A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium (Coumadin) has a prothrombin time (PT) of 35 seconds. Based on the prothrombin time, the nurse anticipates which of the following prescriptions?

1. Adding a dose of heparin sodium

2. Holding the next dose of warfarin

3. Increasing the next dose of warfarin

4. Administering the next dose of warfarin

2. Holding the next dose of warfarin

The nurse checks the laboratory result for a serum digoxin level that was prescribed fora client earlier in the day and notes that the result is 2.4 ng/mL. The nurse should take which immediate action?

1. Notify the physician.

2. Check the client's last pulse rate.

3. Record the normal value on the clien't flow sheet.

4. Administer the next dose of medication as scheduled.

1. Notify the physician.

A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen level drops to:

1. 3 mg/dL

2. 15 mg/dL

3. 29 mg/dL

4. 35 mg/dL

2. 15 mg/dL

A client arrives in the emergency room complaining of chest pain that began 4 hours ago. A troponin T blood specimen is obtained, and the results indicate a level of 0.6 ng/mL. The nurse determines that this result indicates:

1. A normal level

2. A low value that indicates possible gastritis

3. A level that indicates a myocardial infarction

4. A level that indicates the presence of possible angina

3. A level that indicates a myocardial infarction

A client is receiving continuous intravenous infusino of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin (aPTT) time is 65 seconds. The nurse anticipates that which action is needed?

1. Discontinuing the heparin infusion

2. Increasing the rate of the heparin infusion

3. Decreasing the rate of the heparin infusion

4. Leaving the rate of the heparin infusion as is

4. Leaving the rate of the heparin infusion as is

A client with a history of cardiac disease is due for a morning dose of furosemide (Lasix). Which serum potassium level, if noted in the client's laboratory report, should be reported before administering the dose of furosemide?

1. 3.2 mEq/L

2. 3.8 mEq/L

3. 4.2 mEq/L

4. 4.8 mEq/L

1. 3.2 mEq/L

A client with a history of gastrointestinal bleeding has a platelet count of 300,000 cells/mm3. The nurse should take which action after seeing the laboratory results?

1. Report the abnormally low count.

2. Report the abnormally high count.

3. Place the client in bleeding precautions.

4. Place the normal report in the client's medical record.

4. Place the normal report in the client's medical record.

An adult client with cirrhosis has been following a diet with optimal amounts of protein because neither an excess nor a deficiency of protein has been helpful. The nurse evaluates the client's status as being most satisfactory if the total protein level is which of the following values?

1. 0.4 g/dL

2. 3.7 g/dL

3. 6.4 g/dL

4. 9.8 g/dL

3. 6.4 g/dL

A client with diabetes mellitus has a glycosylated hemoglobin A1C level of 9%. Based on this test result, the nurse plans to teach the client aout the need to:

1. Avoid infection.

2. Take in adequate fluids

3. Prevent and recognize hypoglycemia.

4. Prevent and recognize hyperglycemia.

4. Prevent and recognize hyperglycemia.

The nurse is caring for a client diagnosis of cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the client's white blood cell count was which of the following?

1. 2000 cells/mm3

2. 5800 cells/mm3

3. 8400 cells/mm3

4. 11,500 cells/mm3

1. 2000 cells/mm3

A client brought to the emergency department states that he has accidentally been taking two times his prescribed dose of warfarin (Coumadin) for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to do which of the following?

1. Prepare to administer an antidote

2. Draw a sample for type and crossmatch and transfuse the client

3. Draw a sample for an activated partial thromboplastin time (aPTT) level

4. Draw a sample for prothrombin time (PT) and international normalized ratio (INR)

4. Draw a sample for prothrombin time (PT) and international normalized ratio (INR)

The nurse is assigned to a 40-year-old client who has a diagnosis of chronic pancreatitis. The nurse anticipates the client's serum amylase level to be which of the following?

1. 45 units/L

2. 100 units/L

3. 300 units/L

4. 500 units/L

3. 300 units/L

An adult female client has a hemoglobin level of 10.8 g/dL. The nurse interprets that this result is most likely caused by which of the following conditions noted in the client's history?

1. Dehydration

2. Heart failure

3. Iron deficiency anemia

4. Chronic obstructive pulmonary disease

3. Iron deficiency anemia

The nurse is caring for a client with congestive heart failure. On assessment, the nurse notes that the client is dyspneic and that crackels are audible on auscultation. The nurse suspects excess fluid volume. What additional signs would the nurse expect to note in this client if excess fluid volume is present?

1. Weight loss

2. Flat neck and hand veins

3. An increase in blood pressure

4. A decreased central venous pressure (CVP)

A nurse is preparing to care for a client with potassium deficit. The nurse reviews the client's record and determines that the client was at risk for developing the potassium deficit because the client:

1. Sustained tissue damage

2. Requires nasogastric suction

3. Has a history of Addison's disease

4. Is taking a potassium-sparing diuretic

A nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 3.2 mEq/L. Which of the following would the nurse note on the electrocardiogram as a result of the laboratory value?

1. U waves

2. Absent P waves

3. Elevated T waves

4. Elevated ST segment

A nursing student needs to administer potassium chloride intravenously as prescribed to a client with hypokalemia. The nursing instructor determines that the student is unprepared for this procedure if the student states that which of the following is part of the plan for preparation and administration of the potassium?

1. Obtaining a controlled intravenous (IV) infusion pump

2. Monitoring urine output during administration

3. Preparing the medication for bolus administration

4. Diluting the medication in appropriate amount of normal saline

A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a potassium level of 5.5. mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a potassium value at this level?

1. The client with colitis

2. The client with Cushing's syndrome

3. The client who has been overusing laxatives

4. The client who ahs sustained a traumatic burn

A nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L. The nurse reports the serum sodium level to the physician and the physician prescribes dietary instructions based on the sodium level. Which food item does the nurse instruct the client to avoid?

1. Peas

2. Nuts

3. Cauliflower

4. Processed oat cereals

A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following clinical manifestations would the nurse expect to note in the client?

1. Twitching

2. Hypoactive bowel sounds

3. Negative Trousseau's sign

4. Hypoactive deep tendon reflexes

A nurse caring for a client with hypocalcemia would expect to note which of the following changes on the electrocardiogram?

1. Widened T wave

2. Prominent U wave

3. Prolonged QT interval

4. Shortened ST segment

A nurse reveiws the electrolyte results of an assigned client and notes that the potassium level is 5.4 mEq/L on one client's laboratory report. Which of the following would the nurse expect to note on the electrocardiogram as a result of the laboratory value?

1. ST depression

2. Inverted T wave

3. Prominent U wave

4. Tall peaked T waves

A nurse caring for a gorup of clients reviews the electrolyte laboratory results and notes a dosium level of 130 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a sodium value at this level?

1. The client with Cushing's sydrome

2. The client who is taking diuretics

3. The client with hypoaldosteronism

4. The client who is taking corticosteroids

A nurse is caring for a client with acute congestive heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia?

1. Extreme thirst

2. Decreased urinary output

3. Hyperactive bowel sounds

4. Increased specific gravity of the urine

A nurse reviews a client's laboratory report and notes that the client's serum phosphorous level is 2 mg/dL. Which condition most likely caused this serum phosphorous level?

1. Alcoholism

2. Renal insufficiency

3. Hypoparathyroidism

4. Tumor lysis syndrome

A nurse is reading a physician's progress notes in the client's record and reads that the physician has documented "insensible fluid loss of approximately 800 mL dailiy." The nurse interprets that this type of fluid loss can occur through:

1. The skin

2. Urinary output

3. Wound drainage

4. The gastrointestinal tract

A nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is at risk for a fluid volume deficit?

1. A client with a colostomy

2. A client with congestive heart failure

3. A client on long-term corticosteroid therapy

4. A client receiving frequent wound irrigations

A nurse caring for a client who has been receiving IV diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition?

1. Lung congestion

2. Decreased hematocrit

3. Increased blood pressure

4. Decreased central venous pressure (CVP)

A nurse is assigned to care for a group of clients. On review of the clients' medicl records, the nurse determines that which client is at risk for fluid volume excess?

1. The client taking diuretics

2. The client with renal failure

3. The client with an ileostomy

4. The client who requires gastrointestinal suctioning

A nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, PCO2 of 30 mm Hg, and HCO3- of 22 mEq/L. The nurse analyzes thse results as indicating which condition?

1. Metabolic acidosis, compensated

2. Respiratory alkalosis, compensated

3. Metabolic alkalosis, uncompensated

4. Respiratory acidosis, uncompensated

A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client, knowing that the client is at risk for which acid-base disorder?

1. Metabolic acidosis

2. Metabolic alkalosis

3. Respiratory acidosis

4. Respiratory alkalosis

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/min. The electrocardiogram (ECG) monitor displays tachycardia, wth a heart rate of 120 beats/min. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which of the following?

1. A decreased pH and increased CO2

2. An increased pH and decreased CO2

3. A decreased pH and a decreased HCO3-

4. An increased pH with an increased HCO3-

A nurse caring for a client with an ileostomy understands that the client is most at risk for developing which acid-base disorder?

1. Metabolic acidosis

2. Metabolic alkalosis

3. Respiratory acidosis

4. Respiratory alkalosis

A nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Based on this documentation, which of the following did the nurse observe?

1. Respirations that cease for several seconds

2. Respirations that are regular but abnormally slow

3. Respirations that are labored and increased in depth and rate

4. Respirations that are abnormally deep, regular, and increased in rate

A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, PCO2 is 90 mm Hg, and results as indicating which condition?

1. Metabolic acidosis with compensation

2. Respiratory acidosis with compensation

3. Metabolic acidosis without compensation

4. Respiratory acidosis without compensation

A nurse plans to care for a client with chronic obstructive pulmonary disease (COPD), understanding that the client ismost likely to experience what type of acid-base imbalance?

1. Metabolic acidosis

2. Metabolic alkalosis

3. Respiratory acidosis

4. Respiratory alkalosis

A nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines taht the client is experiencing respiratory acidosis. Which of the following validates the nurse's findings?

1. pH 7.25, PCO2 50 mm Hg

2. pH 7.35, PCO2 40 mm Hg

3. pH 7.50, PCO2 52 mm Hg

4. pH 7.52, PCO2 28 mm Hg

A nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a PCO2 of 30 mm Hg. THe nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition?

1. Sodium level of 145 mEq/L

2. Potassium level of 3 mEq/L

3. Magnesium level of 2 mg/dL

4. Phosphorous level of 4 mg/dL

The nurse is teaching a client who has iron deficiency anemia about foods she should include in her diet.  The nurse determines that the client understands the dietary modifications if she selects which of the following from her menu?

1. Nuts and milk

2. Coffee and tea

3. Cooked rolled oats and fish

4. Oranges and dark green leafy vegetables

A nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet.  The nurse develops a list of high-fat foods to avoid and includes which food item on the list?

1. Oranges

2. Broccoli

3. Cream cheese

4. Broiled haddock

The nurse instructs a client with renal failure who is receiving hemodialysis about dietary modifications.  The nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu?

1. Cream of wheat, blueberries, coffee

2. Sausage and eggs, banana, orange juice

3. Bacon, cantaloupe melon, tomato juice

4. Cured pork, grits, strawberries, orange juice

The nurse is conducting a dietary assessment on a client who is on a vegan diet.  The nurse provides dietary teaching focusing on foods high in which vitamin that may be lacking in a vegan diet?

1. Vitamin A

2. Vitamin B12

3. Vitamin C

4. Vitamin E

A client with hypertension has been told to maintain a diet low in sodium.  A nurse who is teaching this client about foods that are allowed includes which food item in a list provided to the client?

1. Tomato soup

2. Boiled shrimp

3. Instant oatmeal

4. Summer squash

A nurse is caring for a client with cirrhosis of the liver.  To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine.  The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intention to increase the intake of:

1. Pork

2. Milk

3. Chicken

4. Broccoli

The nurse is instructing a client with hypertension on the importance of choosing foods low in sodium.  The nurse should teach the client to limit which of the following foods?

1. Apples

2. Bananas

3. Smoked sausage

4. Steamed vegetables

A client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet.  The client is looking forward to the diet change because he has been "bored" with the clear liquid diet.  The nurse would offer which full liquid item to the client?

1. Tea

2. Gelatin

3. Custard

4. Popsicle

A client is recovering from abdominal surgery and has a large abdominal wound.  A nurse encourages the client to eat which food item that is naturally high in vitamin C to promote wound healing?

1. Milk

2. Oranges

3. Bananas

4. Chicken

A client is being weaned from parenteral nutrition (PN) and is expected to begin taking solid food today.  The ongoing solution rate has been 100 mL/hr.  A nurse anticipates that which of the following prescriptions regarding the PN solution will accompany the diet order?

1. Discontinue the PN

2. Decrease PN rate to 50 mL/hr

3. Start 0.9% normal saline at 25 mL/hr

4. Continue current infusion rate orders for PN

A nurse is preparing to change the parenteral nutrition (PN) solution bag and tubing.  The client's central venous line is located in the right subclavian vein.  The nurse asks the client to take which essential action during the tubing change?

1. Breathe normally

2. Turn the head to the right

3. Exhale slowly and evenly

4. Take a deep breath, hold it, and bear down

A client with PN infusing has disconnected the tubing from the central line catheter.  A nurse assesses the client and usspects an air embolism.  The nurse should immediately place the client in which position?

1. On the left side, with the head lower than the feet

2. On the left side, with the head higher than the feet

3. On the right side, with the hed lower than the feet

4. On the right side, with the head higher than the feet

A client receiving PN complains of a headache. A nurse notes that the client has an increased BP, bounding pulse, jugular vein distentino, and crackles bilaterally.  The nurse determines that the client is experiencing which complication of PN therapy?

1. Sepsis

2. Air embolism

3. Hypervolemia

4. Hyperglycemia

A client is receiving nutrition by means of PN.  A nurse monitors the client for complications of the therapy and assesses the client for which of the following signs of hyperglycemia?

1. Fever, weak pulse, and thirst

2. Nausea, vomiting, and oliguria

3. Sweating, chills, and abdominal pain

4. Weakness, thirst, and increased urine output

A nurse is chanaging th ecentral line dressing of a client receiving PN and notes that the catheter insertion site appears reddened.  The nurse next assesses which of the following items?

1. Client's temperature

2. Expiration date on the bag

3. Time of last dressing change

4. Tightness of tubing connections

A nurse is preparing to hang fat emulsion (lipids) and notes that fat globules are visible at the top of the solution.  The nurse takes which of the following actions?

1. Rolls the bottle of solution gently

2. Obtains a different bottle of solution

3. Shakes the bottle of solution vigorously

4. Runs the bottle of solution under warm water

A client receiving PN suddenly spikes a fever.  A nurse notifies the physician, and the physician initially prescribes that the solution and tubing be changed.  The nurse shold do which of the following with the discontinued materials?

1. Discard them in the unit trash

2. Return them to the hsopital pharmacy

3. Send them to the laboratory for culture

4. Save them for return to the manufacturer

A client has been discharged to home on PN.  With each visit, a home care nurse assesses which of the following parameters most closely in monitoring this therapy?

1. Pulse and weight

2. Temperature and weight

3. Pulse and BP

4. Temperature and BP

A nurse is caring for a group of adult clients on an acute care medical-surgical nursing unit.  The nurse understands taht which of the following clients would be the least likely candidate for PN?

1. A 66-year-old client with extensive burns

2. A 42-year-old client who has had an open cholecystectomy

3. A 27-year-old client with severe exacerbation of Crohn's disease

4. A 35-year-old client with persistent nausea and vomiting from chemotherapy

A nurse is preparing to hang the first bag of PN solution via the central line of an assigned client.  The nurse obtains which most essential piece of equipment before hanging the solution?

1. Urine test strips

2. Blood glucose meter

3. Electronic infusion pump

4. Noninvasive BP monitor

A nurse is making initial rounds at the beginning of the shift and notes that the PN bag of an assigned client is empty.  Which of the following solutions readily available on the nursing unit should the nurse hang until another PN solution is mixed and dlivered to the nursing unit?

1. 5% dextrose in water

2. 10% dextrose in water

3. 5% dextrose in Ringer's lactate

4. 5% dextrose in 0.9% sodium chloride

A nurse is monitoring the status of a client's fat emulsion (lipid) infusion and notes that the infusion is 1 hour behind.  Which of the following actions by the nurse is appropriate?

1. Adjust the infusion rate to catch up over the next hour

2. Increase the infusion rate to catch up over the next 2 hours

3. Ensure that the fat emulsion infusion rate is infusing at the prescribed rate

4. Adjust the infusion rate to run wide open until the solution is back on time

A client receiving PN in the home setting has a weight gain of 5 lb in 1 week.  The nurse next assesses the client to detect the presence of which of the following?

1. Thirst

2. Polyuria

3. Decreased BP

4. Crackles on auscultation of the lungs

A nurse is caring for a restless client who is beginning nutritional therapy with PN.  The nurse should plan to ensure that which of the following is done to prevent the client from injury?

1. Calculate daily intake and output

2. Monitor the temperature once daily

3. Secure all connections in the PN system

4. Monitor blood glucose levels every 12 hours

A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 3 PM.  The nurse making rounds at 3:45 PM finds that the client is complaining of a pounding headache and is dyspneic, is experiencing chills, and is apprehensive, with an increased pulse rate.  The IV bag has 400 mL remaining.  The nurse should take which action first?

1. Call the physician

2. Slow the IV infusion

3. Sit the client up in bed

4. Remove the IV catheter

The nurse has a prescription to hang an IV bag of 1000 mL 5% dextrose in water with 20 mEq potassium chloride.  The nurse should plan to do which of the following immediately after injecting the potassium chloride into the port of the IV bag?

1. Rotate the bag gently

2. Attach the tubing to the client

3. Prime the tubing with the IV solution

4. Check the solution for yellowish discoloration

A client with the recent diagnosis of MI and impaired renal function is recuperating on the step-down cardiac unit.  The client's BP ha been borderline low and IV fluids have been infusion at 100 mL/hr via a central line catheter in the right internal jugular for approximately 24 hours to increase renal ouput and maintain the BP.  Upon entering the client's room, the nurse notes that the client is breathing rapidly and is coughing.  The nruse determines that the client is most likely experiencing which complication of IV therapy?

1. Hematoma

2. Air embolism

3. Systemic infection

4. Circulatory overload

The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients.  The nruse notes that a client's IV site is cool, pale, and swollen, and the solution is not infusing.  The nurse concludes that which of the following complications has occurred?

1. Infection

2. Phlebitis

3. Infiltration

4. Thrombosis

The nruse is inserting an IV line into a client's vein.  After the initial stick, the nurse continues to advance the catheter if:

1. The catheter advances easily

2. The vein is distended under the needle

3. The client does not complain of discomfort

4. Blood return shows in the backflash chamber of the catheter

The nurse notes that the site of a client's PIV catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter.  After taking appropriate steps to care for teh client, the nurse documents in the medical record that the client experienced: 

1. Phlebitis of the vein

2. Infiltration of the IV line

3. Hypersensitivity to the IV solution

4. Allergic reaction to the IV catheter material

The nurse is preparing a continuous IV infusion at the medication cart.  As the nurse goes to attach the distal end of the IV tubing to a needleless device, the exposed tubing drops and hits the top of the medication cart.  Which of the following is the appropriate action by the nurse?

1. Obtain new IV tubing

2. Attach a new needleless device

3. Wipe the distal end of the tubing with Betadine

4. Scrub the needleless device with an alcohol swab

A physician has written a prescription to discontinue an IV line.  The nurse obtains which of the following supplies from the unit supply area for applying pressure to the site after removing the IV catheter?

1. Elastic wrap

2. Betadine swab

3. Adhesive bandage

4. Sterile 2 X 2 gauze

A client has just undergone insertion of a central venous catheter at the bedside.  THe nurse would be sure to check the results of which of the following before initiating the flow rate of the client's IV solution at 100 mL/hr?

1. Serum osmolality

2. Serum electrolyte levels

3. Portable chest x-ray film

4. Intake and output record

A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding.  The client is severely hypotensive and unresponsive.  The nurse anticipates that which IV solution will most likely be prescribed to increase intravascular volume, replace immediate blood loss volume, and increase BP?

1. 5% dextrose in lactated Ringer's

2. 0.33% sodium chloride (1/3 normal saline)

3. 0.225% sodium chloride (1/4 normal saline)

4. 0.45% sodium chloride (1/2 normal saline)

The nurse provides a list of instruction to a client being discharged to home with a PICC.  The nurse determines that the client needs further instructions if the client made which statement?

1. "I need to wear a Medic-Alert tag or bracelet"

2. "I need to have a repair kit available in the home for use if needed"

3. "I need to keep the insertion site protected when in the shower or bath"

4. "I need to keep my activity level to a minimum while this catheter is in place"

Packed RBC have been prescribed for a client with low hemoglobin and hematocrit levels.  The nurse takes the client's temperature before hanging the blood transfusion and records 100.6 F orally.  Which of the following is the appropriate nursing action?

1. Begin the transfusion as prescribed

2. Delay hanging the blood and notify the physician

3. Administer an antihistamine and begin the transfusion

4. Administer two tablets of acetaminophen (Tylenol) and begin the transfusion

The nurse has received a prescription to transfuse a client with a unit of packed RBC.  Before explaining the procedure to the client, the nurse asks which initial question?

1. "Have you ever had a transfusion before?"

2. "Why do you think that you need the transfusion?"

3. "Have you ever gone into shock for any reason in the past?"

4. "Do you know the complications and risks of a transfusion?" 

A client receiving a transfusion of PRBCs begins to vomit.  The client's BP is 90/50 mm Hg from a baseline of 125/78 mm Hg.  The client's temperature is 100.8 F orally from a baseline of 99.2 F orally.  The nurse determines the client may be experiencing which complication of a blood transfusion?

1. Septicemia

2. Hyperkalemia

3. Circulatory overload

4. Delayed transfusion reaction

The nurse determines that a client is having a transfusion reaction.  After the nurse stops the transfusion, which action should immediately be taken next?

1. Remove the IV line

2. Run a solution of 5% dextrose in water

3. Run normal saline at a keep-vein-open rate

4. Obtain a culture of the tip of the catheter device removed from the client

The nurse has just received a unit of PRBCs from the blood bank for transfusion to an assigned client.  The nurse is careful to select tubing especially made for blood products, knowing that this tubing is manufactured with:

1. An air vent

2. An in-line filter

3. A microdrip chamber

4. Tinted tubing to protect the blood from light

A client has received a transfusion of platelets.  The nurse evaluates that the client is benefiting most from this therapy if the client exhbits which of the following?

1. Increased hematocrit level

2. Increased hemoglobin level

3. Decline of elevated temperature to normal

4. Decreased oozing of blood from puncture sites and gums

The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse.  Just before beginning the transfusion, the nurse assesses which priority item?

1. Vital signs

2. Skin color

3. Urine output

4. Latest hematocrit level

The nurse has just received a prescription to transfuse a unit of PRBCs for an assigned client.  Approximately how long will the nurse need to stay with the client to ensure that a transfusion reaction is not occurring?

1. 5 minutes

2. 15 minutes

3. 30 minutes

4. 45 minutes

A client has a prescription to receive a unit of PRBCs.  The nurse should obtain which of the following IV solutions from the IV storage area to hang with the blood products at the client's bedside?

1. Lactated Ringer's

2. 0.9% sodium chloride

3. 5% dextrose in 0.9% sodium chloride

4. 5% dextrose in 0.45% sodium chloride

The nurse listening to morning report learns that an assigned client received a unit of granulocytes the previous evening.  The nurse makes a note to assess the results of which of the following daily serum laboratory studies to assess the effectiveness of the transfusion?

1. Hematocrit level

2. Erythrocyte count

3. Hemoglobin level

4. White blood cell count

A client is brought to the ED having experienced blood loss related to an arterial laceration.  Fresh-frozen plasma is prescribed and transfused to replace fluid and blood loss.  The nurse understands that the rationale for transfusing fresh-frozen plasma in this client is:

1. To treat the loss of platelets

2. To promote rapid volume expansion

3. That the transfusion must be done slowly

4. That it will increase the hemoglobin and hematocrit levels

The nurse who is about to begin a blood transfusion knows that the blood cells start to deteriorate after a certain period of time.  Which of the following items is important to check regarding the age of blood cells before the transfusion begins?

1. Expiration date

2. Presence of clots

3. Blood group and type

4. Blood identification number

A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure.  The nurse suggest to the client to do which of the following to reduce the risk of possible transfusion complications?

1. Give an autologous blood donation before the surgery

2. Ask a friend or family member to donate blood ahead of time

3. Take iron supplements before surgery to boost hemoglobin levels

4. Request that any donated blood be screened twice by the blood bank

A client with severe blood loss resulting from multiple trauma requires rapid transfusion of several units of blood.  The nurse asks another health team member to obtain which device for use duing the transfusion procedure to help reduce the risk of cardiac dysrhythmias?

1. Pulse oximetry

2. Cardiac monitor

3. Infusion controller

4. Blood-warming device

A nurse is preparing to initiate an IV line containing a high dose of potassium chloride an dplans to use an IV infusion pump.  The nurse brings the pump to the bedside, prepares to plug the pump cord into the wall, and notes that no receptacle is available in the wall socket.  Which of the following is the appropriate nursing action?

1. Initiate the IV line without the use of a pump

2. Contact the electrical maintenance department for assistance

3. Plug in the pump cord in the available plug above the room sink

4. Use an extension cord from the nurses' lounge for the pump plug

A nurse obtains a prescription from a physician to restrain a client by using a jacket safety device and instructs a nursing assisstant to apply the safety device to the client.  Which observation by the nurse indicates unsafe application of the safety device by the nursing assistant?

1. A safety knot in the safety device straps

2. Safety device straps that are safely secured to the side rails

3. Safety device straps that do not tighten when force is applied against them

4. Safety device secured so that two fingers can slide easily between the safety device and the client's skin

The nurse is caring for a client with meningitis and implements which transmission-based precautions for this client?

1. Private room or cohort client

2. Personal respiratory protection device

3. Private room with negative airflow pressure

4. Mask worn by staff when the client needs to leave the room

A nurse is giving a report to a nursing assistant who will be caring for a client who has hand restraints (safety devices).  The nurse instructs the nursing assistant to check the skin integrity of the restrained hands:

1. Every 2 hours

2. Every 3 hours

3. Every 4 hours

4. Every 30 minutes

A nurse is planning caer for a client with an internal radiation implant.  Which of the following is an incorrect component to include in the plan of care?

1. Wearing gloves when emptyin gthe client's bedpan

2. Keeping all linens in the room until the implant is removed

3. Wearing a lead apron when providing direct care to the patient

4. Placing the client in a semiprivate room at the end of the hallway

Contact precautions are initiated for a client with a health care-associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus.  The nurse prepares to provide colostomy care and obtains which of the following protective items needed to perform this procedure?

1. Gloves and gown

2. Gloves and goggles

3. Gloves, gown, and shoe protectors

4. Gloves, gown, goggles, and face shield

A nurse enters a client's room and finds that the wastebasket is on fire.  The nurse immediately assists the client out of the room.  What is the next nursing action?

1. Call for help

2. Extinguish the fire

3. Activate the fire alarm

4. Confine the fire by closing the room door

A mother calls a neighbor who is a nusre and tells the nurse that her 3-year-old child has just ingested liquid furniture polish.  The nurse would direct the mother immediately to:

1. Induce vomiting

2. Call an ambulance

3. Call the Poison Control Center

4. Bring the child to the ED

An ED nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred.  The victims will be brought to the ED.  The initial nursing action is which of the following?

1. Prepare the triage rooms

2. Activate the emergency response plan

3. Obtain additional supplies from the central supply department

4. Obtain additional nursing staff to assist in treating the casualties

A physician's prescription reads 1000 mL of NS to infuse over 12 hours.  The drop factor is 15 gtt/1 mL.  A nurse prepares to set the flow rate at how many drops per minute? (nearest whole #)

A physician's Rx reads phenytoin (Dilantin) 0.2 g orally twice daily.  The medication label states 100-mg captues.  A nurse prepares how many capsule(s) to administer one dose?

Gentamicin sulfate, 80 mg in 100 mL NS is to be administered over 30 minutes.  The drop factor is 10 gtt/mL.  A nurse sets the flow rate at how many drops per minute? (nearest whole #)

A nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit.  The nurse plans to monitor which of the following parameters most carefully during the next hour?

1. Urinary output of 20 mL/hr

2. Temperature of 37.6 C (99.6 F)

3. BP of 100/70 mm Hg

4. Serous drainage on the surgical dressing

A postoperative client asks a nurse why it is so important to deep breathe and cough after surgery.  When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to:

1. Pneumonia

2. Fluid imbalance

3. Pulmonary embolism

4. Carbon dioxide retention

A nurse is developing a plan of care for a client scheduled for surgery.  THe nurse should include which activity in the nursing care plan for the client on the day of surgery?

1. Have the client void immediately before going into surgery

2. Avoid oral hygiene and rinsing with mouthwash

3. Verify that the client has not eaten for the last 24 hours

4. Report immediately any slight increase in BP or pulse

A client with a perforated gastric ulcer is scheduled for surgery.  The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered.  The nurse should take which appropriate action in the care of this client?

1. Obtain a court order for the surgery

2. Send the client to surgery without the consent form being signed

3. Have the hospital chaplain sign the informed consent immediately

4. Obtain a telephone consent from a family member, following agency policy

A preoperative client expresses anxiety to a nurse about upcoing surgery.  Which response by the nurse is most likely to stimulate further discussion between the client and the nurse?

1. "If it's any help, everyone is nervous before surgery"

2. "I will be happy to explain the entire surgical procedure to you"

3. "Can you share with me what you've been told about your surgery?"

4. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate"

A nurse is conducting preoperative teaching with a client about the use of an incentive spirometer.  The nurse should include which piece of information in discussions with the client?

1. Inhale as rapidly as possible

2. Keep a loose seal between the lips and the mouthpiece

3. After maximum inspiration, hold the breath for 15 seconds and exhale

4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees

A nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week.  The client has a history of arthritis and has been taking acetylsalicylic acid (aspirin).  The nurse determines that the client needs additional teaching if the client states:

1. "Aspirin can cause bleeding after surgery"

2. "Aspirin can cause my ability to clot blood to be abnormal"

3. "I need to continue to take the aspirin until the day of the surgery"

4. "I need to check with my physician about the need to stop the aspirin before the scheduled surgery"

A nurse assesses a client's surgical incision for signs of infection.  Which findings by the nurse would be interpreted as a normal finding at the surgical site?

1. Red, hard skin

2. Serous drainage

3. Purulent drainage

4. Warm, tender skin

A nurse is monitoring the status of a postoperative client.  The nurse would become most concerned with which of the following signs that could indicate an evolving complication?

1. Increasing restlessness

2. A pulse of 86 beats/minute

3. BP of 110/70 mm Hg

4. Hypoactive bowel sounds in all four quadrants

A nurse is reviewing a physician's Rx sheet for a preoperative client that states the client must be NPO after midnight.  The nurse would telephone the physician to clarify that which of the following medications should be given to the client and not withheld?

1. Prednisone

2. Ferrous sulfate

3. Cyclobenzaprine (Flexeril)

4. Conjugated estrogen (Premarin)

A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels.  Which of the following laboratory results should be reported to the surgeon's office by the nurse, knowing that it could cause surger to be postponed?

1. Sodium, 141 mEq/L

2. Hemoglobin, 8.0 g/dL

3. Platelets, 210,000/mm3

4. Serum creatinine, 0.8 mg/dL

A nurse receives a telephone call from the post-anesthesia care unit stating that a client is being transferred to the surgical unit.  The nurse plans to do which of the following first on arrival of the client?

1. Assess the patency of the airway

2. Check tubes or drains for patency

3. Check the dressing to assess for bleeding

4. Assess the vital signs to compare with preoperative measurements

A nurse is providing instructions to a pregnant client with HIV infection regarding care to the newborn infant after delivery.  The client asks the nurse about the feeding options that are available.  The best response by the nurse is:

1. "You will need to bottle-feed the newborn infant"

2. "You will need to feed the newborn infant by nasogastric tube feeding"

3. "You will be able to breast-feed for 6 months and then will need to switch to bottle-feeding"

4. "You will be able to breast-feed for 9 months and then will need to switch to bottle-feeding"

A home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia.  Which assessment finding indicates a worsening of the preeclampsia and the need to notify the physician?

1. Urinary output has increased

2. Dependent edema has resolved

3. BP reading is at the prenatal baseline

4. The client complains of a headache and blurred vision

A stillborn infant was delivered in the birthin suite a few hours ago.  After the delivery, the family remained together, holding and touching the infant.  Which statement by the nurse would further assist the family in their initial period of grief?

1. "What can I do for you?"

2. "Now you have an angel in heaven"

3. "Don't worry, there is nothing you could have done to prevent this from happening"

4. "We will see to it that you have an early discharge so that you don't have to be reminded of this experience"

A nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus.  Which statement made by the client indicates a need for further teaching?

1. "I should stay on the diabetic diet"

2. "I should perform glucose monitoring at home"

3. "I should avoid exercise because of the negative effects on insulin production"

4. "I should be aware of any infections and report signs of infection immediately to my health care provider"

A pregnant client in the last trimester has been admitted to the hospital with a diagnosis of severe preeclampsia.  A nurse monitors for complications associated with the diagnosis and assesses the client for:

1. Enlargement of the breasts

2. Complaints of feeling hot when the room is cool

3. Periods of fetal movement followed by quiet periods

4. Evidence of bleeding, such as in the gums, petechiae, and purpura

A nurse in a maternity unit is reviewing the recods of the clients on the unit.  Which client would the nurse identify as being at the greatest risk for developing DIC?

1. A primigravida with mild preeclampsia

2. A primigravida who delivered a 10-lb infant 3 hours ago

3. A gravida II who has just been diagnosed with dead fetus syndrome

4. A gravida IV who delivered 8 hours ago and has lost 500 mL of blood

A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding.  A threatened abortion is suspected, and the nurse instructs the client regarding management of care.  Which statemnet made by the client indicates a need for further instructions?

1. "I will watch for the evidence of the passage of tissue"

2. "I will maintain strict bedrest throughout the remainder of the pregnancy"

3. "I will count the number of perineal pads used on a daily basis and note the amount and color of blood on the pad"

4. "I will avoid sexual intercourse until the bleeding has stopped, and for 2 weeks following the last evidence of bleeding"

The nurse is assessing a pregnant client with type I DM about her understanding regarding changing insulin needs during pregnancy.  The nurse determines that teaching is needed if the client makes which statement?

1. "I will need to increase my insulin dosage during the first 3 months of pregnancy"

2. "My insulin dose will likely need to be increased during the second and third trimesters"

3. "Episodes of hypoglycemia are more likely to occcur during the first 3 months of pregnancy"

4. "My insulin needs should return to normal within 7 to 10 days after birth if I am bottle-feeding"

A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, and fatigue.  After assessment of the client, tuberculossis is suspected.  A sputum culture is obtained and idetifies Mycobacterium tuberculosis.  The nurse provides instructions to the client regarding therapeutic management of the tuberculosis and the nurse tells the client that:

1. Therapeutic abortion is required

2. She will have to stay home until treatment is completed

3. Medication will not be started until after delivery of the fetus

4. Isoniazid (INH) plus rifampin (Ridafin) will be required for 9 months

A nurse is providing instructions to a maternity client with a history of cardiac disease regarding appropriate dietary measures.  Which statement, if made by the client indicates an understanding of the information provided by the nurse?

1. "I should increase my sodium intake during pregnancy"

2. "I should lower my blood volume by limiting my fluids"

3. "I should maintain a low-calorie diet to prevent any weight gain"

4. "I should drink adequate fluids and increase my intake of high-giber foods"

A clinic nurse is performing a psychosocial assessment of a client who has been told she is pregnant.  Which assessment finding indicates to the nurse that the client is at high risk for contracting HIV?

1. A client who has a history of IV drug use

2. A client who has a significant other who is heterosexual

3. A client who has a history of STDs

4. A clietn who has one sexual partner for the past 10 years

The nurse in a maternity unit is providing emotional support to a client and her husband who are preparing to be discharged home from the hospital after the birth of a dead fetus.  Which statement made by the client indicates a component of the normal grieving process?

1. "We want to attent a support group"

2. "We never want to try to have a baby again"

3. "We are going to try to adopt a child immediately"

4. "We are okay, and we are going to try to have another baby immediately"

A nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle-feeding to her infant during postpartum hospitalization.  Which maternal action best exemplifies the mother's knowledge of potential diease transmission to the infant?

1. The mother requests that the window be closed before feeding

2. The mother holds the infant properly during feeding and burping

3. The mother tests the temperature of the formula before initiating feeding.

4. The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding