NCLEX Quiz 1

A nurse is assessing a 58-year-old client with blurred vision and reduced visual fields.  Which manifestation is of most concern to the nurse?

The nurse reviews the most current laboratory results of assigned clients.  Which result should the nurse report to the health care provider immediately?

During a routine clinic visit, the nurse is providing education to a 24-year-old female client with Marfan syndrome and aortic root dilation.  Which statement made by the nurse is appropriate?

A client with diabetes mellitus is admitted to the surgical unit after a vaginal hysterectomy.  The client received 6 units of regular insulin subcutaneously and metoprolol 50 mg by mouth in the post-anesthesia care unit.  Which statement by the unlicensed assistive personnel would require immediate action by the nurse?

The nurse is reinforcing education about home and lifestyle alterations to a client recently diagnosed with HIV.  Which of the following statements by the client indicates a need for further education?  Select all that apply.

The community health nurse provides an education program about risk factors for prostate cancer.  Which of the following statements by program attendees indicate that teaching has been effective?  Select all that apply.

The nurse teaches a client diagnosed with iron-deficiency anemia about iron-rich foods.  Which meal does the client choose to indicate that teaching has been effective?

The nurse is teaching general skin care guidelines to a client receiving teletherapy (external beam radiation therapy).  Which statements does the client make that indicate proper understanding of the teaching?  Select all that apply.

The nurse prepares to assess a newly admitted client diagnosed with chronic alcohol abuse whose laboratory report shows a magnesium level of 1.0 mEq/L (0.5 mmol/L).  Which assessment finding does the nurse anticipate?

A nurse is preparing a presentation about behavioral modifications to support weight loss for clients at an obesity clinic.  Which of the following points should the nurse include in the teaching plan?  Select all that apply.

The nurse provides discharge instructions to a client one day after laparoscopic cholecystectomy.  Which statement by the client indicates that further teaching is required?

A homeless man known to have chronic alcoholism and who has not eaten for 8 days is undergoing nutritional rehabilitation via oral and enteral feedings.  Which of the following findings would indicate that the client is developing refeeding syndrome?

The nurse is caring for a client with acute pancreatitis admitted 2 days ago.  Which assessment finding is most concerning?

The nurse assessing a client with an upper gastrointestinal bleed would expect the client’s stool to have which appearance?

The nurse reinforces the physical therapist’s teaching regarding the use of a cane when caring for a client with osteoarthritis of the left knee.  Which client statement indicates the need for further teaching?

A client with a hip fracture is placed in Buck traction.  Which activities are appropriate for the nurse to include in the client’s plan of care?  Select all that apply.

The nurse is assigned to care for a client who had a total hip replacement an hour ago.  Which of the following should the nurse assess first?

The nurse is performing discharge teaching on nutritional therapy for a client with chronic kidney disease.  Which statement indicates that further teaching is needed?

A client returns to the unit after receiving hemodialysis for the first time.  The client vomits once, reports headache, and appears restless and disoriented.  What is the priority intervention?

The nurse evaluates the results of laboratory tests completed on a client admitted for a non-healing wound.  Which of the following values would be a priority for the nurse?

The nurse is providing discharge teaching for a client who suffered full-thickness burns.  Which statement by the client demonstrates a need for further instruction on the rehabilitation phase of a burn injury?

The nurse in the emergency department is caring for a client with diabetic ketoacidosis.  After obtaining the client’s blood glucose level, which prescription should the nurse implement first?

The nurse is caring for a client with suspected Graves disease.  Which assessment finding requires priority intervention?

A client diagnosed with septic shock has an upward-trending glucose level (180-225 mg/dL [10.0-12.5 mmol/L]) requiring control with insulin.  The client’s spouse asks why insulin is needed as the client is not a diabetic.  What is the most appropriate response by the nurse?

The nurse is caring for a client recovering from a thyroidectomy to treat hyperthyroidism.  Which assessment finding would require the nurse to immediately notify the health care provider?

The charge nurse evaluates the care provided by a new registered nurse (RN) for a client receiving mechanical ventilation (MV).  Which action by the new RN indicates the need for further education?

A client is brought to the emergency department due to loss of consciousness after binge drinking at a college party and then taking alprazolam.  Pulse oximetry shows 87% on room air.  Which findings would the nurse expect to assess on an arterial blood gas?

The long-term care nurse is caring for a client diagnosed with macular degeneration.  Which client statement supports this diagnosis?

A client receiving a first dose of IV cefazolin has developed a diffuse rash, hypotension, and shortness of breath.  Place the nurse’s subsequent actions in the correct order.  All options must be used.

The nurse is providing education to a couple who desires to use the withdrawal method for contraception.  Which statement by the client indicates a need for further teaching?

The nurse is providing education to a 32-year-old female client diagnosed with human papillomavirus (HPV).  Which client statement indicates a need for further instruction?

An elderly client has a 17-mm induration after a tuberculin skin test (TST).  Based on this result, which statement is most accurate?

A client with polycythemia vera comes to the clinic for a monthly treatment.  The nurse knows that treatment for this condition will consist of which of the following?

A client with throat cancer receives radiation therapy to the head and neck.  Which of the following strategies are appropriate to decrease the adverse effects associated with radiation therapy?  Select all that apply.

A home health nurse is visiting a client who underwent right-sided mastectomy with lymph node removal.  The client is concerned about swelling in her arm on the affected side.  Which instructions should the nurse discuss with the client?  Select all that apply.

The post-anesthesia care unit nurse receives report on a client after abdominal surgery.  What sounds would the nurse expect to hear when auscultating the bowel?

A client is receiving an infusion of total parenteral nutrition (TPN) with 20% dextrose through a central line at 75 mL/hr.  The nurse responds to the client’s IV pump alarm, which indicates that the bag is empty.  The new bag is not expected to arrive from the pharmacy for an hour.  What is the most appropriate nursing action?

The nurse assessing a client’s pain would expect the client to make which statement when describing the abdominal pain associated with appendicitis?

The nurse is caring for a client with cirrhosis of the liver.  Which blood test values would the nurse typically anticipate to be elevated when reviewing the client’s morning laboratory results?  Select all that apply.

The nurse understands that which of these body substances are modes of transmission for hepatitis B?  Select all that apply.

Which group of food selections would be the best choice for a client advancing to a full liquid diet 3 days after bariatric surgery?

The nurse is assessing a diabetic client for pain following right total knee replacement surgery.  The client reports “numbness and tingling” in the bilateral lower extremities.  Pedal pulses are strong bilaterally, and capillary refill is <3 seconds in the right great toe.  Which action should the nurse take?

A graduate nurse (GN) is caring for a client who underwent a total knee replacement 1 day earlier.  Which intervention by the GN would cause the supervising nurse to intervene?

The health care provider (HCP) suspects a fat embolism syndrome (FES) in a client who has had multiple long bone fractures.  Which findings does the nurse expect to assess to support this diagnosis?  Select all that apply.

The nurse assesses a client receiving peritoneal dialysis.  Which assessment findings are most important for the nurse to report to the health care provider?  Select all that apply.

The nurse assesses a client with benign prostatic hyperplasia.  Which client statement requires further assessment?

The charge nurse is making rounds and should immediately intervene when making which observation?

The nurse cares for a client admitted with severe burns who is now on fluid resuscitation therapy.  Which assessment findings would best indicate that fluid resuscitation has been successful?

The nurse assesses a client who had a thyroidectomy 8 hours ago.  The nurse finds the client anxious, with tingling around the mouth and muscle twitching in the right arm.  Which action is most important for the nurse to implement first?

A client is admitted to the intensive care unit with suspected pheochromocytoma.  The client’s vital signs are temperature of 99.6 F (37.5 C), blood pressure (BP) of 200/110 mm Hg, heart rate of 110/min, and respirations of 20/min.  The client is sweating profusely and reports a severe headache.  Which prescription should the nurse implement first?

In the intensive care unit, the nurse cares for a client admitted with a head injury who develops syndrome of inappropriate antidiuretic hormone.  Which data should the nurse expect with the onset of this condition?  Select all that apply.

The nurse teaches proper foot care to a client with diabetes mellitus.  Which statement by the client indicates that further teaching is needed?

An elderly client is admitted with chronic obstructive pulmonary disease (COPD) exacerbation.  Pulse oximetry is 84% on room air.  The client is restless, has expiratory wheezing and a productive cough, and is using his accessory muscles to breathe.  Which prescription should the nurse question?

The nurse cares for a client with a pulmonary embolism.  Which of the following clinical manifestations would the nurse anticipate?  Select all that apply.

A football player is brought to the emergency department after a helmet-to-helmet collision without loss of consciousness or signs of external trauma.  Which clinical finding warrants immediate intervention?

The nurse is caring for a client with scleroderma.  Which assessment finding indicates the most serious complication of the disease and requires priority intervention?

The nurse is providing teaching about contraception to a group of clients.  Which statement by the nurse is appropriate to include?

The nurse prepares a client for discharge following a vasectomy.  The client asks, “When can I have sexual intercourse with my wife without using a condom?”  What is the best response by the nurse?

The nurse is answering questions at a hospital-sponsored health fair.  What actions should the nurse encourage to help prevent contracting the West Nile virus?  Select all that apply.

The nurse is obtaining a client’s health history during a routine physical and wellness examination.  Which of the following statements by the client should cause the nurse to suspect potential Hodgkin lymphoma?  Select all that apply.

The nurse is admitting a client who had mastectomy 6 months ago and is scheduled for elective surgery.  During the physical assessment, the nurse notices a 0.5 cm mobile, firm, nontender lymph node in the upper arm.  What action should the nurse take?

The nurse is reviewing medical histories with several clients during a community health screening event.  Which of the following client statements indicate a risk factor for cervical cancer?  Select all that apply.

The nurse is teaching about the importance of dietary fiber at a community health fair.  Which health benefits of consuming a fiber-rich diet should the nurse include in the teaching plan?  Select all that apply.

The nurse is reinforcing teaching to a client with a hiatal hernia.  Which statement by the client indicates that further teaching is needed?

A client is 1-day postoperative abdominoplasty and is discharged to go home with a Jackson-Pratt (JP) closed-wound system drain in place.  The nurse teaches the client how to care for the drain and empty the collection bulb.  Which statement indicates that the client needs further instruction?

A client admitted 3 days ago with upper gastrointestinal bleeding underwent an endoscopic procedure to stop the bleeding.  The client is started on a clear liquid diet today.  Which foods are appropriate for the nurse to offer the client?  Select all that apply.

The nurse is developing teaching materials for a client diagnosed with ulcerative colitis.  The client will receive sulfasalazine.  Which of the following instructions are included in the discharge teaching plan?  Select all that apply.

The nurse is reviewing lifestyle and nutritional strategies to help reduce symptoms in a client with newly diagnosed gastroesophageal reflux disease.  Which strategies should the nurse include?  Select all that apply.

The nurse is caring for a client who has just returned from external fixation device placement for stabilization of a fractured femur.  Which of the following interventions are appropriate to include in the client’s plan of care?  Select all that apply.

The nurse is caring for a client who is 12 hours postoperative total hip replacement.  Which nursing intervention is appropriate to help prevent dislocation of the hip prosthesis?

A 25-year-old marathon runner is admitted for suspected rhabdomyolysis.  The client has oliguria, dark amber urine, and muscle pain.  The nurse should implement which prescription first?

The nurse is caring for a 72-year-old client with a history of renal calculi and diabetes mellitus who was admitted for acute pyelonephritis.  The nurse assesses shaking chills, temperature of 101.2 F (38.4 C), and flank pain.  Which of the following is the priority nursing intervention?

The nurse is caring for a client with overflow urinary incontinence related to diabetic neuropathy.  Which of the following interventions are appropriate?  Select all that apply.

The nurse prepares to instill dialysate for a client receiving peritoneal dialysis.  Which nursing action is the priority?

The nurse is caring for a client in the intensive care unit who suffered partial-thickness burns to 36% of the body.  During the first 24 hours, the nurse would anticipate which of the following assessments?

The nurse is performing an initial assessment on a client diagnosed with Addison’s disease.  Which assessment findings should the nurse anticipate?  Select all that apply.

A client is admitted to the intensive care unit with diagnoses of a brain tumor complicated by transient diabetes insipidus.  Which client data related to this complication should the nurse expect?  Select all that apply.

The nurse is reviewing the laboratory results of a client who reports fatigue for the last month.  Based on the laboratory results, which additional clinical manifestations would the nurse expect?  Select all that apply.  See the exhibit for additional information.

The nurse assesses a 40-year-old client with acromegaly in an outpatient health clinic.  Which new finding is most important to report to the health care provider?

The nurse is assisting a client with asthma perform a peak flow meter measurement.  Place the instructions for measuring peak expiratory flow using a peak flow meter in the correct order.  All options must be used.

A client comes to the emergency department reporting alkaline drain cleaner splashed into the eye.  The conjunctiva of the affected eye is erythematous, and the client reports a burning sensation.  What action is appropriate currently?

The nurse reinforces education to a female client about the use of a cervical cap to prevent pregnancy.  Which statement by the client indicates a need for further teaching?

The nurse educator is completing a staff education conference about prenatal carrier screening.  Which statement by a participant indicates a correct understanding of the genetic inheritance for cystic fibrosis?

The nurse is caring for an adolescent newly diagnosed with a chlamydial infection.  After administering a one-time dose of azithromycin, the nurse understands that which of the following client statements indicate a correct understanding of client teaching?  Select all that apply.

A client with multidrug-resistant tuberculosis (MDR-TB) has a 1-month follow up visit after beginning medication therapy.  The client states, “I’ve had really bad nausea and fatigue, but because my cough has already improved, I knew it would be alright to stop taking the medications.”  The nurse identifies which priority nursing diagnosis (ND) in this client’s care plan?

The nurse is caring for several clients in a women’s health clinic.  Based on the data collected, which client’s history is most concerning for an increased risk of endometrial cancer?

A nurse is caring for a client 1 day after a left-sided mastectomy with lymph node dissection.  Which nursing intervention is the priority in caring for this client?

The nurse is reinforcing teaching about ulcer prevention with a client newly diagnosed with peptic ulcer disease.  Which of the following client statements indicate appropriate understanding of teaching?  Select all that apply.

Which statements made by the client demonstrate a correct understanding of the home care of an ascending colostomy?  Select all that apply.

A client is admitted with severe acute pancreatitis.  While obtaining the client’s blood pressure, the nurse notices a carpal spasm.  What laboratory result would the nurse assess in response to this symptom?

A client diagnosed with cirrhosis is experiencing pruritus.  Which strategies are appropriate for the nurse to teach the client to promote comfort and skin integrity?  Select all that apply.

The nurse is caring for a client who has a postoperative paralytic ileus following a bowel resection for colon cancer.  The client is receiving patient-controlled analgesia (PCA) with morphine.  Which nursing diagnoses (NDs) are appropriate to include in the client’s care plan?  Select all that apply.

The nurse is assisting with a colorectal cancer screening using the guaiac fecal occult blood test.  Place the steps for completing this test in the correct sequence.  All options must be used.

The unlicensed assistive personnel (UAP) assists a client with cirrhosis who underwent paracentesis 4 hours ago.  The UAP reports to the nurse that the client was lightheaded and unsteady while ambulating to the chair.  Which action should the nurse implement first?

A client comes to the emergency department after being assaulted.  Imaging studies show a simple fracture of the mandible.  The nurse assesses edema of the face and jaw, drooling, and bleeding in the mouth; the client rates pain as a 9 out of 10.  What is the priority nursing intervention?

The nurse is reviewing new prescriptions from the health care provider.  Which prescription would require further clarification?

The nurse working on an orthopedic unit is receiving report on 4 clients with recent fractures.  Which client should the nurse assess first?

The nurse gathers a health history from a 58-year-old male client with acute urinary retention.  Which of the following questions should the nurse ask to aid in assessing for benign prostatic hyperplasia?  Select all that apply.

Place the nursing actions for performing a renal system physical assessment in the correct order.  All options must be used.

The nurse provides post-procedure teaching for a female client who had a cystoscopy as an outpatient.  Which client statement indicates the need for additional instruction?

The emergency nurse admits a client who was rescued from a burning building.  The client’s arms and chest are covered with dry, leathery, charred skin that does not blanch.  Which new prescription should the nurse implement first?

The nurse cares for a client with type 1 diabetes mellitus who is obtunded and responding to only painful stimuli.  A STAT blood sample reveals a blood glucose level of 38 mg/dL (2.11 mmol/L).  Which initial action by the nurse is best?

A client with type 1 diabetes is prescribed NPH insulin before breakfast and dinner.  Although the client reports feeling well, the 6 AM blood glucose level has averaged 60 mg/dL (3.3 mmol/L) over the past week.  Which action is appropriate for the nurse to recommend to the client?

A client is diagnosed with diabetic ketoacidosis (DKA).  The client reports frequent urination, thirst, and weakness.  The nurse assesses a temperature of 102.4 F (39.1 C), fruity breath, deep labored respirations with a rate of 30/min, and dry mucous membranes.  What is the priority nursing diagnosis (ND) at this time?

When an unlicensed assistive personnel (UAP) assists a client with a chest tube back to bed from the bedside commode, the plastic chest drainage unit accidently falls over and cracks.  The UAP immediately reports this incident to the nurse.  What is the nurse’s immediate action?

The charge nurse of the emergency department (ED) is mentoring a new registered nurse (RN).  They are caring for a client who has a chest tube connected to wall suction for a pneumothorax.  The client is being transferred from the ED to the telemetry unit.  Which action by the new RN would cause the charge nurse to intervene?

The nurse is making follow-up phone calls to clients who had cataract surgery with intraocular lens implantation the previous day.  The nurse receives which client report that requires priority intervention?

A 28-year-old client is seeking advice from the nurse about why she has not been able to conceive.  The client is discouraged and states that she has been “trying to get pregnant for 4 months.”  Which statement by the nurse is best?

The nurse employed in a woman’s health care clinic would be most concerned about which client statement?

A home health nurse is giving an infection control presentation on pulmonary tuberculosis (TB) disease to a group of home health aides.  Which statement made by a home health aide indicates an understanding about the mode of transmission of pulmonary TB?

The public health nurse provides care for a client on a directly observed therapy (DOT) program to treat tuberculosis (TB).  Which option best describes the care the nurse provides on this program?

A client is admitted to the medical surgical floor with a hemoglobin level of 5.0 g/dL (50 g/L).  The nurse should anticipate which findings?  Select all that apply.

The nurse is teaching about cervical cancer prevention at a women’s health conference.  Which of the following factors should be taught as risks for cervical cancer?  Select all that apply.

The hospitalized client with anorexia nervosa is started on central parenteral nutrition.  Which client assessment is the most important for the nurse to check during the first 24-48 hours of administration?

After performing a physical assessment and obtaining vital signs for a client immediately after a laparoscopic cholecystectomy, which nursing intervention is the priority?

A nurse is caring for a client who developed paralytic ileus after a stroke.  The client reports nausea, abdominal discomfort, and distension; bowel sounds are absent.  Which prescription does the nurse question?

The registered nurse is developing a nursing care plan for a client who has just undergone surgery for treatment of ulcerative colitis with the creation of a permanent ileostomy.  What is the priority outcome for this client?

The nurse prepares to admit a client with worsening cirrhosis who is on the waiting list for a liver transplant.  Based on the client’s electronic health record, the nurse anticipates which assessment findings?  Select all that apply. See the exhibit button for additional information.

The nurse is preparing a client who had a Roux-en-Y gastric bypass (RYGB) for discharge from the hospital.  What information should the nurse plan to include related to the prevention of dumping syndrome?

The nurse is teaching the home health client how to perform colostomy irrigation.  Which client action reveals that further teaching is required?

The nurse has provided education for a client with newly diagnosed ankylosing spondylitis.  Which client statements indicate a correct understanding of teaching?  Select all that apply.

The nurse receives laboratory reports on 4 clients.  Which report is most concerning and should be reported to the health care provider?

The health care provider suspects a rotator cuff injury in a client who is an avid tennis player.  The nurse would most likely assess which of the following?

The nurse reinforces teaching about self-management strategies for a client with urge incontinence.  Which of the following statements indicate that teaching has been effective?  Select all that apply.

The nurse is conducting a pain assessment on a client with dysuria.  Which pain description is most likely associated with pyelonephritis?

A client diagnosed with end-stage renal disease comes to the dialysis clinic for treatment.  Which actions should the nurse take to prepare the client for hemodialysis?  Select all that apply.

A nurse is teaching home management to a client newly diagnosed with severe psoriasis.  Which client statement indicates that further teaching is needed?

A client with type I diabetes mellitus is brought to the emergency department by his wife.  The client has fruity breath with rapid, deep respirations at 36 breaths per minute, reports abdominal pain, and appears weak.  The nurse should anticipate implementation of which prescription(s)?  Select all that apply.

The nurse assesses a client with Cushing syndrome.  Which of the following clinical manifestations should the nurse expect?  Select all that apply.

The nurse cares for a client with type I diabetes mellitus.  Which action, by the nurse, best assesses the chronic complication of autonomic neuropathy?

A client is brought to the emergency department following a motor vehicle collision.  The client’s admission vital signs are blood pressure 70/50 mm Hg, pulse 123/min, and respirations 8/min.  The nurse anticipates the results of which diagnostic test to best evaluate the client’s oxygenation and ventilation status?

A student nurse initiates oxygen with a nonrebreather mask for a client with acute respiratory distress.  While reassessing the client, the RN notices the reservoir bag is fully deflating on inspiration.  What immediate action does the RN take to correct the problem?

The nurse is reviewing discharge teaching for a client who had surgical repair of a retinal detachment.  Which of the following instructions are appropriate for the nurse to include in the teaching?  Select all that apply.

Which of these instructions is appropriate teaching for a 60-year-old woman?  Select all that apply.

A client is being discharged home after an open radical prostatectomy.  Which statement indicates a need for further teaching?

The nurse is caring for a client in the acute phase of meningococcal meningitis.  Which nursing actions should be included in the client’s plan of care?  Select all that apply.

The nurse plans discharge teaching for a client with active herpes lesions who has a new prescription for oral acyclovir and topical lidocaine.  What information will the nurse include in the teaching plan?

The nurse is caring for a 50-year-old client in the clinic.  The client’s annual physical examination revealed a hemoglobin value of 10 g/dL (100 g/L) compared to 13 g/dL (130 g/L) a year ago.  What should be the nurse’s initial action?

The nurse is caring for a client with hemophilia admitted for a facial laceration and hemarthrosis of the left knee after falling at home.  Which of the following actions by the nurse are appropriate?  Select all that apply.

The nurse who is caring for a client with acute diverticulitis will immediately report which finding to the health care provider?

An older client comes to the outpatient clinic for a routine physical examination and health screening.  Which findings does the nurse recognize as possible indications of colorectal cancer?  Select all that apply.

The nurse provides discharge instructions to a client with cirrhosis who has portal hypertension, ascites, and esophageal varices.  Which statement by the client indicates that the teaching was effective?

A healthy 50-year-old client asks the nurse, “What must I do in preparation for my screening colonoscopy?”  Which statements by the nurse correctly answer the client’s question?  Select all that apply.

The nurse is admitting a client with cholelithiasis and acute cholecystitis.  Suddenly, the client vomits 250 mL of greenish-yellow stomach contents and reports severe pain in the right upper quadrant with radiation to the right shoulder.  Which intervention would have the highest priority?

During the immediate postoperative period after a colostomy, which stoma appearance requires the nurse to contact the health care provider (HCP) immediately?

The health care provider (HCP) orders a small bowel follow-through (SBFT) for a client.  Which instructions should the nurse include when teaching the client about this test?

The nurse teaches a client with osteopenia, who is lactose intolerant, how to increase dietary calcium and vitamin D intake.  Which lunch food is the best choice?

A nurse in the emergency department cares for 4 clients with orthopedic injuries.  Which client should the nurse assess first?

The nurse is educating a client newly diagnosed with rheumatoid arthritis about the disease process and home management.  Which statement by the client indicates comprehension of teaching?

The nurse is caring for a 78-year-old client with a urinary tract infection (UTI).  Which assessment finding would be most concerning and require immediate follow-up by the nurse?

A client has been given instructions about collecting a urine specimen to test creatinine clearance.  The client indicates correct understanding of the specimen collection procedure by making which statement?

The nurse is caring for a 68-year-old male client following a laparoscopic cholecystectomy 6 hours ago.  The client has not urinated since surgery.  Which of the following interventions are appropriate?  Select all that apply.

The nurse assesses a client with a burn on the arm and finds that the area is red, moist, and covered in shiny, fluid-filled vesicles.  Which burn stage does the nurse document?

The nurse cares for a client with Addison’s disease who was involved in a motor vehicle accident and hospitalized for a fracture of the right femur.  Which client information is most important to report to the primary health care provider (PHCP)?

The nurse cares for a client with type 2 diabetes mellitus and hemoglobin A1C results of 8% at an outpatient health clinic.  Which statement by the nurse will best address these results?

The nurse cares for a client admitted to the hospital due to confusion.  The client has a nonmetastatic lung mass and a diagnosis of syndrome of inappropriate antidiuretic hormone (SIADH).  Which action(s) should the nurse expect to implement?  Select all that apply.

The nurse auscultates the lung sounds of a newly admitted client.  The nurse understands that the sonorous wheezes heard are consistent with which health condition?

The nurse is caring for a client who has been receiving mechanical ventilation (MV) for 4 days.  During multidisciplinary morning rounds, the health care provider questions the development of a ventilator-associated pneumonia (VAP).  Which of the following manifestations does the nurse assess as the best indicator of VAP?

The nurse is reinforcing education about lifestyle modifications for a client newly diagnosed with Meniere disease.  Which statement by the client indicates a need for further teaching?

The nurse preparing an educational seminar on sexually transmitted infections for female college students should advise that which 2 infections are leading causes of pelvic inflammatory disease and infertility?

The nurse is reviewing the history of four female clients.  The nurse should recommend a Pap test to screen for cervical cancer in which client?

The nurse assesses the site where a client received an intradermal purified protein derivative (ie, Mantoux) test 48 hours ago and notices a 16-mm area of induration.  The client has no symptoms.  Which action will the nurse take next?

The clinic nurse is completing a health history for a client with suspected rheumatic fever (RF).  Which question is most important for the nurse to ask to establish a diagnosis?

An elderly client reports shortness of breath with activity for the past 2 weeks.  The nurse reviews the admission laboratory results and identifies which value as the most likely cause of the client’s symptoms?

A nurse is screening clients at a community health event.  Which of the following client statements should the nurse recognize as a warning sign of cancer?  Select all that apply.

The nurse is caring for a client with liver cirrhosis who was admitted for cellulitis of the leg.  Which assessments would the nurse perform to determine if the client’s condition has progressed to hepatic encephalopathy?  Select all that apply.

The nurse is caring for a client in the postanesthesia care unit following a gastroduodenostomy.  Which of the following nursing interventions are appropriate?  Select all that apply.

The nurse assesses a client with suspected acute pancreatitis and anticipates the client reporting pain in which anatomical area?

The nurse assesses for cancer risk factors during a screening event at a gastroenterology clinic.  Which of the following client statements include risk factors for esophageal cancer?  Select all that apply.

The nurse is caring for a client with acute diverticulitis who has nausea, vomiting, and rates pain as 8 on a scale of 0-10.  Which of the following interventions should be included in the plan of care?  Select all that apply.  See the exhibit button for additional information.

The nurse is caring for a client who underwent an endoscopic sleeve gastrectomy this morning for the treatment of morbid obesity.  Based on the client’s clinical data, which action by the nurse is appropriate at this time?  See the exhibit button for more information.

The nurse is teaching a client with newly diagnosed lactase deficiency about dietary management.  Which statements by the client indicate a correct understanding of this condition?  Select all that apply.

The registered nurse (RN) on an orthopedic unit is orienting a new graduate nurse (GN) assigned to a client with a fractured hip and in Buck’s traction.  The RN intervenes when the GN performs which action?

A client in the postoperative period after an open reduction and internal fixation of a left wrist fracture reports constant, severe arm pain that is unrelieved by prescribed morphine administered 30 minutes ago.  The client’s nail beds appear dusky.  What are the nurse’s appropriate actions?  Select all that apply.

A registered nurse is precepting a new graduate nurse on the orthopedic unit.  Which action by the graduate nurse requires the registered nurse to intervene?

A sexually active female client has had 3 urinary tract infections (UTIs) in 12 months.  Which instructions should the nurse include in teaching the client how to prevent UTI recurrence?  Select all that apply.

The nurse assesses a client diagnosed with chronic kidney disease who had an internal arteriovenous fistula performed on the left arm yesterday.  Which assessment finding would require immediate follow-up?

The nurse is caring for a client with an ileal conduit.  While assisting the client in removing the external pouch, the nurse observes that the stoma appears bluish grey.  What is the nurse’s best action?

For which client is it most important for the nurse to provide teaching on ways to prevent the spread of the condition?

When no changes are made to the diet or prescribed insulin, which client with type 1 diabetes mellitus does the nurse anticipate having the highest risk of developing hypoglycemia?

The nurse assesses a client with hyperparathyroidism who had a parathyroidectomy 4 hours ago.  Which assessment technique should the nurse use to check for complications in this client?

The nurse cares for a newly admitted client with type 1 diabetes mellitus.  The nurse reviews the electronic health record before the breakfast trays arrive on the unit and contacts the health care provider for which reason?  See the exhibit for additional information.

The nurse is caring for a client receiving mechanical ventilation via tracheostomy 2 weeks following a tracheotomy.  The nurse enters the client’s room to address a ventilator alarm and notes the tracheostomy tube dislodged and lying on the client’s chest.  Which action by the nurse is appropriate?  See the exhibit for additional information.

A client had a thoracotomy 2 days ago to remove a lung mass and has a right chest tube attached to negative suction.  Immediately after turning the client to the left side to assess the lungs, the nurse observes a rush of approximately 125 mL of dark bloody drainage into the drainage tubing and collection chamber.  What is the appropriate nursing action?  See the exhibit for additional information.

The nurse reviews the serum laboratory results of a client who was seen in the clinic 2 days ago for worsening joint pain from a flare of systemic lupus erythematosus.  Which result is of greatest concern and prompts the nurse to notify the health care provider?