with severe preeclampsia. The dose is twice the usual adult dose. When a nurse questions the dosage, the health care provider insists that it is the desired dose and directs the nurse to administer the medication. How should the nurse respond to this directive?
Which nursing action should be included in the plan of care for a child with acute poststreptococcal glomerulonephritis?
A nurse is caring for an older adult who is taking acetaminophen (Tylenol) for the relief of chronic pain. Which substance is most important for the nurse to determine the client is taking because it intensifies the most serious adverse effect of acetaminophen?
The parents of a child who is dying of cancer ask the nurse whether they should tell their 7-yearold son that his sister is dying. What is the most appropriate response by the nurse?
A client with major depression is admitted to the hospital. What is the most therapeutic initial nursing intervention?
During the first trimester, a client tells a nurse at the prenatal clinic that she frequently feels nauseated. What should the nurse teach her about reducing the nausea?
A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD).What complications are most commonly associated with COPD?
A new parent asks a nurse how to care for the baby’s umbilical cord stump. What should the nurse include in the teaching?
After resection of a lower lobe of the lung, a client has excessive respiratory secretions. Which independent nursing action should the nurse implement?
A health care provider explains a cystectomy and an ileal conduit to a client with invasive carcinoma of the bladder. Later the client expresses concerns about the possibility of offensive odors associated with this procedure. What is the best response by the nurse?
Using Piaget’s theory of cognitive development, what should the nurse expect a 6-month-old infant to demonstrate?
An internal fetal monitor is applied while a client is in labor. What should the nurse explain about positioning while the monitor is in place?
During a newborn assessment a nurse reports a sign of respiratory distress. What clinical manifestation did the nurse identify?
On the third postpartum day, a woman who is breastfeeding calls the nurse at the clinic and asks why her breasts are tight and swollen. What should the nurse consider before explaining why her breasts are engorged?
A person on the beach sustains a deep partial-thickness burn because of a severe sunburn. What is the best first-aid measure that a nurse should instruct the person to apply before seeking health care?
A nurse is assessing a newborn. What finding indicates the need for follow-up care?
A nurse is assessing a group of older adults. Which should the nurse consider to be least likely to be affected by aging?
What should be the initial nursingaction after the birth of a preterm infant with an Apgar score of 6?
Which is most important for the nurse to do when providing care to a client who has had a transurethral resection of the prostate?
A client on a psychiatric unit who has been hearing voices is receiving a neuroleptic medication for the first time. The client takes the cup of water and the pill and stares at them.What is the most therapeutic statement the nurse can make?
After a therapy session with a health care provider inthe mental health clinic, a client tells the nurse that the therapist is uncaring and impersonal. What is the nurse’s best response?
A client who has just had a kidney transplant is transferred from the postanesthesia care unit (PACU)to the intensive care unit (ICU). How often should the nurse in the ICU monitor the client’s urinary output?
A client who uses ritualistic behavior taps other clients on the shoulders three times while going through the ritual. The nurse infers that this client has a:
A pregnant client with severe preeclampsia is receiving IV magnesium sulfate. What should the nurse keep at the bedside to preparefor the possibility of magnesium sulfate toxicity?
A person who is hospitalized for alcoholism becomes boisterous and belligerent and verbally threatens the nurse.What is the most appropriate response by the nurse?
A family of a client with myasthenia gravis asks the nurse whether the client will be an invalid. What is the nurse’s best response?
A parent of a 2-year-old child who was just diagnosed with cystic fibrosis expresses concern about the child’s frailty and low weight. What is the nurse’s most appropriate reply?
During the first well-baby visit after discharge from thehospital, the parents inform the nurse that their baby has difficulty sucking and swallowing and tires easily. What should the nurse consider when assessing this infant?
For which clinical indicator should the nurse monitor a child with chronic hypoxia?
A nurse is caring for a client with a fracture of the head of the femur. The health care provider places the client in a Buck extension. What explanation does the nurse give the client for why the traction is being used?
A client has a total hip arthroplasty. What should the nurse do when caring for this client after surgery?
Which client in a psychiatric unit needs immediate therapeutic intervention from the nurse?
A client in a psychiatric hospital with the diagnosis of major depression is tearful and refuses to eat dinner after a visit with a friend. What is the most therapeutic nursingaction?
A person with a history of alcoholism states, “I have been drinking since last Friday to celebrate my son’s graduation from college.” What defense mechanism does the nurse identify the client is using?
The parents of a child with spasmodic croup ask why their child is receiving humidified oxygen. What effect of humidified oxygen should the nurse include in the explanation?
A client has a surgical creation of a colostomy. What is the most effective nursing intervention to initially help the client accept the colostomy?
When planning care for a child with autism, th nurse understands that given a choice, the child with autism usually enjoys playing:
A client who is at 26 weeks’ gestation arrives at the clinicfor her scheduled examination. Her blood pressure is 150/86. She tells the nurse that she has gained 5 pounds in the last 2 weeks. What is the priority nursing action?
What behavior does a nurse expect of a newborn about 1 hour after birth?
A client who has a phobia about dogs is about to begin systematic desensitization. The client asks what the treatment will involve. What is the nurse’s best response?
A nurse is providing dietary teaching for a client who is receiving a high-protein diet while recovering from an acute episode of colitis. What should the nurse include is the rationale for this diet?
A nurse is caring for a client experiencing an acute episode of bronchial asthma. What outcome should be achieved?
When a developmental appraisal is performed on a 6-monthold infant, which observation is most important to the nurse in light of a diagnosis of hydrocephalus?
A new mother refuses to look at her newborn who has a severe birth defect. What is the nurse’s most therapeutic approach?
When teaching a class about parenting, the nurse asks the participants what they do when their toddlers have a temper tantrum. Which statement demonstrates one parent’s understanding of the origin of temper tantrums?
A nursing assistant interrupts the performance of a ritual by a client with obsessive-compulsive disorder. What is the most likely client reaction?
When a nurse is working with a client with psychiatric problems, a primary goal is the establishment of a therapeutic nurse-client relationship. What is the major purpose of this relationship?
An African-American woman is diagnosed with primary hypertension. She asks, “Is hypertension a disease of African- American people?” What is the nurse’s best response?
A health care provider prescribes a diuretic for a client with hypertension. What should the nurse include in the teaching when explaining how diuretics reduce blood pressure?
A nurse is caring for a client who is receiving a thiazide diuretic for hypertension. Which food selected by the client indicates to the nurse that dietary teaching about thiazide diuretics was effective?
A 20-year-old college student comes to the college health clinic reporting increasing anxiety, loss of appetite, and an inability to concentrate. What is the most appropriate response by the nurse?
A nurse is caring for a client who attempted suicide. What is the most desirable short-term client outcome during this crisis situation?
A 31 2-year-old child is admitted to the hospital for an appendectomy. What should the nurse use to best prepare the child for the hospital experience?
A client with adrenal insufficiency reports feeling weak and dizzy, especially in the morning. What should the nurse determine is the most probable cause of these symptoms?
A client is admitted to the hospital with a diagnosis of chronic kidney failure. For signs of what electrolyte imbalance should the nurse monitor the client?
During her sixth month of pregnancy, a woman visits the prenatal clinic for the first time. As part of the initial assessment, a CBC and a urinalysis are performed. Which laboratory finding should alert the nurse that further assessment is required?
4. Glucose level of 1+ in the urine 95. Two hours after an uneventful labor and birth, a client’s uterus is four fingerbreadths above the umbilicus. After urinary catheterization, the fundus remains firm and four fingerbreadths above the umbilicus. What is the priority nursing action?
A client has a history of hypothyroidism. Which skin condition should the nurse expect when performing a physical assessment?
A nurse is caring for a client who has had an open reduction internal fixation of a fractured hip. Which nursing assessment of the affected leg is most important after this surgery?
A nurse is caring for a client with myxedema who has undergone abdominal surgery. What should the nurse consider when administering opioids to this client?
A nurse is caring for a child with spasmodic croup. Which clinical finding alerts the nurse that immediate nursing intervention is required?
What must the nurse emphasize to the family when preparing a child with persistent asthma for discharge?
An older adult with dementia is admitted to a nursing home. The client is confused, agitated, and at times unaware of the presence of others. What is the best nursing approach to help this client adapt to the unit?
The parents of a child with a fever, headache, and stiff neck express concern that the child be tested for meningitis. Which test should the nurse explain to the parents is used to confirm the diagnosis of meningitis?
A nurse is caring for a client after a left pneumonectomy for cancer. The nurse palpates the client’s trachea routinely. What is the rationale for this nursing intervention?
A CBC, urinalysis, and x-ray examination of the chest are ordered for a client before surgery. The client asks why these tests are done. Which is the best reply by the nurse?
A client is scheduled for emergency abdominal surgery. What is the priority preoperative nursing objective when caring for this client?
An infant born with hydrocephalus is to be discharged after insertion of a ventriculoperitoneal shunt. Which common complication of this type of surgery should the nurse explain to the parents to prepare them for their child’s discharge?
Parents are considering a bone marrow transplant for their child who has recurrent leukemia. The parents ask the nurse for clarification about the procedure. What is the best response by the nurse?
What is most important for a nurse to do when helping a new mother on the postpartum unit develop her parenting role?
When performing a newborn assessment after a vaginal birth, a nurse observes a swelling on one side of the top of the head. What clinical manifestation did the nurse identify?