A 56-year-old client underwent an abdominal perineal resection with creation of a colostomy 8 hours ago. During the postoperative assessment, the nurse inspects the stoma site. Which finding should the nurse expect at this early stage after surgery?

A 25-year-old woman arrives at the birthing unit in active labor. During the admission assessment, the nurse asks about her marital status. The client becomes visibly upset, refuses to answer, and tells the nurse to leave her alone. What is the nurse’s best response?

A 5-week-old infant is admitted to the pediatric unit with a suspected congenital heart defect. The nurse observes that the infant becomes easily fatigued, breathes rapidly, and struggles during feedings. In which position should the nurse place the infant to promote optimal breathing and comfort?

A 48-year-old client who received a kidney transplant 3 weeks ago returns for follow-up. Laboratory results reveal leukopenia. The nurse reviews the client’s medication list and health history. Which factor should the nurse recognize as the most likely cause of the leukopenia?

A 30-year-old pregnant woman with a history of rheumatic heart disease visits the prenatal clinic for nutritional counseling. The nurse discusses dietary recommendations to support her pregnancy and cardiac health. What should the nurse advise this client to do?

A 32-year-old woman who is 5 months pregnant and has a history of mitral valve disease visits the prenatal clinic for dietary guidance. The nurse emphasizes the importance of nutrition during pregnancy. What should the nurse advise this client to do?

At her 6-week postpartum checkup, a new mother tells the nurse she plans to stop breastfeeding when she returns to work in 2 months and will feed her baby whole cow’s milk instead. The nurse explains that whole milk is not appropriate for infants because it lacks adequate amounts of which nutrients?

A 45-year-old client receiving a blood transfusion develops chills, fever, and flank pain. The transfusion is stopped, and a reaction is suspected. Later, the nurse monitors the client for signs of kidney damage related to the transfusion reaction. Which assessment finding is most significant in determining renal impairment?

A 58-year-old client with end-stage renal disease (ESRD) is receiving maintenance hemodialysis and reports nausea, fatigue, and a metallic taste in the mouth. The nurse recognizes these as signs of uremia and provides dietary teaching. The nurse should instruct the client to limit the intake of which nutrient to help control uremia?

A 60-year-old client with chronic kidney disease is undergoing peritoneal dialysis at the bedside. During the procedure, the nurse monitors the client’s condition and the dialysate flow. What should the nurse do to ensure the dialysis is performed safely and effectively?

A school nurse is caring for a 7-year-old child with cerebral palsy. The nurse recognizes that, although the child has the same developmental needs as peers without disabilities, physical and cognitive limitations affect how these needs are met. What effect should the nurse expect these limitations to frequently have on the child?

A 42-year-old client is admitted to the alcohol detoxification unit after being found intoxicated at home. During the initial assessment, the nurse evaluates for early signs of alcohol withdrawal. Which clinical manifestation should the nurse expect during the initial stage of detoxification?

A 50-year-old client undergoes an abdominal cholecystectomy with a T-tube placed for bile drainage. On the day of surgery, at 10:30 PM, the T-tube collection bag contains 300 mL of bile. At 6:30 AM the following morning, the bag contains 60 mL. How should the nurse interpret this change in bile output?

A 28-year-old client is brought to the emergency department after being beaten and sexually assaulted. The client is anxious and visibly injured. As the nurse begins the assessment, which aspect should be addressed first?

An 82-year-old client with heart failure is admitted with shortness of breath and confusion. The health care provider orders oxygen therapy via nasal cannula at 2 L/min. Which nursing action should be performed first?

A 65-year-old client is admitted to the ICU in a coma following a stroke. The health care provider orders oropharyngeal suctioning as needed. During assessment, the nurse notes certain clinical signs. Which finding indicates that suctioning is required?

A parent of three young children is diagnosed with tuberculosis (TB). During the home assessment, the nurse learns that family members have been exposed. Which treatment should the nurse expect the health care provider to prescribe for children who have a positive tuberculin skin test and are candidates for therapy?

A 50-year-old client is diagnosed with varicose veins and expresses concern about managing symptoms. During a teaching session about the condition, the client asks, “What can I do to help myself?” How should the nurse respond?

A 19-year-old client with anorexia nervosa is admitted to the hospital with extreme weight loss, weakness, and dizziness. During the initial assessment, the nurse plans care. What should be the priority treatment for this client at this time?

A 38-year-old client with acquired immunodeficiency syndrome (AIDS) is started on a treatment protocol that includes a protease inhibitor. During follow-up, the nurse assesses the client for expected side effects. Which common adverse effect should the nurse anticipate?

A 60-year-old client is prescribed warfarin (Coumadin) for atrial fibrillation. During a teaching session on diet and medication interactions, the nurse asks which foods or drinks the client should avoid. Which response indicates that the teaching has been effective?

A 7-year-old child diagnosed with attention deficit hyperactivity disorder (ADHD) is prescribed medication to manage symptoms. During a parent-teacher conference, the school nurse discusses the child’s treatment plan. What key information should the nurse emphasize to the parents?

A 72-year-old client is scheduled for cataract surgery and receives preoperative teaching from the nurse. The client asks what precautions are necessary after the procedure. Which instruction is most important for the nurse to include?

A nurse is supervising a recently hired nursing assistant who is providing care for a debilitated, bedbound client. During observation, the nurse notes one of the interventions being performed that may compromise client safety. Which action requires the nurse to intervene immediately?

A 62-year-old client with chronic renal failure is receiving epoetin (Epogen) to treat anemia. During a follow-up visit, the nurse reviews the client’s understanding of the medication. Which statement by the client indicates that further teaching is needed?

A 25-year-old client arrives at the emergency department experiencing an acute asthma attack with labored breathing and wheezing. Which position is most appropriate to help the client breathe more effectively?

A 68-year-old client with chronic obstructive pulmonary disease (COPD) is admitted to the hospital with shortness of breath and low oxygen saturation. Which position should the nurse use to maximize gas exchange?

A 45-year-old client undergoes a tympanoplasty to repair a perforated eardrum. Postoperatively, the nurse plans care to protect the surgical site. Which position should the nurse maintain the client in?

A 60-year-old client is admitted to the ICU after undergoing open-heart surgery. To promote optimal recovery and respiratory function, which position should the nurse maintain the client in?

A 58-year-old client is recovering in the ICU after cardiac surgery. To promote optimal oxygenation and reduce cardiac workload, which position should the nurse place the client in?

A 2-year-old toddler has just undergone surgical repair of a cleft palate. During postoperative care, the nurse plans the child’s positioning to protect the surgical site and promote healing. How should the nurse position the child?

A 6-month-old infant has recently undergone placement of a ventriculoperitoneal (VP) shunt for hydrocephalus. During assessment, the nurse notes that the anterior fontanelle is bulging, suggesting increased intracranial pressure. How should the nurse position the infant?

A 70-year-old client has just undergone cataract removal surgery on the right eye. During postoperative care, the nurse plans how to position the client to protect the surgical site and promote healing. Which position is most appropriate?

A 45-year-old client is admitted for a neurological workup and scheduled for a spinal tap (lumbar puncture). During preparation, the nurse plans the client’s positioning to ensure safety and ease of the procedure. Which position should the nurse place the client in?

A 65-year-old client with decreased consciousness requires oropharyngeal suctioning to maintain airway patency. To perform this procedure safely and effectively, how should the nurse position the client?

A 32-year-old client has just undergone surgery with spinal anesthesia. The nurse educates the client on measures to prevent post-spinal headache. How should the nurse position the client?

A 40-year-old client with a spinal cord injury at T6 suddenly develops autonomic hyperreflexia, presenting with severe hypertension, headache, and sweating. What is the first action the nurse should take to manage this condition?

A 78-year-old client with dysphagia and limited mobility is admitted to the hospital. To reduce the risk of aspiration pneumonia, the nurse plans interventions during meals and care. Which action should the nurse prioritize?

A 65-year-old client with stroke-related dysphagia is receiving continuous enteral feeding via a nasogastric tube. Which nursing action is essential to ensure safe and effective nutrition delivery?

A 55-year-old client is admitted to the emergency department with hypovolemic shock following severe blood loss. To support circulation and perfusion, in which position should the nurse place the client?

A 68-year-old client is admitted to the stroke unit after a cerebrovascular accident (CVA) and demonstrates altered consciousness. To maintain airway patency and reduce complications, in which position should the nurse place the client?

A 72-year-old client has just undergone right eye cataract removal and is preparing for discharge. The nurse provides home care instructions to the client and family. Which statement by the client indicates understanding of the teaching?

A 60-year-old client is one day post below-knee amputation. The nurse observes that the stump is actively hemorrhaging. What action should the nurse take first to manage this situation?

A 72-year-old male client undergoes a total hip replacement due to long-standing degenerative hip disease. During the postoperative assessment, the nurse considers potential complications. Which is the most common complication following hip surgery?

A 60-year-old client is three days post right below-the-knee amputation. The client reports pain in the right foot and requests pain medication. What is the nurse’s initial appropriate action?

A 35-year-old client presents to the emergency department after a fall from a ladder and reports severe pain in the forearm. During the assessment, the nurse looks for signs that may indicate a possible fracture. Which manifestation would raise suspicion?

A 65-year-old client undergoes an above-the-knee amputation. Forty-five minutes after surgery in the postanesthesia care unit (PACU), the nurse observes a dime-sized bright red spot on the dressing. What is the nurse’s next action?

A 25-year-old client has had a lower extremity cast applied three days ago for a fractured tibia. The client reports swelling and discomfort in the leg. How should the nurse intervene to relieve swelling?

A 48-year-old client with multiple sclerosis (MS) is experiencing bowel incontinence and constipation. The nurse is developing a bowel-retraining plan. Which measure is likely to be least helpful in managing the client’s bowel function?

A 60-year-old diabetic patient with foot gangrene undergoes an above-knee amputation. During a dressing change, the patient complains of pain in the same (amputated) knee. What is the nurse’s most appropriate action?

A 60-year-old diabetic patient who recently underwent an above-knee amputation for foot gangrene complains of severe pain and swelling at the surgical site. The wound is oozing pus with a foul odor. The physician has prescribed cephalexin and metronidazole. Which of the following should the nurse do immediately?

A 55-year-old client is scheduled for colon surgery in the morning. To prepare for the procedure, the physician prescribes a cleansing enema. The nurse is preparing to administer the enema. In which position should the nurse place the client?

A nurse is preparing to administer a rectal enema to a 50-year-old client with constipation. The client is positioned in the left Sims’ position. On which side of the patient should the nurse stand while inserting the enema?

A nurse is administering a soapsuds enema to a client before a diagnostic procedure. During the instillation, the client suddenly complains of abdominal cramping and discomfort. What should the nurse do next?

A nurse is preparing to administer a cleansing enema to an adult client who is constipated. To ensure safe and effective administration, the nurse must carefully insert the enema tubing into the client’s rectum. What is the appropriate insertion distance?

A nurse is caring for a patient with acute decompensated heart failure (ADHF) who is receiving IV furosemide (Lasix) 40 mg and enalapril (Vasotec) 5 mg PO twice daily. The patient previously experienced severe orthopnea and shortness of breath. Which of the following findings best indicates that the treatment has been effective?

A nurse is preparing to insert a Ryle’s tube (nasogastric tube) into an infant for gastric decompression. Before insertion, the nurse must determine the correct length of the tube to ensure accurate placement. How should the nurse measure the length of the tube?

A nurse is caring for a client with a chest tube connected to a water-seal drainage system following surgery for a pneumothorax. During assessment, the nurse evaluates the drainage system for proper function. Which of the following findings indicates that the system is functioning correctly?

A nurse is caring for a client who has just had a chest tube inserted and connected to a water-seal drainage system following a left-sided pneumothorax. To ensure that the system is functioning effectively, what should the nurse do?

A nurse enters the room of a client with a chest tube connected to a water-seal drainage system and finds that the chest tube has accidentally dislodged from the client’s chest. What should the nurse do immediately?

A nurse enters the room of a client with a chest tube connected to a water-seal drainage system and discovers that the chest tube has become dislodged from the client’s chest. What is the most appropriate immediate nursing intervention?

A patient with a chest tube connected to a Pleur-evac drainage system accidentally disconnects the tube while attempting to get out of bed. What should the nurse do first?

A 35-year-old patient with second- and third-degree burns over 40% of the body is admitted to the burn unit. To prevent infection and protect the patient’s compromised skin, which type of isolation should the nurse implement?

A 7-year-old child is admitted to the hospital with diphtheria, presenting with a thick gray membrane in the throat and mild fever. To prevent transmission to others, which type of isolation should the nurse implement?

A 68-year-old woman with acute lymphocytic leukemia is admitted to the hospital and diagnosed with thrombocytopenia. To minimize her risk of infection and bleeding, what type of room assignment should the nurse make?

A nurse is administering medications to a client via a nasogastric (NG) feeding tube when she suspects that the tube has become clogged. What is the first safe action the nurse should take?

A female client who underwent a cholecystectomy reports experiencing abdominal upset and mild discomfort during the postoperative period. Which of the following instructions should the nurse provide to help manage her symptoms?

A nurse is preparing to administer digoxin to a client with heart failure. To ensure safe administration, which pulse should the nurse assess before giving the medication?

A nurse is preparing to administer digoxin to a client diagnosed with congestive heart failure. To ensure the client’s safety, which pulse should the nurse assess before giving the medication?

A nurse is preparing to administer digoxin to a client with heart failure. Which of the following interventions should the nurse perform to ensure safe administration?

A nurse is preparing to administer digoxin to a client with heart failure. The nurse must determine whether it is safe to give the medication. At which pulse rate should the nurse withhold digoxin?

A nurse is caring for a client receiving digoxin for heart failure. During assessment, the nurse suspects digitalis toxicity. Which of the following signs and symptoms should the nurse recognize as indicators of toxicity?

A client is newly admitted to the hospital and takes digoxin 0.25 mg/day for heart failure. The nurse plans to monitor the client’s laboratory values. What is the therapeutic serum range for digoxin that indicates safe and effective dosing?

A patient reports severe pain rated 9/10. The physician has ordered morphine 50 mg IV every 4 hours, and the last dose was administered 2 hours ago. What is the best action for the nurse to take?

A patient was admitted 1 week ago with an acute spinal cord injury at T6. While performing a routine assessment, the nurse notices several changes in the patient’s condition. Which of the following findings would most likely indicate autonomic dysreflexia (hyperreflexia)?

A patient with severe dysphagia is unable to swallow food safely and is at risk for aspiration. The healthcare team is planning for long-term nutritional support. Which of the following methods is the most appropriate for this patient?

A patient’s daily records indicate the following: 650 mL IV normal saline, 50 mL orange juice via NG tube, and 100 mL water with medications via NG tube. The nurse needs to calculate the patient’s total fluid intake for the shift. What is the total intake?

A physician orders 10,000 units of heparin for a patient. The available heparin concentration is 40,000 units/mL. How much should the nurse administer?

A client with a fracture develops a deep vein thrombosis (DVT) in the opposite extremity. The physician orders a heparin drip: D5W 250 mL containing 12,500 units of heparin, to be infused at 16 mL/hr. How many units of heparin per hour is the client receiving?

A patient presents with diarrhea and muscle weakness. The nurse suspects an electrolyte imbalance and prepares to review the patient’s laboratory results. Which abnormal lab value is most likely in this patient?

A client is receiving mannitol for the management of increased intracranial pressure (ICP). When assessing for therapeutic effects, what should the nurse expect to observe?

A patient is admitted to the emergency department after a head trauma from an accident and is diagnosed with increased intracranial pressure (ICP). Which of the following medications would the nurse anticipate being used to help reduce ICP?

A patient is admitted with cerebral edema following a stroke. The physician orders medication to reduce the swelling in the brain. Which of the following drugs is considered the drug of choice for treating cerebral edema?

A client is receiving intravenous heparin for the treatment of a deep vein thrombosis. To determine the effectiveness and safety of the therapy, which laboratory value should the nurse monitor?

A patient receiving heparin therapy develops signs of excessive bleeding. The nurse prepares to administer the antidote to reverse the effects of heparin. Which medication should be given?

A patient is receiving Coumadin (warfarin) for the prevention of thromboembolism. To monitor the effectiveness of the therapy, which laboratory test should the nurse evaluate?

A patient receiving a narcotic analgesic for severe pain develops respiratory depression, extreme sedation, and pinpoint pupils. Which medication should the nurse anticipate to reverse these severe adverse effects?

A patient on warfarin (Coumadin) therapy is admitted to the hospital with gastrointestinal bleeding. To reverse the effects of anticoagulation, which substance should the nurse anticipate administering?

A patient is admitted to the emergency department for acetaminophen (paracetamol) overdose. To prevent liver toxicity, the nurse prepares to administer which of the following medications?

A nurse realizes that she has administered an antihypertensive medication intended for another patient. What is the most appropriate immediate action she should take?

A physician orders an arterial blood gas (ABG) for a patient experiencing respiratory distress. Which artery is the nurse most likely to use to obtain the specimen?

A client has an order for arterial blood gases (ABGs) to be drawn from the radial artery. Before performing the procedure, what should the nurse ensure is positive to safely proceed?

A client is scheduled for arterial blood sampling from the radial artery for ABG analysis. The nurse assists with performing Allen’s test before the procedure. What is the nurse assessing with this test?

A nurse is administering an enema to a preoperative client. After approximately half of the solution has been instilled, the client complains of abdominal pain and cramping. What is the most appropriate nursing action?

A client is receiving total parenteral nutrition (TPN) via a central line. Which complication should the nurse prioritize when assessing this client?

A client has a nasogastric (NG) tube in place following a gastric resection. What should the nurse expect to observe regarding the NG tube output in the immediate postoperative period?

A client with hypoparathyroidism is being assessed. When the nurse taps the client’s facial nerve, the client exhibits twitching of the mouth and tightening of the jaw. How should the nurse document this finding?

A client with type 2 diabetes mellitus presents to the clinic. The nurse notes that the client’s blood glucose levels are very high. Which of the following clinical manifestations is most likely to occur?

A client is admitted with severe hyperthyroidism (thyrotoxicosis). Which of the following clinical findings should the nurse expect to observe?

A client has been receiving long-term high-dose corticosteroid therapy. Which of the following clinical manifestations should the nurse expect to observe?