A nurse is assessing a client 8 hours after the creation of a colostomy. Which assessment finding should the nurse expect?

When admitting a client who is in labor to the birthing unit, a nurse asks the client about her marital status. The client refuses to answer and becomes very agitated, telling the nurse to leave. How should the nurse respond?

A 5-week-old infant is admitted to the hospital with a tentative diagnosis of a congenital heart defect. The infant tires easily and has difficulty breathing and feeding. In what position should the nurse place this infant?

Three weeks after a kidney transplant, a client develops leukopenia. Which factor should the nurse conclude is the most probable cause of the leukopenia?

A nurse in the prenatal clinic is providing nutritional counseling for a pregnant woman with a cardiac problem. What should the nurse advise the client to do?

Control the number of calories consumed.

On a 6-week postpartum visit, a new mother tells a nurse she wants to feed her baby whole milk after 2 months because she will be returning to work and can no longer breastfeed. The nurse plans to teach her that she should switch to formula feeding because whole milk does not meet the infant’s nutritional requirements for which constituents?

A client develops kidney damage as a result of a transfusion reaction. What is the most significant clinical response that the nurse should assess when determining kidney damage?

A nurse is caring for a client with chronic kidney failure. What should the nurse teach the client to limit the intake of to help control uremia associated with end-stage renal disease (ESRD)?

What should the nurse do when caring for a client who is receiving peritoneal dialysis?

Children with special needs have the same needs as those without special needs, although their means of satisfying these needs may be limited. What effect should the nurse expect that these limitations will frequently cause in the child?

A nurse assesses a client recently admitted to an alcoholdetoxification unit. What common clinical manifestation should the nurse expect during the initial stage of alcohol detoxification?

After an abdominal cholecystectomy, a client has a T-tube attached to a collection device. On the day of surgery, at 10:30 PM, 300 mL of bile is emptied from the collection bag. At 6:30 AM the next day, the bag contains 60 mL of bile. What should the nurse consider in response to this information?

A nurse in the emergency department is assessing a client who was beaten and sexually assaulted. Which is the nurse’s priority assessment?

A health care provider orders oxygen therapy via nasal cannula at 2 L/min for an older, confused client with heart failure. Which nursing action is the priority?

A health care provider orders oropharyngeal suctioning as needed for a client in a coma. Which assessment made by the nurse indicates the need for suctioning?

A parent of three young children has contracted tuberculosis. Which should the nurse expect the health care provider to prescribe for members of the family who have a positive reaction to the tuberculin skin test and are candidates for treatment?

A client is diagnosed with varicose veins, and the nurse teaches the client about the pathophysiology associated with this disorder. The client asks, “What can I do to help myself?” What should the nurse respond?

A nurse is caring for a newly admitted client with anorexia nervosa. What is the priority treatment for the client at this time?

A client with acquired immunodeficiency syndrome (AIDS) is receiving a treatment protocol that includes a protease inhibitor. When assessing the client’s response to this drug, which common side effect should the nurse expect?

A nurse teaches a client about warfarin (Coumadin). Which juice to avoid identified by the client indicates that the teaching is effective?

Medication is prescribed for a 7-year-old child with attention deficit hyperactivity disorder (ADHD). What information should the school nurse emphasize when discussing this child’s treatment with the parents?

A nurse performs preoperative teaching for a client who is to have cataract surgery. Which is most important for the nurse to include concerning what the client should do after surgery?

A nurse is supervising a recently hired nursing assistant who is caring for a debilitated, bedbound client. What intervention being implemented necessitates the nurse to intervene?

A client is receiving epoetin (Epogen) for the treatment of anemia associated with chronic renal failure. Which client statement indicates to the nurse that further teaching about this medication is necessary?

Which of the following is the appropriate position for a patient who is suffering from acute asthma attack is:

A patient with COPD is admitted to the admitted to the hospital. How can the nurse best position the patient to improve gas exchange:

Following a tympanoplasty, the nurse should maintain the client in which position:

Which of the following is the proper position for a patient undergoing a cardiac surgery:

Which of the following is the proper position for a patient undergoing a cardiac surgery:

A nurse is caring for a toddler after surgical repair of a cleft palate. The nurse should position the child:

The nurse observes that the infant's anterior fontanelle is bulging after placement of a ventriculoperitoneal shunt. The nurse positions this infant:

A nurse is providing care for a client following surgery to remove a cataract from the right eye. In which position should the nurse place the client?

An adult is admitted for a neurological workup and is scheduled for a spinal tap. When preparing the client for the procedure, the nurse should position the client in which position:

When suctioning the oropharynx, which of the following is the proper position of the patient:

To prevent headache after spinal anesthesia the patient should be positioned:

If a patient develops autonomic hyperreflexia the first action his caring nurse should take is to:

To protect susceptible patients in the hospital from aspiration pneumonia, the nurse will plan to:

Which nursing action is essential when providing continuous enteral feeding?

Which of the following positions is appropriate for the patient who has hypovolemic shock:

When caring for a patient admitted post-stroke (CVA) who has altered consciousness, the nurse should place the patient in which position:

A nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions:

The day after an amputation, the client begins to haemorrhage from his stump. What action should the nurse take first:

A 72-year-old male client has a total hip replacement for long-standing degenerative bone disease of the hip. When assessing this client postoperatively, the nurse considers that the most common complication of hip surgery is:

The nurse is caring for a client who had a right below-the-knee amputation three days ago. The client complains of pain in the right foot and asks for pain medication. What nursing action is appropriate initially?

During the assessment of an injury for a possible fracture, which of the following manifestations would make you suspicious that a fracture has occurred:

A client who has had an above-the-knee amputation develops a dime-sized bright red spot on the dressing after 45 minutes in the postanesthesia recovery unit. The nurse should:

How you will interfere to relieve swelling of the lower extremity in a cast for 3 days now:

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:

A diabetic patient with foot gangrene undergone above knee amputation, while the nurse changing the dressing he complains of pain on the same knee which was amputated. What should the nurse do:

A diabetic patient with foot gangrene undergone above knee amputation he complain of pain and swelling at the wound site which is oozing bus and has a bad odor, the physician ordered cephalexin and metronidazole. Which of the following you should do immediately:

The physician has prescribed a cleansing enema to a client scheduled for colon surgery. The nurse would place the client:

At which side of the patient will the nurse stand when inserting a rectal enema:

While undergoing a soapsuds enema, the client complains of abdominal cramping. The nurse should:

The nurse must administer an enema to an adult patient with constipation. Which of the following would be a safe and effective distance for the nurse to insert the tubing into the patient's rectum:

The nurse is caring for a patient receiving IV furosemide (Lasix) 40 mg and Enalapril (Vasotec) 5 mg PO bid for ADHF with severe orthopnea. When evaluating the patient response to the medications, the best indicator that the treatment has been effective is:

The nurse in preparing to insert RYLE’S tube (NGT) into an infant, the nurse knows that the length of the tube should be taken as following:

The nurse is caring for a client who has had a chest tube inserted and connected to water seal drainage. The nurse determines the drainage system is functioning correctly when which of the following is observed:

The nurse is caring for a client who has just had a chest tube attached to a water seal drainage system. To ensure that the system is functioning effectively the nurse should:

The nurse enters the room of a client who has a chest tube attached to a water seal drainage system and notices the chest tube is dislodged from the chest. The most appropriate nursing intervention is to:

which type of isolation category is indicated for patient with tuberculosis:

While attempting to get out of bed, a patient accidentally disconnects the chest tube from the Pleur-evac drainage system. Which of the following actions should the nurse take first?

which type of isolation category is indicated for a burn patient:

which type of isolation category is indicated for patient with diphtheria:

A 68-years-old woman diagnosed with thrombocytopenia due to acute lymphocytic leukemia is admitted to the hospital. The nurse should assign the patient to a:

A nurse who begins to administer medications to a client via a nasogastric feeding tube suspects that the tube has become clogged. The nurse should take which safe action first:

Which of the following instructions is appropriate for the nurse to give to a female client a who complains of abdominal upset after cholecystectomy operation:

Which of the following pulses should be checked before administrating Digoxin:

Which of the following pulses should be checked before administrating Digoxin:

which of the following interventions must the nurse take when administrating digoxin to the patient:

The nurse must withhold Digoxin from a patient if his pulse rate is:

The nurse is assessing the client for possible evidence of digitalis toxicity. The nurse acknowledges that which is included in the signs and symptoms for digitalis toxicity:

A newly admitted client takes digoxin 0.25 mg/day. The nurse knows that the serum therapeutic range for digoxin is:

A patient complains of severe pain which he stated to be 9/10, the physician ordered morphine 50 mg IV every 4 hours, the last dose was given 2 hours ago, what is the best action his caring nurse would take:

The nurse is caring for a patient admitted 1 week agowith an acute spinal cord injury. Which of the following assessment findings would alert the nurse to the presence of autonomic dysreflexia (hyperreflexia)?

Which of the following is the best way for long term feeding for a patient experiencing severe dysphagia:

Patient records are as following, he had 650cc of IV fluid (n/s), 50 ml of orange Juice in the NG tube, 100 water with the medications, and urinate 500 cc, and 100 cc collected in the NG bag. What is the total intake for this patient?

The physician ordered to give the patient 10,000 unit of heparin, the preparation available is 40,000/ml. how much would the nurse give this patient:

The nurse is caring for a client with a fracture. The client develops a deep vein thrombosis in the opposite extremity. Physician orders include a heparin drip of D5W 250 mL with heparin 12,500 units at 16 mL/hr. How many units of heparin is this client receiving per hour:

A patient suffers from diarrhea and muscle weakness, the nurse would assess this patient for which of the following abnormal laboratory blood tests:

When assessing for therapeutic effects of mannitol, the nurse would expect to see:

Which drug would be used to treat a patient who has increased intracranial pressure (ICP) resulting from head trauma after an accident:

Which of the following is the drug of choice for treatment of cerebral edema:

The nurse would assess which laboratory value to determine the effectiveness of intravenous heparin:

The antidote to heparin is:

How do we monitor the effectiveness of Coumadin (Warfarin):

Which medication is used to treat a patient suffering from severe adverse effects of a narcotic analgesic:

A patient who has been anticoagulated with warfarin (Coumadin) is admitted with gastrointestinal bleeding. The nurse will anticipate administering which substance

While admitting a patient for treatment of an acetaminophen overdose, the nurse prepares to administer which of the following medications to prevent toxicity:

If the nurse gave a patient antihypertensive drug that is prescribed for another patient, what should she do:

When a physician orders an arterial blood gas, which artery is the appropriate one to use to obtain the specimen:

A client has an order to have a set of arterial blood gases (ABG's) drawn. The intended site is the radial artery. The nurse ensures that which of the following is positive before the ABGs are drawn

A client is scheduled for blood to be drawn from the radial artery for an ABG determination. A nurse assists with performing Allen's test before drawing the blood to determine the adequacy of the:

A nurse has administered approximately half of an enema solution to a preoperative client when the client complains of pain and cramping. Which nursing action is the most appropriate:

When caring for a client who is receiving total parenteral nutrition (TPN), which of the following complications would be most important for the nurse to assess:

A client has a nasogastric tube after a gastric resection. The nurse should expect to observe:

While assessing a client with hypoparathyroidism, the nurse taps the client's facial nerve and observes twitching of the mouth and tightening of the jaw. The nurse would document this finding as which of the following:

Which of the following clinical manifestations of type 2 diabetes occurs if glucose levels are very high:

Which of the following would the nurse expect to find in a client with severe hyperthyroidism:

A client is receiving long-term treatment with high-dose corticosteroids. Which of the following would the nurse expect the client to exhibit: