A 45-year-old patient has a cast applied from the ankle to the thigh after sustaining a tibial fracture. The nurse is now tasked with assessing the neurovascular status of the affected leg to monitor for potential complications such as compartment syndrome. Which action should the nurse take to effectively assess the neurovascular status of the casted extremity?

A 50-year-old woman with breast cancer has undergone a lumpectomy followed by chemotherapy. She is now scheduled for outpatient radiation therapy. The nurse is preparing teaching about self-care during radiation treatment. Which nursing intervention is most important?

A 27-year-old man with type 1 diabetes is hospitalized due to fluctuating blood glucose levels. During the night, the nurse notices his blood sugar drops suddenly, followed by elevated glucose in the morning. This pattern suggests the Somogyi effect. What is the most appropriate nursing intervention?

A 32-year-old man with a diagnosis of a personality disorder with antisocial behavior is hospitalized. He openly discusses conflicts with family members and a work supervisor from whom he previously stole money. The client is also facing pending criminal charges. Which of the following behaviors indicates that the client is meeting treatment goals?

A 30-year-old woman at 36 weeks gestation is admitted with severe preeclampsia. She has high blood pressure, severe headaches, and blurred vision. As the nurse, what should you do first to ensure her physical safety?

A 58-year-old woman with type 2 diabetes attends a follow-up visit with the nurse to review her diet and blood glucose management. During the discussion, the nurse asks about her typical food choices. Which statement indicates that additional teaching about diet is needed?

A 6-year-old child is diagnosed with a dust allergy after repeated episodes of sneezing, nasal congestion, and itchy eyes. The nurse is teaching the child’s parents about ways to reduce allergen exposure. Which instruction should the nurse include in the teaching plan?

A 40-year-old man with schizophrenia has just started a regimen of haloperidol (Haldol). During the nursing assessment, he is observed pacing the room and frequently shifting weight from one foot to another. What side effect should the nurse document in the client’s chart?

A 35-year-old client has been hospitalized on a psychiatric unit for several weeks due to schizophrenia. During interactions, the client repeatedly discusses delusional beliefs. Which response by the nurse is most therapeutic?

A 28-year-old client with a history of epilepsy is admitted to the hospital. While under observation, the client suddenly develops a tonic-clonic seizure. During the tonic-clonic stage, what is the nurse’s priority intervention?

A 15-year-old adolescent is admitted to the psychiatric unit with anorexia nervosa. During assessment, the nurse asks about the client’s thoughts and behaviors around food, weight, and body image. What is the primary gain the client usually achieves from this disorder?

A newborn is admitted to the neonatal intensive care unit with a myelomeningocele on the lower back. The sac is intact but covered with a thin membrane. What should be the priority immediate nursing care for this infant?

A 29-year-old primigravida is in active labor. On assessment, her cervix is dilated to 8 cm. She reports a strong urge to push and increasing discomfort, and she requests pain medication. How should the nurse respond?

A newborn, delivered at term, is admitted to the nursery. The nurse prepares to give an intramuscular injection of vitamin K. What is the primary purpose of this injection?

A 6-year-old child is hospitalized with acute poststreptococcal glomerulonephritis. The child asks the nurse for a snack. Which of the following options is the most therapeutic choice for this child?

A 48-year-old client reports nausea, dyspnea, and right upper quadrant pain that is not relieved by antacids. The pain usually occurs after eating at fast-food restaurants. Which diet should the nurse recommend to help prevent these symptoms?

A 35-year-old man sustains deep partial-thickness burns on his arms and chest while working on a boat in a marina. He comes to the first aid station seeking advice. The nurse encourages him to seek medical attention, but he refuses. The nurse advises the client to go to a healthcare provider immediately if which of the following occurs?

A 35-year-old client with a history of gambling addiction is mandated to attend counseling after being charged with embezzlement. During the intake interview, the client states, “I never would have done this if I had been paid what I am worth.” Which factor is likely to create the greatest difficulty in helping the client develop insight into their behavior?

A 65-year-old client has a urinary retention catheter in place following abdominal surgery. As part of planning care, which action should the nurse take to ensure the client’s safety in relation to the catheter?

A 50-year-old client is in the post-operative unit following a kidney transplant. To determine whether the transplanted kidney is functioning properly, which test should the nurse monitor most closely?

A 16-year-old pregnant adolescent at 10 weeks’ gestation comes to the prenatal clinic for her first visit. During the nutrition interview, she reports that her diet mainly consists of soft drinks, candy, French fries, and potato chips. Why does the nurse consider this diet inadequate?

A 30-year-old woman at 34 weeks’ gestation presents to the prenatal clinic. Her blood pressure is 166/100 mm Hg, and her urine shows +3 proteinuria. She complains of a severe headache and occasional blurred vision, with a baseline blood pressure of 100/62 mm Hg. What is the nurse’s priority action?

A 7-year-old child with cystic fibrosis is admitted to the pediatric unit. During a teaching session, the nurse discusses dietary management with the parents. Which statement by the parents demonstrates that they understand the dietary instructions?

A nurse is providing health teaching to a client with glaucoma and asks about the rationale for treatment. Which explanation should the nurse include to help the client understand the need for therapy?

A 60-year-old client has undergone a below-the-knee amputation and is preparing for prosthetic fitting. During rehabilitation, the nurse advises the client on how to care for the residual limb. Which action should the nurse encourage to prepare the limb for a prosthesis?

A 25-year-old client is admitted to the hospital with an exacerbation of asthma. The client reports shortness of breath, wheezing, and chest tightness. What should the nurse plan to do first to help this client?

A 55-year-old client with a suspected respiratory infection has an order for daily sputum specimens. When is the most appropriate time for the nurse to collect these specimens?

A 82-year-old client with moderate dementia is admitted to a medical-surgical unit. The nurse is assessing the unit environment to determine whether it supports the client’s psychological safety. Which factor is most essential to consider?

A 62-year-old client is extubated in the postanesthesia care unit (PACU) after undergoing thoracic surgery. While monitoring the client for acute respiratory distress, which common response should the nurse be most alert for?

A 30-year-old client with severe preeclampsia is prescribed an IV infusion of magnesium sulfate at twice the usual adult dose. The nurse questions the dosage, but the healthcare provider insists it is correct and directs the nurse to administer it. How should the nurse respond?

A 6-year-old child is admitted with acute poststreptococcal glomerulonephritis (APSGN) after a recent streptococcal infection. The child has mild edema and reports fatigue. Which nursing action should be included in the plan of care?

An 72-year-old client with chronic osteoarthritis pain is taking acetaminophen (Tylenol) regularly for pain relief. The nurse reviews the client’s medication history. Which substance is most important to determine the client is taking because it intensifies the most serious adverse effect of acetaminophen?

The parents of a 7-year-old child with terminal cancer ask the nurse whether they should tell their son that his sibling is dying. How should the nurse respond?

A 42-year-old client is admitted to the psychiatric unit with major depression, reporting feelings of hopelessness and withdrawal from daily activities. What is the most therapeutic initial nursing intervention?

A 9-week pregnant client visits the prenatal clinic and reports frequent nausea and occasional vomiting during the first trimester. What should the nurse teach her to help reduce nausea?

A 68-year-old client with a history of chronic obstructive pulmonary disease (COPD) presents to the clinic for follow-up. The nurse reviews the client’s health record and plans care. Which complication is most commonly associated with COPD?

A new parent brings their newborn to the clinic and asks the nurse how to care for the baby’s umbilical cord stump. What should the nurse include in the teaching?

A client has undergone a lower lobe lung resection and is experiencing excessive respiratory secretions postoperatively. Which independent nursing action should the nurse implement to help manage this problem?

A 62-year-old client with invasive bladder carcinoma is scheduled for a cystectomy with an ileal conduit. After the health care provider explains the procedure, the client expresses concern about offensive odors from the urinary diversion. What is the best response by the nurse?

During a 6-month well-baby checkup, a nurse observes the infant’s behavior and interactions. Using Piaget’s theory of cognitive development, what should the nurse expect this infant to demonstrate?

A client in active labor has an internal fetal monitor applied to continuously assess fetal heart rate. What should the nurse explain regarding positioning while the monitor is in place?

A nurse is assessing a newborn in the nursery and observes a clinical sign indicating respiratory distress. Which manifestation did the nurse most likely identify?

On the third postpartum day, a breastfeeding mother calls the clinic and reports that her breasts feel tight and swollen. Before explaining why her breasts are engorged, what should the nurse consider?

A 25-year-old person is sunbathing at the beach and sustains a deep partial-thickness burn from severe sunburn. Before seeking health care, what is the best first-aid measure the nurse should instruct the person to take?

During a routine assessment of older adults in a community center, a nurse evaluates various body systems. Which body system or function should the nurse consider to be least likely affected by aging?

A preterm infant is delivered and assessed immediately after birth. The infant’s Apgar score is 6 at 1 minute. What should the nurse perform as the initial nursing action?

A client has undergone a transurethral resection of the prostate (TURP) and is admitted to the post-op unit. Which action is most important for the nurse to implement when providing care?

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 but stares at them without swallowing. What is the most therapeutic statement the nurse can make?

A client at a mental health clinic tells the nurse after a therapy session, “My therapist is uncaring and impersonal.” What is the nurse’s best response?

A client who attends a mental health clinic tells the nurse after a therapy session, “My therapist is uncaring and impersonal.” How should the nurse respond most therapeutically?

A client who has just undergone a kidney transplant is transferred from the postanesthesia care unit (PACU) to the intensive care unit (ICU). The nurse is planning postoperative monitoring. How often should the nurse measure the client’s urinary output?

During a psychiatric unit observation, the nurse notices a client who, before sitting down for meals or starting any activity, taps other clients on the shoulders three times as part of a repeated ritual. Based on this behavior, the nurse infers that the client most likely has:

A 32-year-old pregnant client at 35 weeks’ gestation is admitted with severe preeclampsia. She is receiving an IV infusion of magnesium sulfate for seizure prophylaxis. The nurse knows there is a risk of magnesium toxicity. Which item should the nurse keep at the bedside to be prepared?

A 48-year-old man admitted to the hospital for alcohol withdrawal suddenly becomes loud, belligerent, and verbally threatens the nurse during evening rounds. The nurse must respond therapeutically while maintaining safety. What is the most appropriate response by the nurse?

The family of a 40-year-old client recently diagnosed with myasthenia gravis asks the nurse, “Will our loved one become an invalid because of this disease?” The nurse needs to respond with accurate information and reassurance. What is the best response?

A parent of a 2-year-old child newly diagnosed with cystic fibrosis says to the nurse, “My child looks so frail and weighs so little. Will this improve?” What is the nurse’s most appropriate reply?

During the first well-baby visit after hospital discharge, the parents tell the nurse, “Our baby has difficulty sucking and swallowing and gets tired quickly while feeding.” What should the nurse consider when assessing this infant?

A child with a history of chronic hypoxia is admitted for monitoring. Which clinical indicator should the nurse closely observe?

A client is admitted with a fracture of the head of the femur. The health care provider applies a Buck extension traction. What explanation should the nurse give the client regarding the purpose of the traction?

A client has just undergone a total hip arthroplasty. Which nursing action should be implemented to ensure safe postoperative care?

A nurse is assigned four clients in a psychiatric unit. Which client requires immediate therapeutic intervention from the nurse?

A client in a psychiatric hospital with a diagnosis of major depression becomes tearful and refuses to eat dinner after a visit with a friend. What is the most therapeutic nursing action?

A client with a known history of alcoholism tells the nurse, “I have been drinking since last Friday to celebrate my son’s graduation from college.” Which defense mechanism is the client demonstrating?

The parents of a child admitted with spasmodic croup ask the nurse why their child is receiving humidified oxygen. Which effect of humidified oxygen should the nurse include in the explanation?

A client has just undergone surgery for the creation of a colostomy. The nurse wants to help the client begin adjusting to this change. Which nursing intervention is most effective initially?

A nurse is caring for a child diagnosed with autism spectrum disorder. When given a choice of activities, which type of play is the child most likely to enjoy?

A 26-week pregnant client comes to the clinic for her routine prenatal checkup. Her blood pressure is 150/86 mmHg, and she reports gaining 5 pounds over the past 2 weeks. What should the nurse do first?

A nurse is caring for a newborn 1 hour after birth in the delivery room. Which behavior should the nurse expect at this time?

A client with a phobia of dogs is preparing to begin systematic desensitization therapy. The client asks the nurse, “What will the treatment involve?” Which is the nurse’s best response?

A client is recovering from an acute episode of colitis and the nurse is providing teaching about a high-protein diet. What rationale should the nurse include for this dietary recommendation?

A client is admitted to the emergency unit with an acute episode of bronchial asthma. Which outcome should the nurse aim to achieve during this episode?

A nurse is conducting a developmental appraisal on a 6-month-old infant diagnosed with hydrocephalus. Which observation is most important for the nurse to recognize?

A nurse is caring for a mother whose newborn has a severe birth defect. The mother refuses to look at her baby. What is the nurse’s most therapeutic approach?

During a parenting class, the nurse asks parents how they respond when their toddlers have a temper tantrum. Which statement demonstrates that a parent understands the usual cause of temper tantrums?

A nursing assistant interrupts a client who is performing a ritual related to obsessive-compulsive disorder (OCD). Which reaction is the nurse most likely to observe?

A nurse is assigned to care for a client with psychiatric problems. The primary goal is to establish a therapeutic nurse-client relationship. What is the major purpose of this relationship?

An African-American woman is newly diagnosed with primary hypertension. She asks the nurse, “Is hypertension a disease of African-American people?” Which response by the nurse is most appropriate?

A client diagnosed with hypertension has been prescribed a diuretic. When teaching the client about the medication, what explanation should the nurse provide regarding how diuretics reduce blood pressure?

A client with hypertension is taking a thiazide diuretic. During a follow-up discussion about diet, the nurse asks which foods the client typically chooses. Which food selection indicates that the client has understood dietary teaching regarding thiazide diuretics?

A 20-year-old college student visits the campus health clinic reporting increasing anxiety, loss of appetite, and difficulty concentrating. What is the most appropriate response by the nurse?

A client has been admitted to the psychiatric unit after a suicide attempt. During this crisis situation, what is the most desirable short-term outcome for the nurse to establish with the client?

A 3½-year-old child is admitted for an appendectomy. Which method should the nurse use to best prepare the child for the hospital experience?

A client diagnosed with adrenal insufficiency reports feeling weak and dizzy, particularly in the mornings. What should the nurse identify as the most probable cause of these symptoms?

A client is admitted with chronic kidney failure. The nurse knows that kidney dysfunction can affect electrolyte balance. For which imbalance should the nurse monitor the client?

A woman at 6 months’ gestation comes to the prenatal clinic for her first visit. As part of the initial assessment, a CBC and urinalysis are performed. Which laboratory finding should alert the nurse that further evaluation is needed?

A client is two hours postpartum following an uneventful labor and birth. The nurse notes the uterus is four fingerbreadths above the umbilicus. The client’s urine glucose is 1+. After urinary catheterization, the fundus remains firm and four fingerbreadths above the umbilicus. What is the priority nursing action?

A client with a history of hypothyroidism presents for a routine physical assessment. Which skin characteristic should the nurse expect to observe?

A client has undergone an open reduction and internal fixation (ORIF) for a fractured hip. Which assessment of the affected leg should the nurse prioritize in the immediate postoperative period?

A client with myxedema is recovering from abdominal surgery and requires pain management. What should the nurse consider when administering opioids to this client?

A 3-year-old child is admitted with spasmodic croup. During assessment, which clinical finding should prompt the nurse to initiate immediate intervention?

A child with persistent asthma is being prepared for discharge from the hospital. What must the nurse emphasize to the family to ensure safe and effective asthma management at home?

An older adult with dementia is admitted to a nursing home. The client is confused, agitated, and sometimes unaware of others. Which nursing approach is most effective to help the client adapt to the unit?

Parents bring their 8-year-old child to the clinic with fever, headache, and stiff neck. They express concern about meningitis and ask which test can confirm the diagnosis. Which test should the nurse explain to the parents?

A client has undergone a left pneumonectomy for lung cancer. During routine postoperative care, the nurse palpates the client’s trachea. What is the primary reason for this assessment?

A client is preparing for surgery and the provider orders a CBC, urinalysis, and chest x-ray. The client asks why these tests are being performed. Which response by the nurse is most appropriate?

A client arrives in the emergency department with acute abdominal pain and is scheduled for emergency abdominal surgery. What should be the priority preoperative nursing objective for this client?

An infant with hydrocephalus has just had a ventriculoperitoneal (VP) shunt inserted and is being prepared for discharge. Which common complication should the nurse explain to the parents to ensure they can monitor for it at home?

Parents of a child with recurrent leukemia are discussing a bone marrow transplant as a treatment option. They ask the nurse to explain the procedure. Which response by the nurse is most accurate?

A new mother on the postpartum unit expresses uncertainty about caring for her newborn and asks for guidance. What is most important for the nurse to do to help her develop her parenting role?

A newborn delivered vaginally is undergoing a routine assessment. The nurse notices swelling on one side of the top of the head. Which clinical manifestation does this finding indicate?

A 45-year-old patient has a long-leg cast applied after sustaining a tibial fracture. The nurse needs to assess neurovascular status of the affected leg to monitor for complications such as compartment syndrome. Which action should the nurse take?

A 2-year-old child has just been diagnosed with cystic fibrosis (CF). The parent expresses concern about the child’s frailty and low weight. Which response by the nurse is most appropriate?