A 56-year-old man is 8 hours postoperative following an abdominoperineal resection with the creation of a colostomy. During the routine assessment, the nurse inspects the new stoma site. Which of the following findings 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 notices that the infant becomes easily fatigued, breathes rapidly, and has difficulty feeding. To promote optimal breathing and comfort, in which position should the nurse place the infant?

A 48-year-old client, three weeks post–kidney transplant, returns to the clinic for a follow-up visit. Laboratory tests reveal leukopenia. The nurse reviews the client’s medication list and medical 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 both 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 proper nutrition during pregnancy. What should the nurse advise this client to do?

At her 6-week postpartum checkup, a new mother tells the nurse that 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 cow’s 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 transfusion reaction is suspected. Later, the nurse closely monitors the client for signs of kidney damage related to the reaction. Which assessment finding would be 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. To help control uremia, the nurse should instruct the client to limit the intake of which nutrient?

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 observes the dialysate inflow and outflow. What should the nurse do to ensure the dialysis is performed safely and effectively?

A 7-year-old child with cerebral palsy is being cared for by the school nurse. The nurse understands that although the child has the same developmental needs as peers, physical and cognitive limitations influence how these needs are met. Which effect should the nurse most frequently expect these limitations to 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?

Mr. Daniel, a 38-year-old client diagnosed with acquired immunodeficiency syndrome (AIDS), has recently been started on antiretroviral therapy that includes a protease inhibitor. During a routine follow-up visit, the nurse evaluates him for possible adverse effects of this medication. Which common side effect should the nurse expect to observe?

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?

During a parent-teacher conference, the school nurse meets with the parents of a 7-year-old child diagnosed with attention deficit hyperactivity disorder (ADHD), who has recently started taking a stimulant medication. The nurse reinforces important aspects of the child’s treatment plan. Which key point should the nurse emphasize to the parents?

During a parent-teacher conference, the school nurse meets with the parents of a 7-year-old child diagnosed with attention deficit hyperactivity disorder (ADHD), who has recently started taking a stimulant medication. The nurse reinforces important aspects of the child’s treatment plan. Which key point should the nurse emphasize to the parents?

A nurse is supervising a newly hired nursing assistant who is caring for a debilitated, bedbound client. During the observation, the nurse notices one of the assistant’s actions that could place the client at risk for injury. Which action by the nursing assistant requires the nurse’s immediate intervention?

Mr. Thomas, a 62-year-old client with chronic renal failure, is receiving epoetin (Epogen) to manage anemia. During a follow-up appointment, the nurse evaluates his understanding of the medication and its effects. Which statement by the client indicates the need for further teaching?

A 25-year-old client arrives at the emergency department experiencing an acute asthma attack, presenting with labored breathing and audible wheezing. The nurse quickly assesses the client’s condition and prepares to promote easier breathing. Which position should the nurse place the client in to facilitate optimal respiratory effort?

Mr. Allen, a 68-year-old client with chronic obstructive pulmonary disease (COPD), is admitted to the hospital complaining of increasing shortness of breath and low oxygen saturation levels. The nurse plans interventions to promote effective breathing. Which position should the nurse place the client in to maximize gas exchange?

Mr. Davis, a 45-year-old client, has just undergone a tympanoplasty to repair a perforated eardrum. In the postoperative period, the nurse plans interventions to protect the surgical site and promote healing. Which position should the nurse maintain the client in?

Mr. Harris, a 60-year-old client, is admitted to the intensive care unit (ICU) following open-heart surgery. To promote optimal recovery and enhance respiratory function during the postoperative period, the nurse plans appropriate positioning. Which position should the nurse maintain the client in?

Mr. Wilson, a 58-year-old client, is recovering in the intensive care unit (ICU) following cardiac surgery. The nurse plans to position the client to promote optimal oxygenation and decrease cardiac workload. Which position is most appropriate for this client?

A 2-year-old toddler has just returned to the recovery unit after surgical repair of a cleft palate. The nurse prepares to position the child to protect the surgical site and support healing. Which position should the nurse use?

A 6-month-old infant is recovering after placement of a ventriculoperitoneal (VP) shunt for hydrocephalus. During assessment, the nurse observes a bulging anterior fontanelle, indicating increased intracranial pressure. Which position should the nurse place the infant in to promote cerebrospinal fluid drainage?

Mr. Roberts, a 70-year-old client, has just returned to the recovery area after cataract removal surgery on his right eye. The nurse plans postoperative care to protect the surgical site and promote healing. Which position should the nurse maintain for the client?

Mr. Lewis, a 45-year-old client admitted for a neurological evaluation, is scheduled for a spinal tap (lumbar puncture). As part of the preparation, the nurse ensures proper positioning to promote safety and facilitate the procedure. Which position should the nurse place the client in?

Mr. Anderson, a 65-year-old client with decreased level of consciousness, requires oropharyngeal suctioning to maintain a clear and patent airway. To ensure safety and effectiveness during the procedure, which position should the nurse place the client in?

Ms. Taylor, a 32-year-old client, has just returned to the recovery unit after undergoing surgery with spinal anesthesia. The nurse provides postoperative instructions to help prevent a post-spinal headache. Which position should the nurse maintain for the client?

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

Mr. Johnson, a 78-year-old client with dysphagia and limited mobility, is admitted to the hospital for supportive care. During mealtime, the nurse focuses on preventing aspiration pneumonia. Which nursing action should the nurse prioritize to reduce this risk?

Mr. Thomas, a 65-year-old client recovering from a stroke, has developed dysphagia and is receiving continuous enteral feeding through a nasogastric (NG) tube. During the nurse’s shift, she plans care to ensure the client’s nutrition is delivered safely and effectively. Which nursing action is most essential?

Mr. Daniel, a 55-year-old client, is brought to the emergency department after a major accident resulting in severe blood loss. The client is diagnosed with hypovolemic shock. To promote adequate circulation and tissue perfusion, in which position should the nurse place the client?

Mrs. Helen, a 68-year-old client, is admitted to the stroke unit after experiencing a cerebrovascular accident (CVA). The nurse notes that the client has an altered level of consciousness. To maintain airway patency and prevent aspiration, in which position should the nurse place the client?

Mr. Robert, a 72-year-old client, has just undergone cataract removal surgery on his right eye and is preparing for discharge. The nurse reviews home care instructions with him and his family. Which statement by the client indicates a correct understanding of the postoperative teaching?

Mr. Allen, a 60-year-old client, is one day postoperative following a below-knee amputation. During the nurse’s assessment, active bleeding is noted from the surgical stump. What is the first action the nurse should take to manage this situation?

Mr. George, a 72-year-old male, has undergone a total hip replacement following long-standing degenerative joint disease. During the postoperative assessment, the nurse monitors for possible complications. Which complication is most common after hip replacement surgery?

Mr. Harris, a 60-year-old client, is three days postoperative following a right below-knee amputation. He reports experiencing severe pain in his right foot and requests pain medication. What is the nurse’s initial appropriate action?

Mr. Kevin, a 35-year-old client, arrives at the emergency department after falling from a ladder and complains of severe pain in his forearm. During the assessment, the nurse evaluates for signs that may indicate a possible fracture. Which manifestation would raise the greatest suspicion of a fracture?

Mr. Raymond, a 65-year-old client, has just undergone an above-the-knee amputation. Forty-five minutes after arrival in the postanesthesia care unit (PACU), the nurse notes a dime-sized bright red spot on the surgical dressing. What should the nurse do next?

Mr. Alex, a 25-year-old client, had a lower extremity cast applied three days ago for a fractured tibia. He reports increasing swelling and discomfort in the affected leg. What should the nurse do to help relieve the swelling?

Mrs. Linda, a 48-year-old client diagnosed with multiple sclerosis (MS), reports alternating episodes of constipation and bowel incontinence. The nurse is developing a bowel-retraining program to help regulate her bowel function. Which intervention would be least helpful for this client?

Mr. Jacob, a 60-year-old client with diabetes, underwent an above-knee amputation due to foot gangrene. During a postoperative dressing change, he reports severe pain in the same (amputated) knee. What is the nurse’s most appropriate action?

Mr. Samuel, a 60-year-old client with diabetes, recently underwent an above-knee amputation due to foot gangrene. He now reports severe pain and swelling at the surgical site, and the nurse observes pus with a foul odor oozing from the wound. The physician prescribes cephalexin and metronidazole. What should the nurse do immediately?

Mr. Daniel, a 55-year-old client, is scheduled for colon surgery the next morning. As part of the preoperative preparation, the physician orders a cleansing enema. While preparing to administer the enema, the nurse considers proper positioning. In which position should the nurse place the client?

Mrs. Grace, a 50-year-old client, is being prepared by the nurse for a rectal enema to relieve constipation. The client is positioned in the left Sims’ position for the procedure. On which side of the client should the nurse stand while inserting the enema?

Mr. Lewis, a 52-year-old client, is receiving a soapsuds enema as preparation for a diagnostic procedure. During the instillation, he suddenly reports abdominal cramping and discomfort. What should the nurse do next?

Mr. Andrew, an adult client, is constipated and requires a cleansing enema. The nurse prepares the equipment and positions the client appropriately. To ensure safe and effective administration, the nurse must insert the enema tubing into the rectum to what appropriate depth?

Mr. Johnson, a 68-year-old client with acute decompensated heart failure (ADHF), is receiving IV furosemide (Lasix) 40 mg and oral enalapril (Vasotec) 5 mg twice daily. Earlier, he experienced severe orthopnea and shortness of breath. Which assessment finding would best indicate that the treatment has been effective?

A nurse is preparing to insert a Ryle’s (nasogastric) tube into a 6-month-old infant for gastric decompression. To ensure accurate placement and prevent complications, the nurse must first determine the correct length of the tube. How should the nurse measure the appropriate insertion length?

Mr. Adams, a 45-year-old client, has a chest tube connected to a water-seal drainage system following surgery for a pneumothorax. During assessment, the nurse evaluates the drainage system to ensure it is functioning properly. Which finding indicates correct system function?

Mr. Carter, a 50-year-old client, has just had a chest tube inserted and connected to a water-seal drainage system following a left-sided pneumothorax. To ensure the system is functioning effectively, what should the nurse do?

Mr. Lewis, a 46-year-old client with a chest tube connected to a water-seal drainage system for a pneumothorax, accidentally dislodges the chest tube while turning in bed. The nurse enters the room and notices the tube has come out of the chest. What should the nurse do immediately?

Mr. Anderson, a 58-year-old client with a chest tube connected to a water-seal drainage system for a pneumothorax, suddenly calls the nurse after accidentally dislodging the chest tube from his chest. On entering the room, the nurse confirms that the tube is completely out. What is the most appropriate immediate nursing intervention?

Mr. Harris, a 62-year-old patient with a chest tube connected to a Pleur-evac drainage system for a pneumothorax, accidentally disconnects the chest tube while trying to get out of bed. What should the nurse do first?

Mr. Ryan, a 35-year-old patient with second- and third-degree burns covering 40% of his body, is admitted to the burn unit. To prevent infection and protect his compromised skin barrier, which type of isolation precaution should the nurse implement?

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

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

Mr. Davis, a 64-year-old client with a nasogastric (NG) feeding tube, is receiving his prescribed medications. During administration, the nurse suspects that the tube has become clogged. What is the first safe action the nurse should take?

Mrs. Allen, a 45-year-old woman recovering from a cholecystectomy, reports mild abdominal upset and discomfort during her postoperative recovery. Which of the following instructions should the nurse provide to help manage her symptoms?

A 70-year-old client with chronic heart failure is prescribed digoxin. Before administering the medication, the nurse prepares to assess the client’s pulse to ensure safe administration. Which pulse should the nurse check prior to giving digoxin?

A 68-year-old client admitted with congestive heart failure is prescribed digoxin 0.25 mg daily. Before administering the medication, the nurse prepares to assess the client’s pulse to ensure safe administration. Which pulse should the nurse assess prior to giving digoxin?

A 70-year-old client admitted with heart failure is prescribed digoxin 0.25 mg daily. Before administering the medication, the nurse takes measures to ensure safe administration. Which of the following nursing actions is most appropriate?

A 70-year-old client with chronic heart failure has been receiving digoxin for several weeks. During the morning assessment, the nurse notes that the client complains of nausea, loss of appetite, and seeing yellow halos around lights. Which of the following findings should the nurse recognize as signs of digitalis toxicity?

A 68-year-old client newly admitted with heart failure is prescribed digoxin 0.25 mg daily. The nurse reviews the laboratory results to ensure safe and effective therapy. Which digoxin serum level indicates a therapeutic range?

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 40-year-old client admitted one week ago with a spinal cord injury at the T6 level suddenly complains of a severe pounding headache and blurred vision during assessment. The nurse notes elevated blood pressure, flushed skin above the injury, and sweating. Which finding most likely indicates autonomic dysreflexia (hyperreflexia)?

A 70-year-old client with a history of stroke has severe dysphagia and is unable to swallow food or liquids safely, placing them at high risk for aspiration. The healthcare team discusses options for long-term nutritional support. Which feeding method is most appropriate for this client?

A 70-year-old client with a history of stroke has severe dysphagia and is unable to swallow food or liquids safely, placing them at high risk for aspiration. The healthcare team discusses options for long-term nutritional support. Which feeding method is most appropriate for this client?

A physician prescribes 10,000 units of heparin subcutaneously for a patient with deep vein thrombosis. The vial available is labeled 40,000 units/mL. How many milliliters should the nurse administer?

A 50-year-old client hospitalized with a leg fracture develops a deep vein thrombosis (DVT). The physician prescribes an IV heparin infusion of D5W 250 mL containing 12,500 units of heparin, to run at 16 mL/hr. How many units of heparin per hour is the client receiving?

A 45-year-old patient arrives at the emergency department complaining of frequent diarrhea and muscle weakness over the past few days. The nurse suspects an electrolyte imbalance and reviews the lab results. Which abnormal value is most consistent with these symptoms?

A 58-year-old client with a traumatic brain injury is receiving mannitol to manage increased intracranial pressure (ICP). During reassessment, the nurse evaluates the client for therapeutic effectiveness of the medication. Which finding indicates that mannitol is working as intended?

A 35-year-old patient is brought to the emergency department after a motor vehicle accident and is diagnosed with increased intracranial pressure (ICP). To help reduce cerebral edema and lower ICP, which medication should the nurse anticipate being prescribed?

A 67-year-old patient is admitted to the intensive care unit with cerebral edema following an ischemic stroke. The physician prescribes medication to decrease brain swelling and prevent further neurological damage. Which drug is considered the drug of choice for treating cerebral edema?

A 60-year-old client is receiving intravenous heparin therapy for the treatment of a deep vein thrombosis (DVT). To evaluate the effectiveness and safety of the anticoagulant therapy, which laboratory value should the nurse closely monitor?

A 58-year-old patient receiving heparin therapy for a pulmonary embolism develops bleeding from the gums and IV sites. The healthcare provider orders an antidote to reverse the effects of heparin. Which medication should the nurse prepare to administer?

A 65-year-old patient is prescribed warfarin (Coumadin) for long-term prevention of thromboembolism following a valve replacement surgery. To monitor the effectiveness and safety of this therapy, which laboratory test should the nurse evaluate?

A 50-year-old patient receiving a narcotic analgesic for postoperative pain becomes extremely drowsy, has shallow respirations (8/min), and pinpoint pupils. The healthcare provider orders an antidote to reverse the opioid effects. Which medication should the nurse prepare to administer?

A 32-year-old patient is brought to the emergency department after ingesting a large amount of acetaminophen (paracetamol) in a suicide attempt. To prevent hepatic toxicity, the healthcare provider prescribes an antidote. Which medication should the nurse prepare to administer?

A nurse accidentally administers an antihypertensive medication to the wrong patient. Realizing the medication error immediately after administration, what should be the nurse’s most appropriate immediate action?

A nurse accidentally administers an antihypertensive medication to the wrong patient. Realizing the medication error immediately after administration, what should be the nurse’s most appropriate immediate action?

A nurse accidentally administers an antihypertensive medication to the wrong patient. Realizing the medication error immediately after administration, what should be the nurse’s most appropriate immediate action?

A 58-year-old patient in the intensive care unit is experiencing respiratory distress, and the physician orders an arterial blood gas (ABG) analysis to assess oxygenation and acid–base balance. Which artery should the nurse most commonly use to obtain the specimen?

A 45-year-old client requires arterial blood gases (ABGs) to be drawn from the radial artery to assess respiratory function. Before performing the procedure, which test must the nurse ensure is positive to confirm it is safe to proceed?

A 50-year-old client is scheduled for arterial blood sampling from the radial artery for ABG analysis. Before the procedure, the nurse performs an Allen’s test. What is the nurse assessing with this test?

A nurse is administering a cleansing enema to a preoperative client. After about half of the solution has been instilled, the client suddenly complains of abdominal pain and cramping. What should the nurse do next?

A client is receiving total parenteral nutrition (TPN) through a central venous catheter. During routine assessment, the nurse monitors for potential complications. Which complication should the nurse prioritize assessing for in this client?

A client is recovering from a gastric resection and has a nasogastric (NG) tube connected to low intermittent suction. During the immediate postoperative period, the nurse assesses the NG tube drainage. What should the nurse expect to observe regarding the NG output?

A client diagnosed with hypoparathyroidism is being assessed for neuromuscular irritability. When the nurse taps over the facial nerve in front of the ear, the client’s mouth twitches and the jaw tightens. How should the nurse document this finding?

A 58-year-old client with type 2 diabetes mellitus arrives at the clinic complaining of excessive thirst and frequent urination. The nurse reviews the client’s chart and notes a markedly elevated blood glucose level. Which of the following clinical manifestations is most likely to occur?

A 32-year-old client is admitted to the hospital with severe hyperthyroidism (thyrotoxicosis). During assessment, the nurse closely monitors for characteristic manifestations of this condition. Which of the following clinical findings should the nurse expect to observe?

A 45-year-old client with rheumatoid arthritis has been receiving long-term high-dose corticosteroid therapy. During a follow-up assessment, the nurse monitors for complications related to chronic steroid use. Which of the following clinical manifestations should the nurse expect to observe?