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Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

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250 questions, answers, and explanations are offered in this sample exam from the 2013 edition of NCLEX-RN Exam Cram.

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  • A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every two hours. Which of the following outcome criteria would the nurse use?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Body temperature of 99°F or less

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Toes moved in active range of motion

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Sensation reported when soles of feet are touched

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Capillary refill of < 3 seconds

    Quick Answer: 223

    Detailed Answer: 225

  • A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is the best position for this client?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Side-lying with knees flexed

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Knee-chest

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    High Fowler’s with knees flexed

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Semi-Fowler’s with legs extended on the bed

    Quick Answer: 223

    Detailed Answer: 225

  • A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Taking hourly blood pressures with mechanical cuff

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Encouraging fluid intake of at least 200mL per hour

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Position in high Fowler’s with knee gatch raised

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Administering Tylenol as ordered

    Quick Answer: 223

    Detailed Answer: 225

  • Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Steak

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Cottage cheese

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Popsicle

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Lima beans

    Quick Answer: 223

    Detailed Answer: 225

  • A newly admitted client has sickle cell crisis. He is complaining of pain in his feet and hands. The nurse’s assessment findings include a pulse oximetry of 92. Assuming that all the following interventions are ordered, which should be done first?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Adjust the room temperature

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Give a bolus of IV fluids

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Start O2

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Administer meperidine (Demerol) 75mg IV push

    Quick Answer: 223

    Detailed Answer: 225

  • The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Roast beef, gelatin salad, green beans, and peach pie

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Chicken salad sandwich, coleslaw, French fries, ice cream

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Pork chop, creamed potatoes, corn, and coconut cake

    Quick Answer: 223

    Detailed Answer: 225

  • Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    A family vacation in the Rocky Mountains

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Chaperoning the local boys club on a snow-skiing trip

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Traveling by airplane for business trips

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    A bus trip to the Museum of Natural History

    Quick Answer: 223

    Detailed Answer: 225

  • The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which finding reinforces the diagnosis of B12 deficiency?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Enlarged spleen

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Elevated blood pressure

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Bradycardia

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Beefy tongue

    Quick Answer: 223

    Detailed Answer: 225

  • The body part that would most likely display jaundice in the dark-skinned individual is the:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Conjunctiva of the eye

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Soles of the feet

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Roof of the mouth

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Shins

    Quick Answer: 223

    Detailed Answer: 225

  • The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    BP 146/88

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Respirations 28 shallow

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Weight gain of 10 pounds in six months

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Pink complexion

    Quick Answer: 223

    Detailed Answer: 226

  • The nurse is teaching the client with polycythemia vera about prevention of complications of the disease. Which of the following statements by the client indicates a need for further teaching?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    “I will drink 500mL of fluid or less each day.”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    “I will wear support hose.”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    “I will check my blood pressure regularly.”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    “I will report ankle edema.”

    Quick Answer: 223

    Detailed Answer: 226

  • A 33-year-old male is being evaluated for possible acute leukemia. Which of the following findings is most likely related to the diagnosis of leukemia?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    The client collects stamps as a hobby.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    The client recently lost his job as a postal worker.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    The client had radiation for treatment of Hodgkin’s disease as a teenager.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    The client’s brother had leukemia as a child.

    Quick Answer: 223

    Detailed Answer: 226

  • Where is the best site for examining for the presence of petechiae in an African American client?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    The abdomen

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    The thorax

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    The earlobes

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    The soles of the feet

    Quick Answer: 223

    Detailed Answer: 226

  • The client is being evaluated for possible acute leukemia. Which inquiry by the nurse is most important?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    “Have you noticed a change in sleeping habits recently?”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    “Have you had a respiratory infection in the last six months?”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    “Have you lost weight recently?”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    “Have you noticed changes in your alertness?”

    Quick Answer: 223

    Detailed Answer: 226

  • Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Oral mucous membrane, altered related to chemo-therapy

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Risk for injury related to thrombocytopenia

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Fatigue related to the disease process

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Interrupted family processes related to life-threatening illness of a family member

    Quick Answer: 223

    Detailed Answer: 226

  • A 21-year-old male with Hodgkin’s lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Sexual dysfunction related to radiation therapy

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Anticipatory grieving related to terminal illness

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Tissue integrity related to prolonged bed rest

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Fatigue related to chemotherapy

    Quick Answer: 223

    Detailed Answer: 226

  • A client has autoimmune thrombocytopenic purpura. To determine the client’s response to treatment, the nurse would monitor:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Platelet count

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    White blood cell count

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Potassium levels

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Partial prothrombin time (PTT)

    Quick Answer: 223

    Detailed Answer: 226

  • The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client’s platelet count currently is 80,000. It will be most important to teach the client and family about:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Bleeding precautions

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Prevention of falls

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Oxygen therapy

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Conservation of energy

    Quick Answer: 223

    Detailed Answer: 226

  • The client has surgery for removal of a Prolactinoma. Which of the following interventions would be appropriate for this client?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Place the client in Trendelenburg position for postural drainage.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Encourage coughing and deep breathing every two hours.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Elevate the head of the bed 30°.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Encourage the Valsalva maneuver for bowel movements.

    Quick Answer: 223

    Detailed Answer: 226

  • The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Measure the urinary output.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Check the vital signs.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Encourage increased fluid intake.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Weigh the client.

    Quick Answer: 223

    Detailed Answer: 227

  • A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Place the client in a sitting position.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Administer acetaminophen (Tylenol).

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Pinch the soft lower part of the nose.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Apply ice packs to the forehead.

    Quick Answer: 223

    Detailed Answer: 227

  • A client has had a unilateral adrenalectomy to remove a tumor. The most important measurement in the immediate post-operative period for the nurse to take is:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    The blood pressure

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    The temperature

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    The urinary output

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    The specific gravity of the urine

    Quick Answer: 223

    Detailed Answer: 227

  • A client with Addison’s disease has been admitted with a history of nausea and vomiting for the past three days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Glucometer readings as ordered

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Intake/output measurements

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Evaluating the sodium and potassium levels

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Daily weights

    Quick Answer: 223

    Detailed Answer: 227

  • A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurses’ next action be?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Obtain a crash cart.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Check the calcium level.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Assess the dressing for drainage.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Assess the blood pressure for hypertension.

    Quick Answer: 223

    Detailed Answer: 227

  • A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in four months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Impaired physical mobility related to decreased endurance

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Hypothermia r/t decreased metabolic rate

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Disturbed thought processes r/t interstitial edema

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Decreased cardiac output r/t bradycardia

    Quick Answer: 223

    Detailed Answer: 227

  • The client presents to the clinic with a serum cholesterol of 275mg/dL and is placed on rosuvastatin (Crestor). Which instruction should be given to the client taking rosuvastatin (Crestor)?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Report muscle weakness to the physician.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Allow six months for the drug to take effect.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Take the medication with fruit juice.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Report difficulty sleeping.

    Quick Answer: 223

    Detailed Answer: 227

  • The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During administration, the nurse should:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Utilize an infusion pump.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Check the blood glucose level.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Place the client in Trendelenburg position.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Cover the solution with foil.

    Quick Answer: 223

    Detailed Answer: 227

  • The six-month-old client with a ventral septal defect is receiving Digitalis for regulation of his heart rate. Which finding should be reported to the doctor?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Blood pressure of 126/80

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Blood glucose of 110mg/dL

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Heart rate of 60bpm

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Respiratory rate of 30 per minute

    Quick Answer: 223

    Detailed Answer: 227

  • The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Replenish his supply every three months.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Take one every 15 minutes if pain occurs.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Leave the medication in the brown bottle.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Crush the medication and take with water.

    Quick Answer: 223

    Detailed Answer: 228

  • The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Macaroni and cheese

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Shrimp with rice

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Turkey breast

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Spaghetti with meat sauce

    Quick Answer: 223

    Detailed Answer: 228

  • The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Feet

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Neck

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Hands

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Sacrum

    Quick Answer: 223

    Detailed Answer: 228

  • The nurse is checking the client’s central venous pressure. The nurse should place the zero of the manometer at the:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Phlebostatic axis

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    PMI

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Erb’s point

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Tail of Spence

    Quick Answer: 223

    Detailed Answer: 228

  • The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Question the order.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Administer the medications.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Administer separately.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Contact the pharmacy.

    Quick Answer: 223

    Detailed Answer: 228

  • The best method of evaluating the amount of peripheral edema is:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Weighing the client daily

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Measuring the extremity

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Measuring the intake and output

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Checking for pitting

    Quick Answer: 223

    Detailed Answer: 228

  • A client with vaginal cancer is being treated with a radioactive vaginal implant. The client’s husband asks the nurse if he can spend the night with his wife. The nurse should explain that:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Overnight stays by family members is against hospital policy.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    There is no need for him to stay because staffing is adequate.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    His wife will rest much better knowing that he is at home.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Visitation is limited to 30 minutes when the implant is in place.

    Quick Answer: 223

    Detailed Answer: 228

  • The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Roast beef sandwich, potato chips, pickle spear, iced tea

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Split pea soup, mashed potatoes, pudding, milk

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Tomato soup, cheese toast, Jello, coffee

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Hamburger, baked beans, fruit cup, iced tea

    Quick Answer: 223

    Detailed Answer: 228

  • The physician has prescribed Novalog insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    “I will make sure I eat breakfast within 10 minutes of taking my insulin.”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    “I will need to carry candy or some form of sugar with me all the time.”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    “I will eat a snack around three o’clock each afternoon.”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    “I can save my dessert from supper for a bedtime snack.”

    Quick Answer: 223

    Detailed Answer: 229

  • The nurse is teaching basic infant care to a group of first-time parents. The nurse should explain that a sponge bath is recommended for the first two weeks of life because:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    New parents need time to learn how to hold the baby.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    The umbilical cord needs time to separate.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Newborn skin is easily traumatized by washing.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    The chance of chilling the baby outweighs the benefits of bathing.

    Quick Answer: 223

    Detailed Answer: 229

  • A client with leukemia is receiving Trimetrexate. After reviewing the client’s chart, the physician orders Wellcovorin (leucovorin calcium). The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Treat iron-deficiency anemia caused by chemotherapeutic agents

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Create a synergistic effect that shortens treatment time

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Increase the number of circulating neutrophils

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Reverse drug toxicity and prevent tissue damage

    Quick Answer: 223

    Detailed Answer: 229

  • A four-month-old is brought to the well-baby clinic for immunization. In addition to the DPT and polio vaccines, the baby should receive:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Hib titer

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Mumps vaccine

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Hepatitis B vaccine

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    MMR

    Quick Answer: 223

    Detailed Answer: 229

  • The physician has prescribed Nexium (esomeprazole) for a client with erosive gastritis. The nurse should administer the medication:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    30 minutes before a meal

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    With each meal

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    In a single dose at bedtime

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    30 minutes after meals

    Quick Answer: 223

    Detailed Answer: 229

  • A client on the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff. What is the most appropriate action for the nurse to take?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Call security for assistance and prepare to sedate the client.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Tell the client to calm down and ask him if he would like to play cards.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Tell the client that if he continues his behavior he will be punished.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Leave the client alone until he calms down.

    Quick Answer: 223

    Detailed Answer: 229

  • When the nurse checks the fundus of a client on the first postpartum day, she notes that the fundus is firm, is at the level of the umbilicus, and is displaced to the right. The next action the nurse should take is to:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Check the client for bladder distention.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Assess the blood pressure for hypotension.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Determine whether an oxytocic drug was given.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Check for the expulsion of small clots.

    Quick Answer: 223

    Detailed Answer: 229

  • A client is admitted to the hospital with a temperature of 99.8°F, complaints of blood-tinged hemoptysis, fatigue, and night sweats. The client’s symptoms are consistent with a diagnosis of:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Pneumonia

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Reaction to antiviral medication

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Tuberculosis

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Superinfection due to low CD4 count

    Quick Answer: 223

    Detailed Answer: 229

  • The client is seen in the clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan succinate) is prescribed for the client. Which of the following in the client’s history should be reported to the doctor?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Diabetes

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Prinzmetal’s angina

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Cancer

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Cluster headaches

    Quick Answer: 223

    Detailed Answer: 229

  • The client with suspected meningitis is admitted to the unit. The doctor is performing an assessment to determine meningeal irritation and spinal nerve root inflammation. A positive Kernig’s sign is charted if the nurse notes:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Pain on flexion of the hip and knee

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Nuchal rigidity on flexion of the neck

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Pain when the head is turned to the left side

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Dizziness when changing positions

    Quick Answer: 223

    Detailed Answer: 229

  • The client with Alzheimer’s disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Agnosia

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Apraxia

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Anomia

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Aphasia

    Quick Answer: 223

    Detailed Answer: 229

  • The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Chronic fatigue syndrome

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Normal aging

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Sundowning

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Delusions

    Quick Answer: 223

    Detailed Answer: 230

  • The client with confusion says to the nurse, “I haven’t had anything to eat all day long. When are they going to bring breakfast?” The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Which response would be best for the nurse to make?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    “You know you had breakfast 30 minutes ago.”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    “I am so sorry that they didn’t get you breakfast. I’ll report it to the charge nurse.”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    “I’ll get you some juice and toast. Would you like something else?”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    “You will have to wait a while; lunch will be here in a little while.”

    Quick Answer: 223

    Detailed Answer: 230

  • The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer’s disease. Which side effect is most often associated with this drug?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Urinary incontinence

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Headaches

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Confusion

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Nausea

    Quick Answer: 223

    Detailed Answer: 230

  • A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Document the finding.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Report the finding to the doctor.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Prepare the client for a C-section.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Continue primary care as prescribed.

    Quick Answer: 223

    Detailed Answer: 230

  • A client with a diagnosis of HPV is at risk for which of the following?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Hodgkin’s lymphoma

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Cervical cancer

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Multiple myeloma

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Ovarian cancer

    Quick Answer: 223

    Detailed Answer: 230

  • During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Syphilis

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Herpes

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Gonorrhea

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Condylomata

    Quick Answer: 223

    Detailed Answer: 230

  • A client visiting a family planning clinic is suspected of having an STI. The best diagnostic test for treponema pallidum is:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Venereal Disease Research Lab (VDRL)

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Rapid plasma reagin (RPR)

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Fluorescent treponemal antibody (FTA)

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Thayer-Martin culture (TMC)

    Quick Answer: 223

    Detailed Answer: 230

  • A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Elevated blood glucose

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Elevated platelet count

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Elevated creatinine clearance

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Elevated hepatic enzymes

    Quick Answer: 223

    Detailed Answer: 230

  • The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    The nurse loosely suspends the client’s arm in an open hand while tapping the back of the client’s elbow.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist.

    Quick Answer: 223

    Detailed Answer: 230

  • A primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor’s order should the nurse question?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Magnesium sulfate 4gm (25%) IV

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Brethine 10mcg IV

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Stadol 1mg IV push every 4 hours as needed prn for pain

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Ancef 2gm IVPB every 6 hours

    Quick Answer: 223

    Detailed Answer: 230

  • A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. The nurse’s assessment of this data is:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    The infant is at low risk for congenital anomalies.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    The infant is at high risk for intrauterine growth retardation.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    The infant is at high risk for respiratory distress syndrome.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    The infant is at high risk for birth trauma.

    Quick Answer: 223

    Detailed Answer: 231

  • Which observation in the newborn of a diabetic mother would require immediate nursing intervention?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Crying

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Wakefulness

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Jitteriness

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Yawning

    Quick Answer: 223

    Detailed Answer: 231

  • The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Decreased urinary output

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Hypersomnolence

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Absence of knee jerk reflex

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Decreased respiratory rate

    Quick Answer: 223

    Detailed Answer: 231

  • The client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension, the nurse would:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Place her in Trendelenburg position.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Decrease the rate of IV infusion.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Administer oxygen per nasal cannula.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Increase the rate of the IV infusion.

    Quick Answer: 223

    Detailed Answer: 231

  • A client has cancer of the pancreas. The nurse should be most concerned about which nursing diagnosis?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Alteration in nutrition

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Alteration in bowel elimination

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Alteration in skin integrity

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Ineffective individual coping

    Quick Answer: 223

    Detailed Answer: 231

  • The nurse is caring for a client with uremic frost. The nurse is aware that uremic frost is often seen in clients with:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Severe anemia

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Arteriosclerosis

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Liver failure

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Parathyroid disorder

    Quick Answer: 223

    Detailed Answer: 231

  • The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client’s most appropriate priority nursing diagnosis?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Alteration in cerebral tissue perfusion

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Fluid volume deficit

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Ineffective airway clearance

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Alteration in sensory perception

    Quick Answer: 223

    Detailed Answer: 231

  • The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Likes to play football

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Drinks carbonated drinks

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Has two sisters

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Is taking acetaminophen for pain

    Quick Answer: 223

    Detailed Answer: 231

  • The nurse working the organ transplant unit is caring for a client with a white blood cell count of 450. During evening visitation, a visitor brings a basket of fruit. What action should the nurse take?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Allow the client to keep the fruit.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Place the fruit next to the bed for easy access by the client.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Offer to wash the fruit for the client.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Ask the family members to take the fruit home.

    Quick Answer: 223

    Detailed Answer: 231

  • The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale, with a BP of 90/40. The initial nurse’s action should be to:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Place the client in Trendelenburg position.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Increase the infusion of normal saline.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Administer atropine intravenously.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Move the emergency cart to the bedside.

    Quick Answer: 223

    Detailed Answer: 231

  • The client admitted two days earlier with a lung resection accidentally pulls out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Order a chest x-ray.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Reinsert the tube.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Cover the insertion site with a Vaseline gauze.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Call the doctor.

    Quick Answer: 223

    Detailed Answer: 231

  • A client being treated with sodium warfarin (Coumadin) has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Assess for signs of abnormal bleeding.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Anticipate an increase in the Coumadin dosage.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Instruct the client regarding the drug therapy.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Increase the frequency of neurological assessments.

    Quick Answer: 223

    Detailed Answer: 231

  • Which selection would provide the most calcium for the client who is four months pregnant?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    A granola bar

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    A bran muffin

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    A cup of yogurt

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    A glass of fruit juice

    Quick Answer: 223

    Detailed Answer: 232

  • The client with preeclampsia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates the understanding of magnesium toxicity?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    The nurse performs a vaginal exam every 30 minutes.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    The nurse places a padded tongue blade at the bedside.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    The nurse inserts a Foley catheter.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    The nurse darkens the room.

    Quick Answer: 223

    Detailed Answer: 232

  • The best size cathlon for administration of a blood transfusion to a six-year-old is:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    18 gauge

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    19 gauge

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    22 gauge

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    20 gauge

    Quick Answer: 223

    Detailed Answer: 232

  • A client is admitted to the unit two hours after an explosion causes burns to the face. The nurse would be most concerned with the client developing which of the following?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Hypovolemia

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Laryngeal edema

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Hypernatremia

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Hyperkalemia

    Quick Answer: 223

    Detailed Answer: 232

  • The client has recently been diagnosed with diabetes. Which of the following indicates understanding of the management of diabetes?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    The client selects a balanced diet from the menu.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    The client can tell the nurse the normal blood glucose level.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    The client asks for brochures on the subject of diabetes.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    The client demonstrates correct insulin injection technique.

    Quick Answer: 223

    Detailed Answer: 232

  • The client is admitted following cast application for a fractured ulna. Which finding should be reported to the doctor?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Pain at the site

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Warm fingers

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Pulses rapid

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Paresthesia of the fingers

    Quick Answer: 223

    Detailed Answer: 232

  • The client with AIDS should be taught to:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Avoid warm climates.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Refrain from taking herbals.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Avoid exercising.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Report any changes in skin color.

    Quick Answer: 223

    Detailed Answer: 232

  • Which action by the healthcare worker indicates a need for further teaching?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    The nursing assistant ambulates the elderly client using a gait belt.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    The nurse wears goggles while performing a veno-puncture.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    The nurse washes his hands after changing a dressing.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    The nurse wears gloves to monitor the IV infusion rate.

    Quick Answer: 223

    Detailed Answer: 232

  • The client is having electroconvulsive therapy for treatment of severe depression. Prior to the ECT, the nurse should:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Apply a tourniquet to the client’s arm.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Administer an anticonvulsant medication.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Ask the client if he is allergic to shellfish.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Apply a blood pressure cuff to the arm.

    Quick Answer: 223

    Detailed Answer: 232

  • The five-year-old is being tested for enterobiasis (pinworms). Which symptom is associated with enterobiasis?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Rectal itching

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Nausea

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Oral ulcerations

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Scalp itching

    Quick Answer: 223

    Detailed Answer: 232

  • The nurse is teaching the mother regarding treatment for pedicalosis capitis. Which instruction should be given regarding the medication?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Treatment is not recommended for children less than 10 years of age.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Bed linens should be washed in hot water.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Medication therapy will continue for one year.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Intravenous antibiotic therapy will be ordered.

    Quick Answer: 223

    Detailed Answer: 232

  • The registered nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    The client with HIV

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    The client with a radium implant for cervical cancer

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    The client with RSV (respiratory synctial virus)

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    The client with cytomegalovirus

    Quick Answer: 223

    Detailed Answer: 232

  • The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    The client with methicillin resistant-staphylococcus aureas (MRSA)

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    The client with diabetes

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    The client with pancreatitis

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    The client with Addison’s disease

    Quick Answer: 223

    Detailed Answer: 232

  • The doctor accidentally cuts the bowel during surgery. As a result of this action, the client develops an infection and suffers brain damage. The doctor can be charged with:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Negligence

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Tort

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Assault

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Malpractice

    Quick Answer: 223

    Detailed Answer: 233

  • Which assignment should not be performed by the nursing assistant?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Feeding the client

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Bathing the client

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Obtaining a stool

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Administering a fleet enema

    Quick Answer: 223

    Detailed Answer: 233

  • The mother calls the clinic to report that her newborn has a rash on his forehead and face. Which action is most appropriate?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Tell the mother to wash the face with soap and apply powder.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Tell her that 30% of newborns have a rash that will go away by one month of life.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Report the rash to the doctor immediately.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Ask the mother if anyone else in the family has had a rash in the last six months.

    Quick Answer: 223

    Detailed Answer: 233

  • Which nurse should not be assigned to care for the client with a radium implant for vaginal cancer?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    The LPN who is six months postpartum

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    The RN who is pregnant

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    The RN who is allergic to iodine

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    The RN with a three-year-old at home

    Quick Answer: 223

    Detailed Answer: 233

  • Which information should be reported to the state Board of Nursing?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    The facility fails to provide literature in both Spanish and English.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    The narcotic count has been incorrect on the unit for the past three days.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    The client fails to receive an itemized account of his bills and services received during his hospital stay.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath.

    Quick Answer: 223

    Detailed Answer: 233

  • The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Call the Board of Nursing.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    File a formal reprimand.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Terminate the nurse.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Charge the nurse with a tort.

    Quick Answer: 223

    Detailed Answer: 233

  • The home health nurse is planning for the day’s visits. Which client should be seen first?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    The 78-year-old who had a gastrectomy three weeks ago and has a PEG tube

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    The five-month-old discharged one week ago with pneumonia who is being treated with amoxicillin liquid suspension

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    The 50-year-old with MRSA being treated with Vancomycin via a PICC line

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter

    Quick Answer: 223

    Detailed Answer: 233

  • The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    A client having auditory hallucinations and the client with ulcerative colitis

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    The client who is pregnant and the client with a broken arm

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    A child who is cyanotic with severe dypsnea and a client with a frontal head injury

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    The client who arrives with a large puncture wound to the abdomen and the client with chest pain

    Quick Answer: 223

    Detailed Answer: 233

  • Before administering eardrops to a toddler, the nurse should recognize that it is essential to consider which of the following?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    The age of the child

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    The child’s weight

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    The developmental level of the child

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    The IQ of the child

    Quick Answer: 223

    Detailed Answer: 233

  • The nurse is discussing meal planning with the mother of a two-year-old. Which of the following statements, if made by the mother, would require a need for further instruction?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    “It is okay to give my child white grape juice for breakfast.”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    “My child can have a grilled cheese sandwich for lunch.”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    “We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch.”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    “For a snack, my child can have ice cream.”

    Quick Answer: 223

    Detailed Answer: 233

  • A client with AIDS has a viral load of 200 copies per ml. The nurse should interpret this finding as:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    The client is at risk for opportunistic diseases.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    The client is no longer communicable.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    The client’s viral load is extremely low so he is relatively free of circulating virus.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    The client’s T-cell count is extremely low.

    Quick Answer: 223

    Detailed Answer: 233

  • The client has an order for sliding scale insulin at 1900 hours and Lantus insulin at the same hour. The nurse should:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Administer the two medications together.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Administer the medications in two injections.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Draw up the Lantus insulin and then the regular insulin and administer them together.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Contact the doctor because these medications should not be given to the same client.

    Quick Answer: 223

    Detailed Answer: 234

  • A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Altered nutrition

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Impaired communication

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Risk for injury/aspiration

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Altered urinary elimination

    Quick Answer: 223

    Detailed Answer: 234

  • What would the nurse expect the admitting assessment to reveal in a client with glomerulonephritis?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Hypertension

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Lassitude

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Fatigue

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Vomiting and diarrhea

    Quick Answer: 223

    Detailed Answer: 234

  • Which action is contraindicated in the client with epiglottis?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Ambulation

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Oral airway assessment using a tongue blade

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Placing a blood pressure cuff on the arm

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Checking the deep tendon reflexes.

    Quick Answer: 223

    Detailed Answer: 234

  • A 25-year-old client with a goiter is admitted to the unit. What would the nurse expect the admitting assessment to reveal?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Slow pulse

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Anorexia

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Bulging eyes

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Weight gain

    Quick Answer: 223

    Detailed Answer: 234

  • Which of the following foods, if selected by the mother with a child with celiac, would indicate her understanding of the dietary instructions?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Whole-wheat toast

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Angel hair pasta

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Reuben on rye

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Rice cereal

    Quick Answer: 223

    Detailed Answer: 234

  • The first action that the nurse should take if she finds the client has an O2 saturation of 68% is:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Elevate the head.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Recheck the O2 saturation in 30 minutes.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Apply oxygen by mask.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Assess the heart rate.

    Quick Answer: 223

    Detailed Answer: 234

  • Which observation would the nurse expect to make after an amniotomy?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Dark yellow amniotic fluid

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Clear amniotic fluid

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Greenish amniotic fluid

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Red amniotic fluid

    Quick Answer: 223

    Detailed Answer: 234

  • The client taking Glyburide (Diabeta) should be cautioned to:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Avoid eating sweets.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Report changes in urinary pattern.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Allow three hours for onset.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Check the glucose daily.

    Quick Answer: 223

    Detailed Answer: 234

  • The obstetric client’s fetal heart rate is 80–90 during the contractions. The first action the nurse should take is:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Reposition the monitor.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Turn the client to her left side.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Ask the client to ambulate.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Prepare the client for delivery.

    Quick Answer: 223

    Detailed Answer: 234

  • Arterial ulcers are best described as ulcers that:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Are smooth in texture

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Have irregular borders

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Are cool to touch

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Are painful to touch

    Quick Answer: 223

    Detailed Answer: 234

  • A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Anticipate the need for a Caesarean section.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Apply an internal fetal monitor.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Place the client in Genu Pectoral position.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Perform an ultrasound.

    Quick Answer: 223

    Detailed Answer: 234

  • A vaginal exam reveals that the cervix is 4cm dilated, with intact membranes and a fetal heart tone rate of 160–170bpm. The nurse decides to apply an external fetal monitor. The rationale for this implementation is:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    The cervix is closed.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    The membranes are still intact.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    The fetal heart tones are within normal limits.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    The contractions are intense enough for insertion of an internal monitor.

    Quick Answer: 223

    Detailed Answer: 234

  • The following are all nursing diagnoses appropriate for a gravida 1 para 0 in labor. Which one would be most appropriate for the primagravida as she completes the early phase of labor?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Impaired gas exchange related to hyperventilation

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Alteration in placental perfusion related to maternal position

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Impaired physical mobility related to fetal-monitoring equipment

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Potential fluid volume deficit related to decreased fluid intake

    Quick Answer: 223

    Detailed Answer: 235

  • As the client reaches 6cm dilation, the nurse notes late decelerations on the fetal monitor. What is the most likely explanation of this pattern?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    The baby is sleeping.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    The umbilical cord is compressed.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    There is head compression.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    There is uteroplacental insufficiency.

    Quick Answer: 223

    Detailed Answer: 235

  • The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Notify her doctor.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Start an IV.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Reposition the client.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Readjust the monitor.

    Quick Answer: 223

    Detailed Answer: 235

  • Which of the following is a characteristic of an ominous periodic change in the fetal heart rate?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    A fetal heart rate of 120–130bpm

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    A baseline variability of 6–10bpm

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Accelerations in FHR with fetal movement

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    A recurrent rate of 90–100bpm at the end of the contractions

    Quick Answer: 223

    Detailed Answer: 235

  • The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    The bladder fills more rapidly because of the medication used for the epidural.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Her level of consciousness is such that she is in a trancelike state.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    The sensation of the bladder filling is diminished or lost.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    She is embarrassed to ask for the bedpan that frequently.

    Quick Answer: 223

    Detailed Answer: 235

  • A client in the family planning clinic asks the nurse about the most likely time for her to conceive. The nurse explains that conception is most likely to occur when:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Estrogen levels are low

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Lutenizing hormone is high

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    The endometrial lining is thin

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    The progesterone level is low

    Quick Answer: 223

    Detailed Answer: 235

  • A client tells the nurse that she plans to use the rhythm method of birth control. The nurse is aware that the success of the rhythm method depends on the:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Age of the client

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Frequency of intercourse

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Regularity of the menses

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Range of the client’s temperature

    Quick Answer: 223

    Detailed Answer: 235

  • A client with diabetes asks the nurse for advice regarding methods of birth control. Which method of birth control is most suitable for the client with diabetes?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Intrauterine device

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Oral contraceptives

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Diaphragm

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Contraceptive sponge

    Quick Answer: 223

    Detailed Answer: 235

  • The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a diagnosis of a ruptured ectopic pregnancy?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Painless vaginal bleeding

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Abdominal cramping

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Throbbing pain in the upper quadrant

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Sudden, stabbing pain in the lower quadrant

    Quick Answer: 223

    Detailed Answer: 235

  • The nurse is teaching a pregnant client about nutritional needs during pregnancy. Which menu selection will best meet the nutritional needs of the pregnant client?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Hamburger patty, green beans, French fries, and iced tea

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Roast beef sandwich, potato chips, baked beans, and cola

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Baked chicken, fruit cup, potato salad, coleslaw, yogurt, and iced tea

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Fish sandwich, gelatin with fruit, and coffee

    Quick Answer: 223

    Detailed Answer: 236

  • The client with hyperemesis gravidarum is at risk for developing:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Respiratory alkalosis without dehydration

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Metabolic acidosis with dehydration

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Respiratory acidosis without dehydration

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Metabolic alkalosis with dehydration

    Quick Answer: 223

    Detailed Answer: 236

  • A client tells the doctor that she is about 20 weeks pregnant. The most definitive sign of pregnancy is:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Elevated human chorionic gonadatropin

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    The presence of fetal heart tones

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Uterine enlargement

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Breast enlargement and tenderness

    Quick Answer: 223

    Detailed Answer: 236

  • The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to be:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Hypoglycemic, small for gestational age

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Hyperglycemic, large for gestational age

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Hypoglycemic, large for gestational age

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Hyperglycemic, small for gestational age

    Quick Answer: 223

    Detailed Answer: 236

  • Which of the following instructions should be included in the nurse’s teaching regarding oral contraceptives?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Weight gain should be reported to the physician.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    An alternate method of birth control is needed when taking antibiotics.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    If the client misses one or more pills, two pills should be taken per day for one week.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Changes in the menstrual flow should be reported to the physician.

    Quick Answer: 223

    Detailed Answer: 236

  • The nurse is discussing breastfeeding with a postpartum client. Breastfeeding is contraindicated in the postpartum client with:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Diabetes

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    HIV

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Hypertension

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Thyroid disease

    Quick Answer: 224

    Detailed Answer: 236

  • A client is admitted to the labor and delivery unit complaining of vaginal bleeding with very little discomfort. The nurse’s first action should be to:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Assess the fetal heart tones.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Check for cervical dilation.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Check for firmness of the uterus.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Obtain a detailed history.

    Quick Answer: 224

    Detailed Answer: 236

  • A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Her contractions are two minutes apart.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    She has back pain and a bloody discharge.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    She experiences abdominal pain and frequent urination.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Her contractions are five minutes apart.

    Quick Answer: 224

    Detailed Answer: 236

  • The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development. Which characteristic is associated with babies born to mothers who smoked during pregnancy?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Low birth weight

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Large for gestational age

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Preterm birth, but appropriate size for gestation

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Growth retardation in weight and length

    Quick Answer: 224

    Detailed Answer: 237

  • The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A negative but whose baby is O positive. To provide postpartum prophylaxis, RhoGam should be administered:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Within 72 hours of delivery

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Within one week of delivery

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Within two weeks of delivery

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Within one month of delivery

    Quick Answer: 224

    Detailed Answer: 237

  • After the physician performs an amniotomy, the nurse’s first action should be to assess the:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Degree of cervical dilation

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Fetal heart tones

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Client’s vital signs

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Client’s level of discomfort

    Quick Answer: 224

    Detailed Answer: 237

  • A client is admitted to the labor and delivery unit. The nurse performs a vaginal exam and determines that the client’s cervix is 5cm dilated with 75% effacement. Based on the nurse’s assessment, the client is in which phase of labor?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Active

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Latent

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Transition

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Early

    Quick Answer: 224

    Detailed Answer: 237

  • A newborn with narcotic abstinence syndrome is admitted to the nursery. Nursing care of the newborn should include:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Teaching the mother to provide tactile stimulation

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Wrapping the newborn snugly in a blanket

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Placing the newborn in the infant seat

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Initiating an early infant-stimulation program

    Quick Answer: 224

    Detailed Answer: 237

  • A client elects to have epidural anesthesia to relieve the discomfort of labor. Following the initiation of epidural anesthesia, the nurse should give priority to:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Checking for cervical dilation

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Placing the client in a supine position

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Checking the client’s blood pressure

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Obtaining a fetal heart rate

    Quick Answer: 224

    Detailed Answer: 237

  • The nurse is aware that the best way to prevent post-operative wound infection in the surgical client is to:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Administer a prescribed antibiotic.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Wash her hands for two minutes before care.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Wear a mask when providing care.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Ask the client to cover her mouth when she coughs.

    Quick Answer: 224

    Detailed Answer: 237

  • The elderly client is admitted to the emergency room. Which symptom is the client with a fractured hip most likely to exhibit?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Pain

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Disalignment

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Cool extremity

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Absence of pedal pulses

    Quick Answer: 224

    Detailed Answer: 237

  • The nurse knows that a 60-year-old female client’s susceptibility to osteoporosis is most likely related to:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Lack of exercise

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Hormonal disturbances

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Lack of calcium

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Genetic predisposition

    Quick Answer: 224

    Detailed Answer: 237

  • A two-year-old is admitted for repair of a fractured femur and is placed in Bryant’s traction. Which finding by the nurse indicates that the traction is working properly?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    The infant no longer complains of pain.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    The buttocks are 15° off the bed.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    The legs are suspended in the traction.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    The pins are secured within the pulley.

    Quick Answer: 224

    Detailed Answer: 238

  • Which statement is true regarding balanced skeletal traction? Balanced skeletal traction:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Uses a Steinman pin

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Requires that both legs be secured

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Utilizes Kirschner wires

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Is used primarily to heal the fractured hips

    Quick Answer: 224

    Detailed Answer: 238

  • The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery, the nurse should give priority to assessing the:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Serum collection (Davol) drain

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Client’s pain

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Nutritional status

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Immobilizer

    Quick Answer: 224

    Detailed Answer: 238

  • Which statement made by the family member caring for the client with a percutaneous gastrostomy tube indicates understanding of the nurse’s teaching?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    “I must flush the tube with water after feedings and clamp the tube.”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    “I must check placement four times per day.”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    “I will report to the doctor any signs of indigestion.”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    “If my father is unable to swallow, I will discontinue the feeding and call the clinic.”

    Quick Answer: 224

    Detailed Answer: 238

  • The nurse is assessing the client with a total knee replacement two hours post-operative. Which information requires notification of the doctor?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Scant bleeding on the dressing

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Low-grade temperature

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Hemoglobin of 7gm

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    The urinary output has been 120ml during the last hour

    Quick Answer: 224

    Detailed Answer: 238

  • The nurse is caring for the client with a five-year-old diagnosis of plumbism. Which information in the health history is most likely related to the development of plumbism?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    The client has traveled out of the country in the last six months.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    The client’s parents are skilled stained-glass artists.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    The client lives in a house built in 1990.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    The client has several brothers and sisters.

    Quick Answer: 224

    Detailed Answer: 238

  • A client with a total hip replacement requires special equipment. Which equipment would assist the client with a total hip replacement with activities of daily living?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    High-seat commode

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Recliner

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    TENS unit

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Abduction pillow

    Quick Answer: 224

    Detailed Answer: 238

  • An elderly client with an abdominal surgery is admitted to the unit following surgery. In anticipation of complications of anesthesia and narcotic administration, the nurse should:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Administer oxygen via nasal cannula.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Have narcan (naloxane) available.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Prepare to administer blood products.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Prepare to do cardioresuscitation.

    Quick Answer: 224

    Detailed Answer: 238

  • Which roommate would be most suitable for the six-year-old male with a fractured femur in Russell’s traction?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    16-year-old female with scoliosis

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    12-year-old male with a fractured femur

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    10-year-old male with sarcoma

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    6-year-old male with osteomylitis

    Quick Answer: 224

    Detailed Answer: 239

  • A client with osteoarthritis has a prescription for Celebrex (celecoxib). Which instruction should be included in the discharge teaching?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Take the medication with milk.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Report chest pain.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Remain upright after taking for 30 minutes.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Allow six weeks for optimal effects.

    Quick Answer: 224

    Detailed Answer: 239

  • A client with a fractured tibia has a plaster-of-Paris cast applied to immobilize the fracture. Which action by the nurse indicates understanding of a plaster-of-Paris cast? The nurse:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Handles the cast with the fingertips

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Petals the cast

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Dries the cast with a hair dryer

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Allows 24 hours before bearing weight

    Quick Answer: 224

    Detailed Answer: 239

  • The teenager with a fiberglass cast asks the nurse if it will be okay to allow his friends to autograph his cast. Which response would be best?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    “It will be alright for your friends to autograph the cast.”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    “Because the cast is made of plaster, autographing can weaken the cast.”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    “If they don’t use chalk to autograph, it is okay.”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    “Autographing or writing on the cast in any form will harm the cast.”

    Quick Answer: 224

    Detailed Answer: 239

  • The nurse is assigned to care for the client with a Steinman pin. During pin care, she notes that the LPN uses sterile gloves and Q-tips to clean the pin. Which action should the nurse take at this time?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Assisting the LPN with opening sterile packages and peroxide

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Telling the LPN that clean gloves are allowed

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Telling the LPN that the registered nurse should perform pin care

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Asking the LPN to clean the weights and pulleys with peroxide

    Quick Answer: 224

    Detailed Answer: 239

  • A child with scoliosis has a spica cast applied. Which action specific to the spica cast should be taken?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Check the bowel sounds.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Assess the blood pressure.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Offer pain medication.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Check for swelling.

    Quick Answer: 224

    Detailed Answer: 239

  • The client with a cervical fracture is placed in traction. Which type of traction will be utilized at the time of discharge?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Russell’s traction

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Buck’s traction

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Halo traction

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Crutchfield tong traction

    Quick Answer: 224

    Detailed Answer: 239

  • A client with a total knee replacement has a CPM (continuous passive motion device) applied during the post-operative period. Which statement made by the nurse indicates understanding of the CPM machine?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    “Use of the CPM will permit the client to ambulate during the therapy.”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    “The CPM machine controls should be positioned distal to the site.”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    “If the client complains of pain during the therapy, I will turn off the machine and call the doctor.”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    “Use of the CPM machine will alleviate the need for physical therapy after the client is discharged.”

    Quick Answer: 224

    Detailed Answer: 239

  • A client with a fractured hip is being taught correct use of the walker. The nurse is aware that the correct use of the walker is achieved if the:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Palms rest lightly on the handles

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Elbows are flexed 0°

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Client walks to the front of the walker

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Client carries the walker

    Quick Answer: 224

    Detailed Answer: 240

  • When assessing a laboring client, the nurse finds a prolapsed cord. The nurse should:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Attempt to replace the cord.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Place the client on her left side.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Elevate the client’s hips.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Cover the cord with a dry, sterile gauze.

    Quick Answer: 224

    Detailed Answer: 240

  • The nurse is caring for a 30-year-old male admitted with a stab wound. While in the emergency room, a chest tube is inserted. Which of the following explains the primary rationale for insertion of chest tubes?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    The tube will allow for equalization of the lung expansion.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Chest tubes serve as a method of draining blood and serous fluid and assist in reinflating the lungs.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Chest tubes relieve pain associated with a collapsed lung.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Chest tubes assist with cardiac function by stabilizing lung expansion.

    Quick Answer: 224

    Detailed Answer: 240

  • A client who delivered this morning tells the nurse that she plans to breastfeed her baby. The nurse is aware that successful breastfeeding is most dependent on the:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Mother’s educational level

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Infant’s birth weight

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Size of the mother’s breast

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Mother’s desire to breastfeed

    Quick Answer: 224

    Detailed Answer: 240

  • The nurse is monitoring the progress of a client in labor. Which finding should be reported to the physician immediately?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    The presence of scant bloody discharge

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Frequent urination

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    The presence of green-tinged amniotic fluid

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Moderate uterine contractions

    Quick Answer: 224

    Detailed Answer: 240

  • The nurse is measuring the duration of the client’s contractions. Which statement is true regarding the measurement of the duration of contractions?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Duration is measured by timing from the beginning of one contraction to the beginning of the next contraction.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Duration is measured by timing from the end of one contraction to the beginning of the next contraction.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Duration is measured by timing from the beginning of one contraction to the end of the same contraction.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Duration is measured by timing from the peak of one contraction to the end of the same contraction.

    Quick Answer: 224

    Detailed Answer: 240

  • The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin, the nurse should monitor for:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Maternal hypoglycemia

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Fetal bradycardia

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Maternal hyperreflexia

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Fetal movement

    Quick Answer: 224

    Detailed Answer: 240

  • A client with diabetes visits the prenatal clinic at 28 weeks gestation. Which statement is true regarding insulin needs during pregnancy?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Insulin requirements moderate as the pregnancy progresses.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    A decreased need for insulin occurs during the second trimester.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Elevations in human chorionic gonadotrophin decrease the need for insulin.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Fetal development depends on adequate insulin regulation.

    Quick Answer: 224

    Detailed Answer: 240

  • A client in the prenatal clinic is assessed to have a blood pressure of 180/96. The nurse should give priority to:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Providing a calm environment

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Obtaining a diet history

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Administering an analgesic

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Assessing fetal heart tones

    Quick Answer: 224

    Detailed Answer: 240

  • A primigravida, age 42, is six weeks pregnant. Based on the client’s age, her infant is at risk for:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Down syndrome

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Respiratory distress syndrome

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Turner’s syndrome

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Pathological jaundice

    Quick Answer: 224

    Detailed Answer: 241

  • A client with a missed abortion at 29 weeks gestation is admitted to the hospital. The client will most likely be treated with:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Magnesium sulfate

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Calcium gluconate

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Dinoprostone (Prostin E.)

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Bromocrystine (Parlodel)

    Quick Answer: 224

    Detailed Answer: 241

  • A client with preeclampsia has been receiving an infusion containing magnesium sulfate for a blood pressure that is 160/80; deep tendon reflexes are 1 plus, and the urinary output for the past hour is 100mL. The nurse should:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Continue the infusion of magnesium sulfate while monitoring the client’s blood pressure.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Stop the infusion of magnesium sulfate and contact the physician.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Slow the infusion rate and turn the client on her left side.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Administer calcium gluconate IV push and continue to monitor the blood pressure.

    Quick Answer: 224

    Detailed Answer: 241

  • Which statement made by the nurse describes the inheritance pattern of autosomal recessive disorders?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    An affected newborn has unaffected parents.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    An affected newborn has one affected parent.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Affected parents have a one in four chance of passing on the defective gene.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Affected parents have unaffected children who are carriers.

    Quick Answer: 224

    Detailed Answer: 241

  • A pregnant client, age 32, asks the nurse why her doctor has recommended a serum alpha fetoprotein. The nurse should explain that the doctor has recommended the test:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Because it is a state law

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    To detect cardiovascular defects

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Because of her age

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    To detect neurological defects

    Quick Answer: 224

    Detailed Answer: 241

  • A client with hypothyroidism asks the nurse if she will still need to take thyroid medication during the pregnancy. The nurse’s response is based on the knowledge that:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    There is no need to take thyroid medication because the fetus’s thyroid produces a thyroid-stimulating hormone.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Regulation of thyroid medication is more difficult because the thyroid gland increases in size during pregnancy.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    It is more difficult to maintain thyroid regulation during pregnancy due to a slowing of metabolism.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Fetal growth is arrested if thyroid medication is continued during pregnancy.

    Quick Answer: 224

    Detailed Answer: 241

  • The nurse is responsible for performing a neonatal assessment on a full-term infant. At one minute, the nurse could expect to find:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    An apical pulse of 100

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    An absence of tonus

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Cyanosis of the feet and hands

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Jaundice of the skin and sclera

    Quick Answer: 224

    Detailed Answer: 241

  • A client with sickle cell anemia is admitted to the labor and delivery unit during the first phase of labor. The nurse should anticipate the client’s need for:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Supplemental oxygen

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Fluid restriction

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Blood transfusion

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Delivery by Caesarean section

    Quick Answer: 224

    Detailed Answer: 241

  • A client with diabetes has an order for ultrasonography. Preparation for an ultrasound includes:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Increasing fluid intake

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Limiting ambulation

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Administering an enema

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Withholding food for eight hours

    Quick Answer: 224

    Detailed Answer: 241

  • An infant who weighs 8 pounds at birth would be expected to weigh how many pounds at one year?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    14 pounds

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    16 pounds

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    18 pounds

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    24 pounds

    Quick Answer: 224

    Detailed Answer: 241

  • A pregnant client with a history of alcohol addiction is scheduled for a nonstress test. The nonstress test:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Determines the lung maturity of the fetus

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Measures the activity of the fetus

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Shows the effect of contractions on the fetal heart rate

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Measures the neurological well-being of the fetus

    Quick Answer: 224

    Detailed Answer: 242

  • A full-term male has hypospadias. Which statement describes hypospadias?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    The urethral opening is absent

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    The urethra opens on the top side of the penis

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    The urethral opening is enlarged

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    The urethra opens on the under side of the penis

    Quick Answer: 224

    Detailed Answer: 242

  • A gravida III para II is admitted to the labor unit. Vaginal exam reveals that the client’s cervix is 8cm dilated, with complete effacement. The priority nursing diagnosis at this time is:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Alteration in coping related to pain

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Potential for injury related to precipitate delivery

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Alteration in elimination related to anesthesia

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Potential for fluid volume deficit related to NPO status

    Quick Answer: 224

    Detailed Answer: 242

  • The client with varicella will most likely have an order for which category of medication?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Antibiotics

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Antipyretics

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Antivirals

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Anticoagulants

    Quick Answer: 224

    Detailed Answer: 242

  • A client is admitted complaining of chest pain. Which of the following drug orders should the nurse question?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Nitroglycerin

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Ampicillin

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Propranolol

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Verapamil

    Quick Answer: 224

    Detailed Answer: 242

  • Which of the following instructions should be included in the teaching for the client with rheumatoid arthritis?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Avoid exercise because it fatigues the joints.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Take prescribed anti-inflammatory medications with meals.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Alternate hot and cold packs to affected joints.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Avoid weight-bearing activity.

    Quick Answer: 224

    Detailed Answer: 242

  • A client with acute pancreatitis is experiencing severe abdominal pain. Which of the following orders should be questioned by the nurse?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Meperidine 100mg IM m 4 hours PRN pain

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Mylanta 30 ccs m 4 hours via NG

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Cimetadine 300mg PO m.i.d.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Morphine 8mg IM m 4 hours PRN pain

    Quick Answer: 224

    Detailed Answer: 242

  • The client is admitted to the chemical dependence unit with an order for continuous observation. The nurse is aware that the doctor has ordered continuous observation because:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Hallucinogenic drugs create both stimulant and depressant effects.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Hallucinogenic drugs induce a state of altered perception.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Hallucinogenic drugs produce severe respiratory depression.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Hallucinogenic drugs induce rapid physical dependence.

    Quick Answer: 224

    Detailed Answer: 242

  • A client with a history of abusing barbiturates abruptly stops taking the medication. The nurse should give priority to assessing the client for:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Depression and suicidal ideation

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Tachycardia and diarrhea

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Muscle cramping and abdominal pain

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Tachycardia and euphoric mood

    Quick Answer: 224

    Detailed Answer: 242

  • During the assessment of a laboring client, the nurse notes that the FHT are loudest in the upper-right quadrant. The infant is most likely in which position?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Right breech presentation

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Right occipital anterior presentation

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Left sacral anterior presentation

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Left occipital transverse presentation

    Quick Answer: 224

    Detailed Answer: 243

  • The primary physiological alteration in the development of asthma is:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Bronchiolar inflammation and dyspnea

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Hypersecretion of abnormally viscous mucus

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Infectious processes causing mucosal edema

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Spasm of bronchiolar smooth muscle

    Quick Answer: 224

    Detailed Answer: 243

  • A client with mania is unable to finish her dinner. To help her maintain sufficient nourishment, the nurse should:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Serve high-calorie foods she can carry with her.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Encourage her appetite by sending out for her favorite foods.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Serve her small, attractively arranged portions.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Allow her in the unit kitchen for extra food whenever she pleases.

    Quick Answer: 224

    Detailed Answer: 243

  • To maintain Bryant’s traction, the nurse must make certain that the child’s:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Hips are resting on the bed, with the legs suspended at a right angle to the bed

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Hips are slightly elevated above the bed and the legs are suspended at a right angle to the bed

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Hips are elevated above the level of the body on a pillow and the legs are suspended parallel to the bed

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Hips and legs are flat on the bed, with the traction positioned at the foot of the bed

    Quick Answer: 224

    Detailed Answer: 243

  • Which action by the nurse indicates understanding of herpes zoster?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    The nurse covers the lesions with a sterile dressing.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    The nurse wears gloves when providing care.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    The nurse administers a prescribed antibiotic.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    The nurse administers oxygen.

    Quick Answer: 224

    Detailed Answer: 243

  • There is an order for a trough to be drawn on the client receiving Vancomycin. The nurse is aware that he should contact the lab for them to collect the blood:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    15 minutes after the infusion

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    30 minutes before the fourth infusion

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    One hour after the infusion

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Two hours after the infusion

    Quick Answer: 224

    Detailed Answer: 243

  • The client using a diaphragm should be instructed to:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Refrain from keeping the diaphragm in longer than four hours

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Keep the diaphragm in a cool location

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Have the diaphragm resized if she gains five pounds

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Have the diaphragm resized if she has any surgery

    Quick Answer: 224

    Detailed Answer: 243

  • The nurse is providing postpartum teaching for a mother planning to breastfeed her infant. Which of the client’s statements indicates the need for additional teaching?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    “I’m wearing a support bra.”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    “I’m expressing milk from my breast.”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    “I’m drinking four glasses of fluid during a 24-hour period.”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    “While I’m in the shower, I’ll allow the water to run over my breasts.”

    Quick Answer: 224

    Detailed Answer: 243

  • Damage to the VII cranial nerve results in:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Facial pain

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Absence of ability to smell

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Absence of eye movement

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Tinnitus

    Quick Answer: 224

    Detailed Answer: 243

  • A client is receiving Pyridium (phenazopyridine hydrochloride) for a urinary tract infection. The client should be taught that the medication may:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Cause diarrhea

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Change the color of her urine

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Cause mental confusion

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Cause changes in taste

    Quick Answer: 224

    Detailed Answer: 244

  • Which of the following tests should be performed before beginning a prescription of Accutane?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Check the calcium level.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Perform a pregnancy test.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Monitor apical pulse.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Obtain a creatinine level.

    Quick Answer: 224

    Detailed Answer: 244

  • A client with AIDS is taking Zovirax (acyclovir). Which nursing intervention is most critical during the administration of acyclovir?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Limit the client’s activity.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Encourage a high-carbohydrate diet.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Use an incentive spirometer to improve respiratory function.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Encourage fluids.

    Quick Answer: 224

    Detailed Answer: 244

  • A client is admitted for an CAT scan. The nurse should question the client regarding:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Pregnancy

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    A titanium hip replacement

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Allergies to antibiotics

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Inability to move his feet

    Quick Answer: 224

    Detailed Answer: 244

  • The nurse is caring for the client receiving Amphotericin B. Which of the following indicates that the client has experienced toxicity to this drug?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Changes in vision

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Nausea

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Urinary frequency

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Changes in skin color

    Quick Answer: 224

    Detailed Answer: 244

  • The nurse should visit which of the following clients first?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    The client with diabetes with a blood glucose of 95mg/dL

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    The client with hypertension being maintained on Lisinopril

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    The client with chest pain and a history of angina

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    The client with Raynaud’s disease

    Quick Answer: 224

    Detailed Answer: 244

  • A client with cystic fibrosis is taking pancreatic enzymes. The nurse should administer this medication:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Once per day in the morning

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Three times per day with meals

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Once per day at bedtime

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Four times per day

    Quick Answer: 224

    Detailed Answer: 244

  • Cataracts result in opacity of the crystalline lens. Which of the following best explains the functions of the lens?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    The lens controls stimulation of the retina.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    The lens orchestrates eye movement.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    The lens focuses light rays on the retina.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    The lens magnifies small objects.

    Quick Answer: 224

    Detailed Answer: 244

  • A client who has glaucoma is to have miotic eyedrops instilled in both eyes. The nurse knows that the purpose of the medication is to:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Anesthetize the cornea

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Dilate the pupils

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Constrict the pupils

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Paralyze the muscles of accommodation

    Quick Answer: 224

    Detailed Answer: 244

  • A client with a severe corneal ulcer has an order for Gentamicin gtt. q 4 hours and Neomycin 1 gtt q 4 hours. Which of the following schedules should be used when administering the drops?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Allow five minutes between the two medications.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    The medications may be used together.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    The medications should be separated by a cycloplegic drug.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    The medications should not be used in the same client.

    Quick Answer: 224

    Detailed Answer: 244

  • The client with color blindness will most likely have problems distinguishing which of the following colors?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Orange

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Violet

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Red

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    White

    Quick Answer: 224

    Detailed Answer: 244

  • The client with a pacemaker should be taught to:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Report ankle edema

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Check his blood pressure daily

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Refrain from using a microwave oven

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Monitor his pulse rate

    Quick Answer: 224

    Detailed Answer: 245

  • The client with enuresis is being taught regarding bladder retraining. The nurse should advise the client to refrain from drinking after:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    1900

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    1200

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    1000

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    0700

    Quick Answer: 224

    Detailed Answer: 245

  • Which of the following diet instructions should be given to the client with recurring urinary tract infections?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Increase intake of meats.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Avoid citrus fruits.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Perform pericare with hydrogen peroxide.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Drink a glass of cranberry juice every day.

    Quick Answer: 224

    Detailed Answer: 245

  • The physician has prescribed NPH insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    “I will make sure I eat breakfast within two hours of taking my insulin.”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    “I will need to carry candy or some form of sugar with me all the time.”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    “I will eat a snack around three o’clock each afternoon.”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    “I can save my dessert from supper for a bedtime snack.”

    Quick Answer: 224

    Detailed Answer: 245

  • A client with pneumacystis carinii pneumonia is receiving Methotrexate. The rationale for administering leucovorin calcium to a client receiving Methotrexate is to:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Treat anemia

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Create a synergistic effect

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Increase the number of white blood cells

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Reverse drug toxicity

    Quick Answer: 224

    Detailed Answer: 245

  • A client tells the nurse that she is allergic to eggs, dogs, rabbits, and chicken feathers. Which order should the nurse question?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    TB skin test

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Rubella vaccine

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    ELISA test

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Chest x-ray

    Quick Answer: 224

    Detailed Answer: 245

  • The physician has prescribed ranitidine (Zantac) for a client with erosive gastritis. The nurse should administer the medication:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    30 minutes before meals

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    With each meal

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    In a single dose at bedtime

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    60 minutes after meals

    Quick Answer: 224

    Detailed Answer: 245

  • A temporary colostomy is performed on the client with colon cancer. The nurse is aware that the proximal end of a double barrel colostomy:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Is the opening on the client’s left side

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Is the opening on the distal end on the client’s left side

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Is the opening on the client’s right side

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Is the opening on the distal right side

    Quick Answer: 224

    Detailed Answer: 245

  • While assessing the postpartal client, the nurse notes that the fundus is displaced to the right. Based on this finding, the nurse should:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Ask the client to void.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Assess the blood pressure for hypotension.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Administer oxytocin.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Check for vaginal bleeding.

    Quick Answer: 224

    Detailed Answer: 245

  • The physician has ordered an MRI for a client with an orthopedic ailment. An MRI should not be done if the client has:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    The need for oxygen therapy

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    A history of claustrophobia

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    A permanent pacemaker

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Sensory deafness

    Quick Answer: 224

    Detailed Answer: 246

  • A six-month-old client is placed on strict bed rest following a hernia repair. Which toy is best suited to the client?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Colorful crib mobile

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Hand-held electronic games

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Cars in a plastic container

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    30-piece jigsaw puzzle

    Quick Answer: 224

    Detailed Answer: 246

  • The nurse is preparing to discharge a client with a long history of polio. The nurse should tell the client that:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Taking a hot bath will decrease stiffness and spasticity.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    A schedule of strenuous exercise will improve muscle strength.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Rest periods should be scheduled throughout the day.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Visual disturbances can be corrected with prescription glasses.

    Quick Answer: 224

    Detailed Answer: 246

  • A client on the postpartum unit has a proctoepisiotomy. The nurse should anticipate administering which medication?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Dulcolax suppository

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Docusate sodium (Colace)

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Methyergonovine maleate (Methergine)

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Bromocriptine sulfate (Parlodel)

    Quick Answer: 224

    Detailed Answer: 246

  • A client with pancreatic cancer has an infusion of TPN (Total Parenteral Nutrition). The doctor has ordered for sliding-scale insulin. The most likely explanation for this order is:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Total Parenteral Nutrition leads to negative nitrogen balance and elevated glucose levels.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Total Parenteral Nutrition cannot be managed with oral hypoglycemics.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Total Parenteral Nutrition is a high-glucose solution that often elevates the blood glucose levels.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Total Parenteral Nutrition leads to further pancreatic disease.

    Quick Answer: 224

    Detailed Answer: 246

  • An adolescent primigravida who is 10 weeks pregnant attends the antepartal clinic for a first check-up. To develop a teaching plan, the nurse should initially assess:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    The client’s knowledge of the signs of preterm labor

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    The client’s feelings about the pregnancy

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Whether the client was using a method of birth control

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    The client’s thought about future children

    Quick Answer: 224

    Detailed Answer: 246

  • An obstetric client is admitted with dehydration. Which IV fluid would be most appropriate for the client?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    .45 normal saline

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Dextrose 1% in water

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Lactated Ringer’s

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Dextrose 5% in .45 normal saline

    Quick Answer: 224

    Detailed Answer: 246

  • The physician has ordered a thyroid scan to confirm the diagnosis of a goiter. Before the procedure, the nurse should:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Assess the client for allergies.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Bolus the client with IV fluid.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Tell the client he will be asleep.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Insert a urinary catheter.

    Quick Answer: 224

    Detailed Answer: 246

  • The physician has ordered an injection of RhoGam for a client with blood type A negative. The nurse understands that RhoGam is given to:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Provide immunity against Rh isoenzymes

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Prevent the formation of Rh antibodies

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Eliminate circulating Rh antibodies

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Convert the Rh factor from negative to positive

    Quick Answer: 224

    Detailed Answer: 246

  • The nurse is caring for a client admitted to the emergency room after a fall. X-rays reveal that the client has several fractured bones in the foot. Which treatment should the nurse anticipate for the fractured foot?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Application of a short inclusive spica cast

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Stabilization with a plaster-of-Paris cast

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Surgery with Kirschner wire implantation

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    A gauze dressing only

    Quick Answer: 224

    Detailed Answer: 246

  • A client with bladder cancer is being treated with iridium seed implants. The nurse’s discharge teaching should include telling the client to:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Strain his urine

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Increase his fluid intake

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Report urinary frequency

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Avoid prolonged sitting

    Quick Answer: 224

    Detailed Answer: 247

  • Following a heart transplant, a client is started on medication to prevent organ rejection. Which category of medication prevents the formation of antibodies against the new organ?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Antivirals

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Antibiotics

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Immunosuppressants

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Analgesics

    Quick Answer: 224

    Detailed Answer: 247

  • The nurse is preparing a client for cataract surgery. The nurse is aware that the procedure will use:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Mydriatics to facilitate removal

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Miotic medications such as Timoptic

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    A laser to smooth and reshape the lens

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Silicone oil injections into the eyeball

    Quick Answer: 224

    Detailed Answer: 247

  • A client with Alzheimer’s disease is awaiting placement in a skilled nursing facility. Which long-term plans would be most therapeutic for the client?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Placing mirrors in several locations in the home

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Placing a picture of herself in her bedroom

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Placing simple signs to indicate the location of the bedroom, bathroom, and so on

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Alternating healthcare workers to prevent boredom

    Quick Answer: 224

    Detailed Answer: 247

  • A client with an abdominal cholecystectomy returns from surgery with a Jackson-Pratt drain. The chief purpose of the Jackson-Pratt drain is to:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Prevent the need for dressing changes

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Reduce edema at the incision

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Provide for wound drainage

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Keep the common bile duct open

    Quick Answer: 224

    Detailed Answer: 247

  • The nurse is performing an initial assessment of a newborn Caucasian male delivered at 32 weeks gestation. The nurse can expect to find the presence of:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Mongolian spots

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Scrotal rugae

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Head lag

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Polyhydramnios

    Quick Answer: 224

    Detailed Answer: 247

  • The nurse is caring for a client admitted with multiple trauma. Fractures include the pelvis, femur, and ulna. Which finding should be reported to the physician immediately?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Hematuria

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Muscle spasms

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Dizziness

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Nausea

    Quick Answer: 224

    Detailed Answer: 247

  • A client is brought to the emergency room by the police. He is combative and yells, “I have to get out of here. They are trying to kill me.” Which assessment is most likely correct in relation to this statement?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    The client is experiencing an auditory hallucination.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    The client is having a delusion of grandeur.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    The client is experiencing paranoid delusions.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    The client is intoxicated.

    Quick Answer: 224

    Detailed Answer: 247

  • The nurse is preparing to suction the client with a tracheotomy. The nurse notes a previously used bottle of normal saline on the client’s bedside table. There is no label to indicate the date or time of initial use. The nurse should:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Lip the bottle and use a pack of sterile 4×4 for the dressing.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Obtain a new bottle and label it with the date and time of first use.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Ask the ward secretary when the solution was requested.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Label the existing bottle with the current date and time.

    Quick Answer: 224

    Detailed Answer: 247

  • An infant’s Apgar score is 9 at five minutes. The nurse is aware that the most likely cause for the deduction of one point is:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    The baby is hypothermic.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    The baby is experiencing bradycardia.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    The baby’s hands and feet are blue.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    The baby is lethargic.

    Quick Answer: 224

    Detailed Answer: 247

  • The primary reason for rapid continuous rewarming of the area affected by frostbite is to:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Lessen the amount of cellular damage

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Prevent the formation of blisters

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Promote movement

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Prevent pain and discomfort

    Quick Answer: 224

    Detailed Answer: 248

  • A client recently started on hemodialysis wants to know how the dialysis will take the place of his kidneys. The nurse’s response is based on the knowledge that hemodialysis works by:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Passing water through a dialyzing membrane

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Eliminating plasma proteins from the blood

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Lowering the pH by removing nonvolatile acids

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Filtering waste through a dialyzing membrane

    Quick Answer: 224

    Detailed Answer: 248

  • During a home visit, a client with AIDS tells the nurse that he has been exposed to measles. Which action by the nurse is most appropriate?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Administer an antibiotic.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Contact the physician for an order for immune globulin.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Administer an antiviral.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Tell the client that he should remain in isolation for two weeks.

    Quick Answer: 224

    Detailed Answer: 248

  • A client hospitalized with MRSA is placed on contact precautions. Which statement is true regarding precautions for infections spread by contact?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    The client should be placed in a room with negative pressure.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Infection requires close contact; therefore, the door may remain open.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Transmission is highly likely, so the client should wear a mask at all times.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Infection requires skin-to-skin contact and is prevented by hand washing, gloves, and a gown.

    Quick Answer: 224

    Detailed Answer: 248

  • A client who is admitted with an above-the-knee amputation tells the nurse that his foot hurts and itches. Which response by the nurse indicates understanding of phantom limb pain?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    “The pain will go away in a few days.”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    “The pain is due to peripheral nervous system interruptions. I will get you some pain medication.”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    “The pain is psychological because your foot is no longer there.”

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    “The pain and itching are due to the infection you had before the surgery.”

    Quick Answer: 224

    Detailed Answer: 248

    Quick Answer: 224

    Detailed Answer: 248

  • A client with cancer of the pancreas has undergone a Whipple procedure. The nurse is aware that during the Whipple procedure, the doctor will remove the:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Head of the pancreas

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Proximal third section of the small intestines

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Stomach and duodenum

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Esophagus and jejunum

    Quick Answer: 224

    Detailed Answer: 248

  • The physician has ordered a minimal-bacteria diet for a client with neutropenia. The client should be taught to avoid eating:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Fruits

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Salt

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Pepper

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Ketchup

    Quick Answer: 224

    Detailed Answer: 248

  • A client is discharged home with a prescription for Coumadin (sodium warfarin). The client should be instructed to:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Have a Protime done monthly.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Eat more fruits and vegetables.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Drink more liquids.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Avoid crowds.

    Quick Answer: 224

    Detailed Answer: 248

  • The nurse is assisting the physician with removal of a central venous catheter. To facilitate removal, the nurse should instruct the client to:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Perform the Valsalva maneuver as the catheter is advanced

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Turn his head to the left side and hyperextend the neck

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Take slow, deep breaths as the catheter is removed

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Turn his head to the right while maintaining a sniffing position

    Quick Answer: 224

    Detailed Answer: 248

  • A client has an order for streptokinase. Before administering the medication, the nurse should assess the client for:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Allergies to pineapples and bananas

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    A history of streptococcal infections

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Prior therapy with phenytoin

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    A history of alcohol abuse

    Quick Answer: 224

    Detailed Answer: 249

  • The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Using oil- or cream-based soaps

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Flossing between the teeth

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    The intake of salt

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Using an electric razor

    Quick Answer: 224

    Detailed Answer: 249

  • The nurse is changing the ties of the client with a tracheotomy. The safest method of changing the tracheotomy ties is to:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Apply the new tie before removing the old one.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Have a helper present.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Hold the tracheotomy with the nondominant hand while removing the old tie.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Ask the doctor to suture the tracheostomy in place.

    Quick Answer: 224

    Detailed Answer: 249

  • The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was 300mL. The nurse should give priority to:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Turning the client to the left side

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Milking the tube to ensure patency

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Slowing the intravenous infusion

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Notifying the physician

    Quick Answer: 224

    Detailed Answer: 249

  • The infant is admitted to the unit with tetralogy of Fallot. The nurse would anticipate an order for which medication?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Digoxin

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Epinephrine

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Aminophyline

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Atropine

    Quick Answer: 224

    Detailed Answer: 249

  • The nurse is educating the lady’s club in self-breast exam. The nurse is aware that most malignant breast masses occur in the Tail of Spence. On the diagram, place an X on the Tail of Spence.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    Quick Answer: 224

    Detailed Answer: 249

  • The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Tire easily

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Grow normally

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Need more calories

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Be more susceptible to viral infections

    Quick Answer: 224

    Detailed Answer: 249

  • The nurse is monitoring a client with a history of stillborn infants. The nurse is aware that a nonstress test can be ordered for this client to:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Determine lung maturity

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Measure the fetal activity

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Show the effect of contractions on fetal heart rate

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Measure the well-being of the fetus

    Quick Answer: 224

    Detailed Answer: 250

  • The nurse is evaluating the client who was admitted eight hours ago for induction of labor. The following graph is noted on the monitor. Which action should be taken first by the nurse?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Instruct the client to push.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Perform a vaginal exam.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Turn off the Pitocin infusion.

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Place the client in a semi-Fowler’s position.

    Quick Answer: 224

    Detailed Answer: 250

  • The nurse notes the following on the ECG monitor. The nurse would evaluate the cardiac arrhythmia as:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Atrial flutter

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    A sinus rhythm

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Ventricular tachycardia

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Atrial fibrillation

    Quick Answer: 224

    Detailed Answer: 250

  • A client with clotting disorder has an order to continue Lovenox (enoxaparin) injections after discharge. The nurse should teach the client that Lovenox injections should:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Be injected into the deltoid muscle

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Be injected into the abdomen

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Aspirate after the injection

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Clear the air from the syringe before injections

    Quick Answer: 224

    Detailed Answer: 250

  • The nurse has a preop order to administer Valium (diazepam) 10mg and Phenergan (promethazine) 25mg. The correct method of administering these medications is to:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Administer the medications together in one syringe

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Administer the medication separately

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Administer the Valium, wait five minutes, and then inject the Phenergan

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Question the order because they cannot be given at the same time

    Quick Answer: 224

    Detailed Answer: 250

  • A client with frequent urinary tract infections asks the nurse how she can prevent the reoccurrence. The nurse should teach the client to:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Douche after intercourse

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Void every three hours

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Obtain a urinalysis monthly

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Wipe from back to front after voiding

    Quick Answer: 224

    Detailed Answer: 250

  • Which task should be assigned to the nursing assistant?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Placing the client in seclusion

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Emptying the Foley catheter of the preeclamptic client

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Feeding the client with dementia

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Ambulating the client with a fractured hip

    Quick Answer: 224

    Detailed Answer: 250

  • The client has recently returned from having a thyroidectomy. The nurse should keep which of the following at the bedside?

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    A tracheotomy set

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    A padded tongue blade

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    An endotracheal tube

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    An airway

    Quick Answer: 224

    Detailed Answer: 250

  • The physician has ordered a histoplasmosis test for the elderly client. The nurse is aware that histoplasmosis is transmitted to humans by:

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    A.

    Cats

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    B.

    Dogs

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    C.

    Turtles

    Which of the following assessment findings would best help the nurse decide that the flow is within normal limits?

    D.

    Birds

    Quick Answer: 224

    Detailed Answer: 250

    • Which of the following findings would make nurse even think that Divine is developing a postpartum complication?

    Which finding would lead the nurse to suspect that a woman is developing a postpartum complication? Women should have a lochia flow following birth. Absence of a flow is abnormal; it suggests dehydration from infection and fever.

    Which of the following findings would lead you to suspect that a woman is developing a postpartum complication *?

    Which of the following findings would lead you to suspect that a woman is developing a postpartum complication? Explanation: Women should have a lochia flow following childbirth. Absence of a flow is abnormal; it suggests dehydration from infection and fever.

    What criteria are assessed when looking at her lochia explain each one?

    The lochia should be assessed for color, amount, and odor. Too much lochia may indicate hemorrhage so it is important to know how the lochia is expected to look. In addition, foul smelling lochia may indicate infection. Lochia is usually bright red and contains small clots after birth.

    Which of the following findings would be expected when assessing the postpartum client?

    Which of the following findings would be expected when assessing the postpartum client? Fundus 1 cm above the umbilicus 1 hour postpartum. Within the first 12 hours postpartum, the fundus usually is approximately 1 cm above the umbilicus. The fundus should be below the umbilicus by PP day 3.

    assessment findings nurse decide flow normal limits

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