Nursing Exam Questions PDF

Exiting never felt so good. 1) A nurse is discussing weight loss with a client who is concerned about losing 6.8 kg (15 lb) from an original weight of 90.7 kg (200 lb). The nurse should identify the weight loss as which of the following total percentages? A. 8.1% B. 15.9% C. 13.3% D. 7.5% 2) A nur...

Exiting never felt so good. 1) A nurse is discussing weight loss with a client who is concerned about losing 6.8 kg (15 lb) from an original weight of 90.7 kg (200 lb). The nurse should identify the weight loss as which of the following total percentages? A. 8.1% B. 15.9% C. 13.3% D. 7.5% 2) A nurse is caring for a client who has Graves' disease and is experiencing a thyroid storm. Which of the following actions is the nurse's priority? A. Provide a cooling blanket. B. Monitor the client's cardiac rhythm. C. Administer 0.9% sodium chloride IV. D. Obtain the client's blood glucose. 3) A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include? A. Excessive sweating B. Dry cough C. Increased urinary frequency D. Metallic taste in mouth (All SSRIs run the risk of sweating. Another word for excessive sweating is hyperhidrosis) 4) A charge nurse is teaching a newly licensed nurse about the facility's computerized documentation system. Which of the following information should the nurse include? A. "Documentation of sensitive material is performed by the charge nurse." B. "Information Technology will install a firewall to secure client information." C. "You will be asked to change your password once per year." D. “You will be given access to the medical records of every client in the facility." 6) Exhibits Click to specify which of the following actions the nurse should anticipate including in the client's plan of care. Select all that apply. Exhibit 1 Assessment 1000: Client is Gravida 1 Para 0 and reports headache, nausea, vomiting, and right upper abdominal pain. Client is alert and oriented, appears restless. Client has gained 0.68 kg (1.5 lb) within the last week. Slight facial edema is present. Heart rate regular and without murmur. Respirations even, non-labored. Lungs clear to auscultation. Abdomen gravid. Fundal height measurement 29 cm. 1+ dependent edema noted bilaterally. Deep tendon reflex (DTR) is 3+ bilaterally. Applied external fetal heart monitor. No contractions noted. Fetal heart rate 140/min. Exhibit 2 Vital Signs 1000: Temperature 37.4" C (99.3° F) Heart rate 90/min Respiratory rate 20/min Blood pressure 148/94 mm Hg Oxygen saturation 95% on room air 1100: Temperature 37° C (98.6° F) Heart rate 92/min Respiratory rate 24/min Blood pressure 156/96 mm Hg Oxygen saturation 94% on room air Exhibit 3 Laboratory Results 1100: Bloodwork WBC count 12,500 mm3 (5,000 to 15,000 mm3) Hemoglobin 12.5 g/dL (11 g/dL to 16 g/dL) Hematocrit 37% (33% to 47%) Platelet count 98,000/mm3 (150,000 to 400,000/mm3) Fibrinogen 500 mg/dL (200 to 400 mg/ dL) BUN 23 mg/dL (10 to 20 mg/dL) Creatinine 1.2 mg/dL (0.5 to 1.0 mg/dL) Lactate dehydrogenase 220 units/L (100 to 190 units/L) Aspartate aminotransferase 38 units/L (0 to 35 units/L) Alanine aminotransferase 40 units/L (4 to 36 units/L) Uric acid 8.5 mg/dL (2.7 to 7.3 mg/dL) Urinalysis Protein 25 mg/dL (0 to 8 mg/dL) Ketones none (none) WBCS 2 (0 to 4 per low power field) A. Initiate contact precautions. B. Check urinary output. C. Decrease lighting in the client's room. D. Monitor blood pressure. E. Prepare for amniocentesis. F. Apply Internal fetal monitor. G. Assess DTR. H. Bed rest Answer: B,D,F,G,H 7) A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder? A. "The client is exceptionally clingy to others." B. "The client might act seductively." C. "The client exhibits impulsive behavior." D. "The client is overly concerned about minor details." Borderline also exhibits self harm 8) A nurse is caring for a 1-day-old newborn who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take? A. Keep the infant's head covered with a cap. B. Apply lotion to the newborn every 4 hr. C. Give the infant 30 mL (1 oz) of glucose water every 2 hr. D. Ensure that the newborn wears a diaper. 9) A nurse is assessing the skin turgor of an older adult client. In which of the following areas should the nurse lift the skin? A. Sternum B. Abdomen C. Shoulder D. Neck 10) A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include? A. Increase intake of milk products. B. Sweeten foods with fructose corn syrup. C. Increase intake of foods high in gluten. D. Consume foods high in bran fiber. 11) A nurse is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP? A. Change a dressing on an implanted central venous access device. B. Remove an NG tube. C. Suction a new tracheostomy. D. Perform postmortem care. 12) A nurse is caring for a client who has cancer and is terminally ill. The client reports feeling depressed. Which of the following statements should the nurse make? A. "Do you need information on hospice care?" B. "Would you like to talk to a counselor about advance directives?" C. "Would you like to speak to a spiritual advisor?" D. "Do you need a prescription for an antianxiety medication?" 13) A nurse is reviewing laboratory data from a client who has chronic kidney disease. Which of the following findings should the nurse expect? A. Increased bicarbonate B. Increased calcium C. Increased hemoglobin D. Increased creatinine 14) A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV Infusion. For which of the following therapeutic effects should the nurse monitor the client? A. BP 150/92 mm Hg B. Flushed face C. Pulse rate 100/min D. Negative clonus 15) A nurse is caring for an adolescent who has hyperthermia. Which of the following actions should the nurse take? A. Administer oral acetaminophen. B. Initiate seizure precautions. C. Submerge the adolescent's feet in ice water. D. Cover the adolescent with a thermal blanket. Always do szr precaution first because it will protect the airway always abc first 16) A nurse is providing Information for a client who has a new prescription for simvastatin. For which of the following should the nurse Instruct the client to monitor and report to the provider? A. Edema B. Weight loss C. Muscle weakness D. Fever Can cause muscle breakdown and liver failure from muscle metabolism 17) A nurse is caring for a client who speaks a different language than the nurse and is using an interpreter. Which of the following actions should the nurse take when working with the interpreter? A. Direct statements to the interpreter. B. Speak in a normal voice at a natural pace. C. Pause in the middle of sentences. D. Use gestures when speaking with the client. 18) A nurse is caring for a client who is recovering from a cerebrovascular accident in a rehabilitation facility. The client tells the nurse, "I am sick of being in here, and I want to go home." Which of the following responses should the nurse make? A. "It would be best to discuss your feelings with your provider." B. "It must be very frustrating for you to be here." C. "You are making progress in your treatment plan." D. "You should call your partner to discuss this." 19) A nurse is teaching the parents of a child who has a new onset of seizures and is to undergo an electroencephalogram (EEG) about the procedure. Which of the following instructions should the nurse include in teaching? A. "Make the child NPO before the procedure." B. "Ensure the child's hair is clean and without conditioner before the procedure." C. "Keep the child out of the sun for 4 hr following the procedure." D. "Give the child acetaminophen for pain following the procedure." 20) A nurse is preparing to administer three medications to a client who is receiving continuous enteral feeding through an NG tube. Which of the following actions is appropriate for the nurse to take? A. Add medication directly to enteral feeding. B. Flush the NG tube with 5 mL water. C. Dissolve the medications together. D. Use a syringe to allow the medications to flow by gravity. Flush should be 15-30 mL between, we want to give the meds slow to see if there is a reaction so with a syringe one at a time by gravity. 21) A nurse is caring for a client who has systemic lupus erythematosus. Which of the following client findings should the nurse expect? A. Raised facial rash B. Hemangiomas C. Kaposi's sarcoma lesions D. Psoriasis 22) A nurse is planning care for a client who is scheduled to have a paracentesis. Which of the following actions should the nurse include in the plan of care? A. Position the client over an overbed table prior to the procedure. B. Instruct the client to empty her bladder prior to the procedure. C. Administer 1 L dextrose 5% in water IV bolus prior to the procedure. D. Initiate NPO status 4 hr prior to the procedure. 23) A nurse is providing discharge teaching to a client who is postoperative following surgery for carpal tunnel syndrome. Which of the following statements by the client indicates an understanding of the teaching? A. "I will need to keep my hand elevated above my heart for several days." B. "I can apply heat for the first 24 hours to minimize the pain in my hand." C. "I should not use my affected hand for 4 to 6 weeks." D. "I should expect numbness and tingling in my hand." 25) A nurse in labor and delivery is caring for a client who is at 30 weeks of gestation Exhibits Select the 5 findings that require follow up by the nurse Exhibit 1 Assessment 1000: Client is Gravida 1 Para 0 and reports headache, nausea, vomiting, and right upper abdominal pain. Client is alert and oriented, appears restless. Client has gained 0.68 kg (1.5 lb) within the last week. Slight facial edema is present. Heart rate regular and without murmur. Respirations even, non-labored. Lungs clear to auscultation. Abdome gravid. Fundal height measurement 29 cm. 1+ dependent edema noted bilaterally. Deep tendon reflex (DTR) is 3+ bilaterally. Applied external fetal heart monitor. No contractions noted. Fetal heart rate 140/min. Exhibit 2 Vital Signs 1000: Temperature 37.4° C (99.3° F) Heart rate 90/min Respiratory rate 20/min Blood pressure 148/94 mm Hg Oxygen saturation 95% on room air A. Nausea B. DTR C. Blood pressure D. Fetal heart tracing E. Weight assessment F. Respiratory assessment G. Fundal height H. Lower extremity assessment 26) A nurse is providing teaching to a client who has thrombocytopenia following chemotherapy. Which of the following statements Indicates an understanding of the teaching? A. "I will wipe my nose instead of blowing it." B. "I will remove my shoes when I'm inside my house." C. "I will use an enema to manage my constipation." D. "I will floss between my teeth every time I brush." 28) A nurse is preparing to administer an IV medication to a client and accidentally punctures the IV bag, causing the medication to leak on the counter. Which of the following medications requires the nurse to follow facility procedures in the safe handling of a biohazardous material spill? A. Metronidazole B. Ampicillin sodium C. Doxorubicin hydrochloride D. Phenytoin 29) A nurse is creating a plan of care for a client who has cancer and is experiencing Immunosuppression. Which of the following Interventions should the nurse include in the plan of care? A. Monitor the client's vital signs every 12 hr. B. Inspect the client's mouth every 8 hr. C. Provide fresh fruit with the client's meals. D. Rotate health care staff caring for the client. 30) A nurse is assessing a client who has histrionic personality disorder. Which of the following manifestations should the nurse expect? A. Splitting behavior B. Emotional lability C. Unexpressive affect D. Self-centered behavior 31) A nurse is caring for a client who reports a headache and has a history of a peptic ulcer. Which of the following medications should the nurse administer? A. Acetaminophen B. Ibuprofen C. Aspirin D. Ketorolac 32) A charge nurse is concerned about a recent increase in facility-acquired catheter Infections. Which of the following actions should the nurse take first? A. Revise the current policy for catheter care. B. Identify possible precipitating factors related to the infections. C. Schedule nursing staff training for infection control procedures. D. Meet with providers to discuss measures to decrease the infections. 33) A nurse is caring for a client who has experienced a stillbirth. Which of the following actions should the nurse take during the initial grieving process? A. Discourage the client from allowing friends to see the newborn. B. Avoid talking to the client about the newborn. C. Assure the client that she can have additional children. D. Offer to take pictures of the newborn for the client. 34) A nurse is providing teaching to an older adult client who has a seizure disorder and a new prescription for phenytoin. Which of the following instructions should the nurse include? A. "Plan to take this medication with food." B. "Limit foods that contain vitamin D while taking this medication. C. "Limit foods that contain folic acid while taking this medication. D. "Plan to take this medication with antacids. 35) A nurse is reviewing the medical record of a client. Which of the following findings should the nurse report to the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) Exhibit 1 Nurses' Notes Hypoactive bowel sounds upon auscultation Abdomen soft, not distended on palpation Urinary output of 130 mL/4 hr Exhibit 2 Diagnostic Results Urine specific gravity 1.035 Albumin 4.5 g/dL Prealbumin 25 mg/dL Potassium 4.2 mg/dL Exhibit 3 Graphic Record Blood pressure 126/84 mm Hg Heart rate 85/min Respiratory rate 20/min Temperature 37.6° C (99.7° F) A. Prealbumin B. Temperature C. Urine specific gravity D. Bowel sounds 36) A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first? A. A client who has sinus arrhythmia and is receiving cardiac monitoring. B. A client who has a hip fracture and a new onset of tachypnea. C. A client who has epidural analgesia and weakness in the lower extremities. D. A client who has diabetes mellitus and an HbA1c of 7.2% (less than 7%). 37) A nurse in the emergency department is receiving report on a group of clients. Which of the following clients should the nurse assess first? A. A client who has Clostridium difficile and a temperature of 38.6° C (101.5° F) B. A client who has a complete femur fracture and reports a pain level of 7 on a scale from 0 to 10 C. A client who has left shoulder pain and S-T elevation on a 12-lead ECG D. A client who has orthostatic hypotension and 4+ pitting edema in the lower extremities 38) A nurse is caring for a child who reports migraine headaches for the past 4 months. Which of the following actions should the nurse take first? A. Refer the family to a chronic pain support group. B. Request a change in medication from the provider. C. Review the child's electronic pain diary. D. Set up an appointment with the school nurse. 39) A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider? A. Contractions lasting 80 seconds B. Early decelerations in the FHR C. FHR baseline 170/min D. Temperature 37.4° C (99.3° F) 40) A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding. The nurse speaks a different language than the client. The client's partner and 10- year-old child are accompanying her. Which of the following actions should the nurse take to gather the client's admission data? A. Have the client's child translate. B. Allow the client's partner to translate. C. Request a female interpreter through the facility. D. Ask a nursing student who speaks the same language as the client to translate. 41) A nurse is caring for a client who is in a coma and is scheduled for a surgical procedure. Which of the following actions should the nurse take? A. Determine if the procedure is medically necessary for the client. B. Ensure that the client's family supports the provider's decision for surgery. C. Send the unsigned informed consent form to the facility's risk manager. D. Determine if the client's health care surrogate is aware of the risks and benefits of the procedure. 42) A nurse is caring for a client who refuses a blood transfusion. Which of the following actions should the nurse take? A. Inform the client that the transfusion is mandatory. B. Notify risk management about the client's refusal. C. Document the client's refusal in the medical record. D. Suggest that the client explore alternative therapies. 43) A nurse is caring for a client who is 4 days postpartum following a cesarean birth Exhibits For each potential assessment finding, click to specify if the assessment finding is consistent with mastitis or endometritis. Each finding may support more than 1 disease process Exhibit 1 Today 0800 Client reports not feeling well with headache, body aches, and chills. Left breast red and tender with swollen, tender lymph nodes in the left axilla. Incision edges well- approximated without erythema or drainage. Small amount of lochia rubra noted. 0830: Provider notified of findings. Prescriptions received Laboratory Results 3 days ago: Hgb 12.0 g/dL (14 to 18 g/dL) Hct 40% (42% to 52%) WBC count 20,500/mm3 (6,200 to 17,000/mm3) Today 0900: Hgb 12.2 g/dL (14 to 18 g/dL) Hct 41% (42% to 52%) WBC count 34,500/mm3 (6,200 to 17,000/mm3) Exhibit 3 Vital Signs Today 0800: BP 116/81 mm Hg Heart rate 104/min/ Temperature 38.8° C (101.9° F) Respiratory rate 19/min Mastiti Endometriti Options s s ▪ A. Painful, tender breast x ▪ B. Temperature ▪ x x ▪ C. Chills ▪ x x D. Foul-smelling lochia ▪ x 45) A nurse is teaching a client who plans to begin following vegan dietary guidelines. Which of the following information should the nurse include? A. Choose foods high in vitamin B12- B. Choose high-fat cheese as a meat substitute. C. Limit intake of nuts and legumes. D. Limit intake of foods high in vitamin C. 46) A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse take? A. Apply the patch within 1 hr of removing it from the protective pouch. B. Shave hairy areas of skin prior to application. C. Wear gloves to apply the patch to the client's skin. D. Remove the previous patch and place it in a tissue. 47) A nurse is caring for a client in a clinic. Exhibits Based on the information in the client's medical record, which of the following findings require immediate follow-up? Select the 4 findings that require follow-up. Exhibit 1 0900: A 16-year-old client reports to the clinic with their caregiver. The client's caregiver informs the nurse that the client has "not been themselves lately." The client's parents and a sibling passed away from injuries sustained when a tornado moved through their town 1 month ago. They were the only survivor and witnessed their family's deaths. 0910: Client appears anxious but answers questions appropriately for age. They report experiencing nightmares that awaken them at night and startle easily during thunderstorm, but the client admits that they have always been afraid of thunderstorms. Client admits smoking marijuana for about 1 month because it helps clear their mind. They also admit that they have no desire to leave the house. They do attend school regularly and are on the honor roll. Client experiences nightmares Heart rate 99/min Attends school regularly Smoking marijuana to clear their mind Startles easy during thunderstorm Witnessing their family's death BP 122/80 mm Hg Caregiver reporting client acting differently than usual Exhibit 2 Vital Signs 0915: Temperature 36.7° C (98° F) BP 122/80 mm Hg Respiratory rate 20/min Heart rate 99/min Vital Signs 0915: Temperature 36.7° C (98° F) BP 122/80 mm Hg Respiratory rate 20/min Heart rate 99/min A. Client experiences nightmares B. Heart rate 99/min C. Attends school regularly D. Smoking marijuana to clear their mind E. Startles easy during thunderstorm Witnessing their family's death F. BP 122/80 mm Hg G. Caregiver reporting client acting differently than usual 48) A nurse is caring for a 36-hr old infant. Exhibits For each nursing action, click to specify if the action is indicated or contraindicated for the newborn. Exhibit 1 Nurses' Notes 24 hr of age: Newborn is alert and active when awake. Respirations easy and unlabored. Buccal membranes jaundiced. Newborn nursing every 2 to 4 hr. Passed meconium stool. Small amount of urine noted in diaper. Transcutaneous bilirubin (TCB) 10 mg/dL 36 hr of age: Newborn sleeping on birthing parent's chest. Birthing parent reports difficulty keeping newborn awake during feedings. Nursing every 3 to 5 hr for 10 to 15 min. Buccal membranes and sclera jaundiced. TCB at 36 hr 15.5 mg/dL Exhibit 2 Laboratory Results 36 hr of age: Total bilirubin 16 mg/dL (1.0 to 12.0 mg/dL) Exhibit 3 Provider Prescriptions 37 hr of age: Initiate phototherapy. Check direct and total bilirubin every 12 hr. Direct and total bilirubin every 8 hr. The nurse is preparing the infant for phototherapy. Indicate Contraindicate Options d d A. Apply lotion to skin every 4 hr. x B. Supplement feeding with sterile water. ▪ x C. Brestfeed every 2 to 3 hr. x  D. Cover newborn's eyes with a shield. ▪ x E. Dress in only a diaper. ▪ x 49) A nurse is caring for a client who has diarrhea and is receiving intermittent enteral feedings. Which of the following actions should the nurse take? A. Flush the tube with 10 mL of water after feedings. B. Discard the open can of formula after 36 hr. C. Administer feedings at a slower rate. D. Provide chilled formula. 50) A nurse is caring for a client who has a fractured right femur. Exhibits Select the 4 findings on day 2 that require immediate follow-up. Exhibit Day 1: Admitted to medical-surgical unit following open reduction internal fixation of right femur. Client is alert and oriented to person, place, and time. Bilateral breath sounds clear and present throughout. Bilateral pedal pulses 2+. Movement and sensation of right foot intact, skin warm. Right femur dressing with small serosanguinous drainage. Day 2: Client restless and agitated. Respirations rapid. Breath sounds with crackles heard at bases. Client reports substernal chest pain. Dressing to right femur with small serosanguinous drainage. Movement and sensation of right foot intact, skin warm with no change in pigmentation. Bilateral pedal pulses 2+. Exhibit 2 Vital Signs Day 1: Temperature 37.2° C (99° F) BP 128/60 mm Hg Heart rate 88/min Respiratory rate 18/min Pulse oximetry 96% on room air Day 2: Temperature 38° C (100.4° F) BP 148/60 mm Hg Heart rate 112/min Respiratory rate 28/min Pulse oximetry 88% on room air A. Pedal pulses B. Breath sounds C. Heart rate D. Movement of right foot E. Respiratory rate F. Pulse oximetry 51) A nurse is caring for a client who has a prescription for 1 unit of packed RBCs. Five minutes after beginning the transfusion, the client becomes febrile with chills. After stopping the transfusion, which of the following actions should the nurse take? A. Document the reaction in the medical record. B. Administer epinephrine subcutaneously. C. Infuse 500 mL lactated Ringer's IV. D. Place the blood bag in a biohazard bag before discarding. ATI: Stop transfusion, admin antipyretics, initiate aIV flush with new tubing. Pg 261 medsurg book 52) A nurse in an outpatient clinic is caring for a client. Exhibits Which of the following statements should the nurse include in the client's teaching? Select all that apply. Exhibit 1 Assessment 0840: Client is calm and cooperative. Skin warm and dry. No rash noted. Lung sounds clear. Abdomen soft to palpation with fundal height at 20 cm. Fetal heart rate 150/min. Bowel sounds active in all four quadrants. No edema to lower extremities. Client denies visual changes or severe headaches. Weight gain of 1.8 kg (4 lb) since last visit. Small amount of mucoid discharge noted on perineal pad. Exhibit 2 Nurses' Notes 0830: Client reports to clinic for monthly prenatal visit. Client is at 20 weeks of gestation. Since last visit, client reports concerns about the occurrence of intermittent mild backaches, increased heartburn, generalized itching, and vaginal discharge. A. "You can douche twice weekly." B. "Wear loose-fitting clothing." C. "Wear flat or low-heeled shoes." D. "Take hot showers to help relieve itching." E. "You should avoid fried foods." F. "Try using an abdominal support belt." G. "Eat two large meals a day." 53) A nurse is caring for a client in the outpatient health clinic Exhibits For each potential nursing intervention, click to specify if the intervention is indicated or not indicated. Nurses' Notes 4 weeks ago: 21-year-old client reports increased stress and worry for the last 3 months. Client is worried about academic performance due to inability to focus on studies. School performance is suffering. Denies illicit drug use and drinks in moderation socially on the weekends. Discussed lifestyle modifications to reduce stress. Instructed client to return in 1 month to reevaluate symptoms. Today: Client reports a slight improvement in stress but is now having loss of appetite and difficulty sleeping. Instructed client to begin trazodone per provider's prescription. Indicat Not Options ed Indicated ▪ A. Encourage a regular sleep-wake schedule. x B. Encourage naps during the day when client is tired. x C. Encourage client to sleep until later in the morning ▪ x ▪ D. Advise client to rise slowly from sitting position. x E. Advise client to notify provider if pregnant. x F. Encourage high-calorie finger foods. x G. Instruct client to avoid foods that have been fermented x or aged. 54) A nurse is caring for a client in theoutpatient mental health clinic "exhibits"Click to highlight the findings thatindicate the client is experiencing adverse eff ectsof the medication. To deselect a finding, click onthe finding again. Exhibit 1 History and Physical 2 months ago: Client states, "My depression has been getting a little worse lately." Client reports increased fatigue, sadness, and hypersomnia over the last few months. Client reports their manifestations have been well-controlled "for years" on fluoxetine, but it seems to have stopped working." Client denies any physical complications or suicidal ideation. Client has history of depression and hyperlipidemia. Client lives at home with partner and 4-year-old child. Denies alcohol, illicit drug, or tobacco use. Exercises occasionally. Exhibit 2 Nurses' Notes Today: Client states, "I'm feeling much better." They report less fatigue, even though they have difficulty sleeping. Client reports they are not sad anymore but are experiencing more frequent headaches. Client continues to deny any suicidal ideation. Exhibit 3 Vital Signs 2 months ago: BP 128/78 mm Hg Heart rate 76/min Respiratory rate 17/min Today: BP 169/91 mm Hg Heart rate 78/min Respiratory rate 18/min Exhibit 4 Plan of Care 2 months ago: Ween fluoxetine per prescription. 2 weeks after the final dose of fluoxetine, start phenelzine as prescribed. Educate client on risks, benefits, and adverse effects of medication. Report any worsening depression symptoms or suicidal ideation immediately. Click to highlight the findings that indicate the client is experiencing adverse effects of the medication. To deselect a finding, click on the finding again. Nurses' Notes Today Client states, "I'm feeling much better." They report less fatigue, even though they have difficulty sleeping. Client reports they are not sad anymore but are experiencing more frequent headaches. Client continues to deny any suicidal ideation. Vital Signs Today BP 169/91 mm Hg Heart rate 78/min Respiratory rate 18/min Correct Answer: Nurses' Notes. Today Client states, I'm feeling much better. They report less fatigue, even though they have difficulty sleeping. Client reports they are not sad anymore but are experiencing more frequent headaches. Client continues to deny any suicidal ideation. Vital Signs Today BP 169/91 mm Hg Heart rate 78 min Respiratory rate 18 min 55) The nurse continues to care for the client who is at 30 weeks of gestation. Exhibits Click to specify which of the following actions the nurse should anticipate including in the client's plan of care. Select all that apply. Assessment 1000: Client is Gravida 1 Para 0 and reports headache, nausea, vomiting, and right upper abdominal pain. Client is alert and oriented, appears restless. Client has gained 0.68 kg (1.5 lb) within the last week. Slight facial edema is present. Heart rate regular and without murmur. Respirations even, non-labored. Lungs clear to auscultation. Abdomen gravid. Fundal height measurement 29 cm. 1+ dependent edema noted bilaterally. Deep tendon reflex (DTR) is 3+ bilaterally. Applied external fetal heart monitor. No contractions noted. Fetal heart rate 140/min. Vital Signs 1000: Temperature 37.4" C (99.3° F) Heart rate 90/min Respiratory rate 20/min Blood pressure 148/94 mm Hg Oxygen saturation 95% on room air 1100: Temperature 37° C (98.6° F) Heart rate 92/min Respiratory rate 24/min Blood pressure 156/96 mm Hg Oxygen saturation 94% on room air Laboratory Results 1100: Bloodwork WBC count 12,500 mm3 (5,000 to 15,000 mm3) Hemoglobin 12.5 g/dL (11 g/dL to 16 g/dL) Hematocrit 37% (33% to 47%) Platelet count 98,000/mm3 (150,000 to 400,000/mm3) Fibrinogen 500 mg/dL (200 to 400 mg/dL) BUN 23 mg/dL (10 to 20 mg/dL) Creatinine 1.2 mg/dL (0.5 to 1.0 mg/dL) Lactate dehydrogenase 220 units/L (100 to 190 units/L) Aspartate aminotransferase 38 units/L (0 to 35 units/L) Alanine aminotransferase 40 units/L (4 to 36 units/L) Uric acid 8.5 mg/dL (2.7 to 7.3 mg/dL) Urinalysis Protein 25 mg/dL (0 to 8 mg/dL) Ketones none (none) WBCS 2 (0 to 4 per low power field) A. Initiate contact precautions. B. Check urinary output. C. Decrease lighting in the client's room. D. Monitor blood pressure. E. Prepare for amniocentesis. F. Apply Internal fetal monitor. G. Assess DTR. H. Encourage bed rest. 56) A nurse is caring for a client who has end-stage kidney disease. The client's adult child asks the nurse about becoming a living kidney donor for their parent. Which of the following conditions in the child's medical history should the nurse Identify as a contraindication to the procedure? A. Primary glaucoma B. Amputation C. Osteoarthritis D. Hypertension 57) A nurse is providing teaching to the parents of a newborn about newborn genetic screening. Which of the following statements should the nurse include in the teaching? A. "This test should be performed after your baby is 24 hours old." B. "This test will be repeated when your baby is 2 months old." C. "Your baby will be given 2 ounces of water to drink prior to the test." D. "A nurse will draw blood from your baby's inner elbow." 58) A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan? A. Maintain eye contact with the newborn during feedings. B. Minimize noise in the newborn's environment. C. Administer naloxone to the newborn. D. Swaddle the newborn with his legs extended. 59) A nurse is providing teaching to a parent of a child who has varicella. Which of the following statements should the nurse include in the teaching? A. "Your child can return to school once the lesions have crusted over." B. "Your child can return to school once the fever has subsided." C. "Your child can return to school 24 hours after beginning antibiotics." D. "Your child can return to school after a negative titer result." 60) A nurse is caring for a client on the medical-surgical unit. Exhibits For each potential nursing action, click to specify if the action is indicated or contraindicated for the client who has a chest tube. Exhibit 1 Vital Signs 1500: Temperature 36.4° C (97.5° F) Heart rate 72/min Respiratory rate 18/min. BP 106/62 mm Hg Oxygen saturation 95% on 2 L oxygen via nasal cannula 1600: Temperature 36.6° C (97.9° F). Heart rate 76/min Respiratory rate 18/min BP 112/72 mm Hg Oxygen saturation 98% on 2 L oxygen via nasal cannula Exhibit 2 Nurses' Notes 1715: Client reports burning pain in chest as 7 on a scale of 0 to 10. Drainage pooling in drainage tubing. 2200: Client ambulated to bathroom with assistance of one person. Dressing at chest tube insertion site dry. Client stated they lifted the edges of dressing to scratch underneath the tape. Exhibit 3 Admission Assessment 1500: Client transferred from post-anesthesia care unit, postoperative left lung lobectomy. Client alert and oriented x 4. Reports pain as 3 on a scale of 0 to 10. Dressing dry and intact to left chest. Water seal chest tube drainage system has 100 mL sanguineous drainage. Right lung sounds clear. Left lung sounds diminished. Indicat Contraindicat Options ed ed A. Clamp chest tube when client ambulates. ▪ x  ▪ B. Report burning pain in chest to provider. x C. Reinforce dressing around the tube as needed if it ▪ loosens. x ▪ D. Maintain water level at 2 cm. x E. Strip the tubing twice daily to ensure patency ▪ x 61) A nurse is contributing to the plan of care for a client who has multiple sclerosis. The nurse should recommend including which of the following interventions in the plan of care to assist the client in overcoming barriers related to this condition? A. Establish alternatives to verbal conversation. B. Use the numbers on a clock to describe the position of food on the client's plate. C. Touch the client's arm before beginning to speak. D. Provide the client with large-handled eating utensils. 62) A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings requires follow-up care? A. A client who is scheduled for a colonoscopy and is taking sodium phosphate. B. A client who received a Mantoux test 48 hr ago and has an induration. C. A client who is taking bumetanide and reports an increase in urination D. A client who is taking warfarin and has started to breastfeed. 63) A nurse is caring for a client who has a new diagnosis of schizophrenia and a prescription for an antipsychotic medication. The nurse should recognize that which of the following indicates an adverse effect that must be reported to the provider? A. The client states, "I feel light-headed when) stand up quickly." B. The client is observed mumbling quietly while alone in the day room. C. The client states, "Being in the sun seems to really hurt my eyes." D. The client is observed displaying a shuffling gait while walking in the hall. 64) A nurse is teaching a parent of a school-age child who is to begin a daily dose of methylphenidate. Which of the following should the nurse include in the teaching? A. "You should administer the medication before breakfast." B. "You should administer the medication at bedtime." C. "Your child should avoid foods containing tyramine." D. "Your child should avoid excess sodium intake." 65) A nurse manager on an interprofessional team is creating a disaster plan. The nurse should include in the plan that which of the following actions is the responsibility of the unit nurse during a disaster? A. Determine the need for additional providers. B. Act as a spokesperson to provide information to the media. C. Recommend to the provider a list of clients for early discharge. D. Decide which clients should be transported for a higher level of care. 66) A nurse is assessing a client who received hydromorphone 4 mg IV 15 min ago. The client has a respiratory rate of 10/min. The nurse should prepare to administer which of the following medications? A. Naloxone B. Flumazenil C. Acetylcysteine D. Protamine 67) A nurse observes a client on the psychiatric unit muttering and standing near a window. The client states, "The voices are telling me to jump." Which of the following is an appropriate response by the nurse? A. "That can't be true. The only voices in this room are yours and mine." B. "You shouldn't be afraid when you think the voices are telling you to hurt yourself." C. "I understand the voices are frightening you, but I do not hear any voices." D. "Do you recognize the voices as belonging to anyone you know?" 68) A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field? A. Set up the sterile field 5 cm (2 in) below waist level. B. Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field. C. Open the outermost flap of the sterile kit toward the body. D. Place the cap from the solution sterile side up on a clean surface. 69) A nurse is observing a newly licensed nurse who is administering total parenteral nutrition (TPN) to a client. Which of the following actions by the newly licensed nurse indicates a need for the nurse to intervene? A. Schedules a bag and tubing change for 24 hr after the start of the infusion B. Plans for a check of the client's fingerstick glucose level every 6 hr C. Gradually increases the TPN infusion rate each hour until the prescribed rate is achieved D. Uses the TPN IV tubing to administer the client's next dose of antibiotics 70) A nurse is verifying a record of Informed consent for a client who is scheduled for surgery. Which of the following actions should the nurse take? A. Provide information on the informed consent form about the benefits of the surgery. B. Inform the client about the condition that requires treatment. C. Explain the procedure to the client before verifying informed consent. D. Confirm the client's signature is authentic. 71) A nurse is providing teaching about nonpharmacological pain management to a client who has osteoarthritis. Which of the following Instructions should the nurse include in the teaching? A. Take a hot shower every day. B. Place a large pillow under the knees when sleeping. C. Limit dietary intake of phosphorus. D. Place an ice pack directly on the skin of the affected joints. 72) A nurse is caring for a client who is febrile. To reduce the client's fever, the nurse applies a cooling blanket. Which of the following findings indicates the client is having an adverse reaction to the cooling? A. Tachycardia B. Shivering C. Flushing D. Restlessness 73) A home health nurse is assessing a client who has amyotrophic lateral sclerosis (ALS) and has had recent weight loss. Which of the following is the priority admission data for the nurse to obtain? A. Swallowing ability B. Changes in appetite C. Prescribed medications D. Daily fluid intake 74) A nurse is planning care for a client who is scheduled to receive a peripherally inserted central catheter in the arm. Which of the following interventions is appropriate for the nurse to include in the plan of care? A. Administer sedation for the procedure. B. Schedule an MRI postprocedure to verify placement. C. Use gauze to secure an arm board to the involved extremity. D. Measure the arm circumference above the insertion site daily 75) A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications? A. Hypertension B. Contractions C. Epigastric pain D. Vomiting 76) A nurse is admitting a client who is hesitant to create advance directives due to concerns about affording legal representation. Which of the following statements should the nurse make? A. "A social worker will assist you to find affordable legal representation." B. "Advance directives can be signed without legal representation." C. "Advance directives can be a verbal agreement between you and your provider until legal review can be obtained." D. "We can initiate medical care until you get legal assistance in preparing your advance directives." 77) A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching? A. Swelling of the face B. Urinary frequency C. Faintness upon rising D. Bleeding gums 78) A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take? A. Hold hand flat to perform percussions on the child. B. Perform the procedure twice each day. C. Perform the procedure prior to meals. D. Administer a bronchodilator after the procedure. 79) A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge? A. A client who is receiving heparin for deep-vein thrombosis. B. A client who is 1 day postoperative following a vertebroplasty. C. A client who has COPD and a respiratory rate of 44/min. D. A client who has cancer and a sealed implant for radiation therapy. 80) A nurse is building a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse plan to take during the orientation phase of the relationship? A. Facilitate the client's problem-solving skills. B. Establish the responsibilities of the nurse and client. C. Assist the client in expressing alternative behaviors. D. Determine previous coping skills used by the client. 82) A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include? A. Attach the restraint to the bed's side rails. B. Remove the client's restraint every 4 hr. C. Document the client's condition every 15 min. D. Request a PRN restraint prescription for clients who are aggressive. 83) A nurse manager is preparing to meet with a group of staff nurses who are experiencing conflict. Which of the following mediation strategies should the nurse manager plan to implement to resolve the conflict? A. Direct anyone who becomes angry to leave the room. B. Establish demands from each party that allow for negotiations. C. Facilitate discussion until all parties agree. D. Determine who is at fault in the situation. 84) A nurse is caring for a client who is being discharged home following a total hip arthroplasty. Which of the following findings in the home should the nurse Identify as a potential risk for Injury? A. Elevated toilet seats B. No stairs in the home C. Reclining chair with a straight back D. Large soaking tub without a shower head 85) A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding? A. Upper extremity hypotension B. Weak femoral pulses C. Frequent nosebleeds D. Increased intracranial pressure 87) A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse Identify as tertiary prevention? A. Helping clients understand health screenings covered by their insurance plans B. Educating clients about contraindications to specific immunizations C. Using an electronic messaging system to remind clients when to take medications D. Providing clients with information about the benefits of exercise 88) A nurse is providing discharge teaching to a new parent about breastfeeding her infant. Which of the following statements should the nurse make? A. "Begin each feeding using the same breast." B. "Offer your infant the breast when he shows signs of hunger." C. "Limit the time your infant feeds to 10 minutes on each breast." D. "Supplement breastfeedings with water every 12 hours." 89) A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching? A. "I can clean my cat's litter box during my pregnancy." B. "I should take antibiotics when I have a virus." C. "I can visit my nephew who has chickenpox 5 days after the sores have crusted." D. "I should wash my hands for 10 seconds with hot water after working in the garden." 90) A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include? A. "This type of seizure lasts 30 to 60 seconds." B. "The child usually has an aura prior to onset." C. "This type of seizure can be mistaken for daydreaming." D. "This type of seizure has a gradual onset." 91) A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following Instructions should the nurse include in the teaching? A. Eat 1 g/kg of protein per day. B. Consume foods high in potassium. C. Take magnesium hydroxide for indigestion. D. Drink at least 3 L of fluid daily. 92) A nurse is caring for a client who is in labor and notes that the umbilical cord is prolapsed. Which of the following actions should the nurse take? A. Evaluate uterine tone. B. Loosely wrap the cord with petroleum gauze. C. Place the client in Trendelenburg position. D. Apply fundal pressure. 93) A nurse is planning care for a client who is returning to the unit following open gastric bypass surgery. Which of the following interventions should the nurse include in the client's plan of care? A. Provide 60 mL (2 oz) of fluid intake every 5 min. B. Measure and compare abdominal girth daily. C. Provide a soft diet on the first postoperative day. D. Ambulate the client 48 hr after the procedure. 94) A nurse is planning care for a preschool-age child who is in the acute phase of Kawasaki disease. Which of the following interventions should the nurse include in the plan of care? A. Monitor the child's cardiac status. B. Give scheduled doses of acetaminophen every 6 hr. C. Provide stimulation with children of the same age in the play room. D. Administer antibiotics via intermittent IV bolus for 24 hr. 95) A nurse is assessing a client who has obsessive-compulsive personality disorder. Which of the following findings should the nurse expect? A. Provocative behavior B. Lack of empathy C. Goal-oriented D. Lability 96) A nurse is providing discharge teaching for the guardian of a school-age child following a cardiac catheterization. Which of the following instructions should the nurse include in the teaching? A. "Your child can take a tub bath this evening." B. "You should give your child a clear liquid diet for 24 hr." C. "You should remove your child's pressure dressing tomorrow." D. "Your child should stay out of school for 7 days following the procedure." 97) A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching? A. "Repeat the dose if your child vomits within 1 hour after taking the medication." B. "You can add the medication to a half-cup of your child's favorite juice" C. "Limit your child's potassium intake while she is taking this medication. D. "Have your child drink a small glass of water after swallowing the medication. 98) A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following factors places the client at risk for aspiration? A. A residual of 65 mL 1 hr postprandial. B. A history of gastroesophageal reflux disease. C. Receiving a high-osmolarity formula. D. Sitting in high-Fowler's position during the feeding. 99) A nurse is providing teaching to family members of a client who has dementia. Which of the following Instructions should the nurse include in the teaching? A. Establish a toileting schedule for the client. B. Use clothing with buttons and zippers. C. Discourage physical activity during the day. D. Engage the client in activities that increase sensory stimulation. 100) A nurse is admitting a client who has acute heart fallure. Which of the following prescriptions from the provider should the nurse anticipate? A. Ambulate the client every 4 hr while awake. B. Infuse 0.9% sodium chloride 500 mL IV bolus over 1 hr. C. Provide the client with a 4 g sodium diet. D. Administer enalapril 2.5 mg PO twice daily. 101) A nurse is caring for a client who is experiencing status epilepticus. Which of the following medications should the nurse expect to administer? A. Clonazepam B. Carbamazepine C. Lamotrigine D. Lorazepam 102) A charge nurse is teaching new staff members about factors that increase a client's risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence? A. A history of being in prison B. Male gender C. Previous violent behavior D. Experiencing delusions 103) A nurse is planning teaching for a client and their family about home oxygen therapy. Which of the following information should the nurse plan to include in the teaching? A. Apply petroleum jelly to soothe the mucous membranes. B. Clean the equipment with an alcohol-based cleaning product. C. Avoid using nail polish remover around the client. D. Use synthetic fabrics for the client's bedding. 104) A nurse is suctioning the airway of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following findings should the nurse identify as an indication that the suctioning has been effective? A. Flattening of the artificial airway cuff B. Decreased peak inspiratory pressure C. Thinning of mucous secretions D. Presence of a productive cough 105) The nurse reviews the client's test results Exhibits For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client. Exhibit 1 History and Physical Day 1: Client reports, "I have a cough." History of present illness: 38-year-old client presents to the ED with a 4-day history of cough, often productive. Client reports fatigue, night sweats, and a low-grade fever. Client reports "blood-tinged sputum." Client also reports, "I used to weigh 167 pounds. Now I weigh 162 pounds." Client reports a decreased appetite along with the 2.26 kg (5 lb) weight loss over the last week. Client states they have been trying to stay hydrated. Family history: Child has asthma. All other family members healthy. Social history: Heavy alcohol use (4 to 5 drinks/day), denies tobacco or illicit drug use. Recently traveled to visit their family in South Africa and stayed for 3 weeks. Exhibit 2 Vital Signs Day 1: Temperature 38.1° C (100.5° F) Blood pressure 112/88 mm Hg Heart rate 98/min Respiratory rate 24/min Oxygen saturation 98% on room air Exhibit 3 Laboratory Results Day 1: Sputum culture: positive for M. tuberculosis Anticipate Contraindicate Options d d A. Contact precautions x B. Ethambutol ▪ x C. Monthly TB skin test for 1 year x D. Isoniazid ▪ x E. Airborne precautions x F. Pyrazinamide ▪ x G. Rifampin ▪ x 106) The nurse is reviewing the client prescriptions."exhibits" For each body system below, click to highlight the findings that indicate a serious adverse reaction. To deselect a finding, click on the finding again.Each body system may support more th an 1potential assessment finding. Exhibit 1 History and Physical Day 1: Client reports, "I have a cough." History of present illness: 38-year-old client presents to the ED with a 4-day history of cough, often productive. Client reports fatigue, night sweats, and a low-grade fever. Client reports "blood-tinged sputum." Client also reports, "I used to weigh 167 pounds. Now I weigh 162 pounds." Client reports a decreased appetite along with the 2.26 kg (5 lb) weight loss over the last week. Client states they have been trying to stay hydrated. Family history: Child has asthma. All other family members healthy. Social history: Heavy alcohol use (4 to 5 drinks/day), denies tobacco or illicit drug use. Recently traveled to visit their family in South Africa and stayed for 3 weeks. Exhibit 2 Vital Signs Day 1: Temperature 38.1° C (100.5° F) Blood pressure 112/88 mm Hg Heart rate 98/min Respiratory rate 24/min Oxygen saturation 98% on room air Exhibit 3 Diagnostic Results Day 1: Chest x-ray: caseation lesions to bilateral upper lungs Exhibit 4 Laboratory Results Day 1: Sputum culture: positive for M. tuberculosis Exhibit 5 Provider Prescriptions Day 1: Ethambutol 1200 mg PO daily Rifampin 600 mg PO daily Isoniazid 300 mg PO daily Pyrazinamide 1600 mg PO daily Acetaminophen 650 mg PO three times daily every 6 hr PRN for fever greater than 38° C (100.4° F) The nurse is administering medications to the client and is monitoring the potential adverse effects of the medications. Which of the following findings indicate the need for further eval? SATA Report of cough BP Sputum characteristics Weight Travel History Temperature Heart Rate Oxygen sat 107) A nurse is teaching a client about condom use. Which of the following client statements should the nurse Identify as an understanding of the teaching? A. "I can re-use the condom one time after initial use." B. "I can store the condoms in the drawer of my nightstand." C. "I can use natural-skin condoms to prevent sexually transmitted infections." D. "I can use petroleum jelly as a lubricant with the condom." 108) A nurse is assessing the fontanels of an 8-month-old infant. Which of the following findings should the nurse recognize as an expected finding? A. Both fontanels show molding. B. The posterior fontanel is open. C. The anterior fontanel is open. D. Both fontanels are the same size 109) A nurse is planning care for a toddler who has epiglottitis. Which of the following interventions should the nurse include? A. Carefully suction the child's oropharynx to remove secretions. B. Offer a high-calorie, high-protein diet. C. Administer pancreatic enzymes with meals. D. Initiate droplet precautions. 110) A nurse is caring for a client receiving mechanical ventilation via an endotracheal (ET) tube. The high-pressure alarm is beeping, and the client is experiencing respiratory distress. The nurse is unable to determine the cause of the alarm. Which of the following actions should the nurse take? A. Reevaluate the client for an ET cuff leak. B. Assess for disconnected tubing. C. Deliver breaths manually with a resuscitation bag. D. Decrease the ventilator flow rate. 111) A nurse is teaching a client who has a new prescription for an MAOI. Which of the following foods is contraindicated with this medication? A. Potatoes B. Grapefruit C. Eggs D. Cheese 112) A nurse on a mental health unit is teaching a newly licensed nurse about the use of mechanical restraints. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "I should assess the client's skin integrity every 8 hours while in mechanical restraints." B. "I should visually monitor the client continuously when in mechanical restraints." C. "I should ask the provider to write a prescription for mechanical restraints as needed." D. "I should expect the provider to evaluate the client within 4 hours of restraint application." 113) A school nurse is performing scollosis screenings. The nurse should recognize which of the following clinical manifestations as an Indication of scollosis? A. Uneven shoulder and pelvic heights B. Mild pain in the hip region C. Exaggerated curvature of the sacrum D. Limited range-of-motion of the hips 114) A nurse is preparing to catheterize a toddler for a urine culture. Which of the following is an appropriate action for the nurse to take? A. Apply EMLA cream prior to the procedure. B. Discard the first 10 mL of urine. C. Obtain a 12-French catheter. D. Don sterile gloves prior to the procedure. 115) A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the client's body should the nurse observe to assess for jaundice? A. Palms of the hands B. Sclera C. Shoulders D. Face 116) A nurse in the emergency department is assessing a newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following actions should the nurse take first? A. Obtain a blood specimen for ABG analysis. B. Apply 100% humidified oxygen. C. Obtain a baseline ECG. D. Insert an 18-gauge IV catheter. 117) A nurse on a medical-surgical unit is planning care for assigned clients. Which of the following actions should the nurse plan to take to demonstrate effective time management? A. Document assessment findings and interventions after providing care for a group of clients. B. Delay cleaning personal work area until the end of the shift. C. Gather supplies for a client's dressing change after removing the old dressing. D. Complete activities for one client before moving to the next client. 118) A nurse is caring for a 30-month-old child. Which of the following activities should the nurse expect the child to participate in? A. Playing with an imaginary friend B. Playing with dress-up clothes C. Playing with a large plastic truck D. Playing with a jump rope 119) A nurse on a telemetry unit is assessing a client who is receiving continuous cardiac monitoring. The client's heart rate is 69/min and the PR interval is 0.24 seconds. The nurse should interpret this finding as which of the following cardiac rhythms? A. Premature ventricular contraction B. Atrial fibrillation C. Sinus bradycardia D. First-degree AV block 120) The nurse is preparing the client for discharge. Exhibits Select the 3 client statements that indicate an understanding of the teaching. Exhibit 1 History and Physical Day 1: Client reports, "I have a cough." History of present illness: 38-year-old client presents to the ED with a 4-day history of cough, often productive. Client reports fatigue, night sweats, and a low-grade fever. Client reports "blood-tinged sputum." Client also reports, "I used to weigh 167 pounds. Now I weigh 162 pounds." Client reports a decreased appetite along with the 2.26 kg (5 lb) weight loss over the last week. Client states they have been trying to stay hydrated. Family history: Child has asthma. All other family members healthy. Social history: Heavy alcohol use (4 to 5 drinks/day), denies tobacco or illicit drug use. Recently traveled to visit their family in South Africa and stayed for 3 weeks. A. "I am no longer contagious." B. "I will need to take my medications for a total of 6 weeks." C. "I can expect my contact lenses to turn red or orange." D. "I will need to have someone observe me when I take my medication," E. "I can continue my current alcohol intake." F. "I should notify my provider if I start taking new over-the-counter or prescription medications." G. "I will need to have a repeat Mantoux test in 4 weeks." Exhibit 2 Vital Signs Day 1: Temperature 38.1° C (100.5° F) Blood pressure 112/88 mm Hg Heart rate 98/min Respiratory rate 24/min Oxygen saturation 98% on room air Day 2, 0800: Blood pressure 112/88 mm Hg Heart rate 98/min Respiratory rate 24/min Temperature 38.1° C (100.5° F) Oxygen saturation 98% on room air Exhibit 3 Screenings Day 1: Mantoux test: results pending (nurse will read the results in 48 hr) Day 2, 0800: Mantoux test: 10 mm induration, positive Exhibit 4 Diagnostic Results Day 1: Chest x-ray: caseation lesions to bilateral upper lungs Exhibit 5 Laboratory Results Day 1: Sputum culture: positive for M. tuberculosis Exhibit 6 Provider Prescriptions Day 1: Ethambutol 1200 mg PO daily Rifampin 600 mg PO daily Isoniazid 300 mg PO daily Pyrazinamide 1600 mg PO daily Acetaminophen 650 mg PO three times daily every 6 hr PRN for fever greater than 38° C (100.4° F) Day 2, 0830: Discharge Prescriptions: Ethambutol 1200 mg PO daily Rifampin 600 mg PO daily Isoniazid 300 mg PO daily Pyrazinamide 1600 mg PO daily A. "I am no longer contagious." B. "I will need to take my medications for a total of 6 weeks." C. "I can expect my contact lenses to turn red or orange." D. "I will need to have someone observe me when I take my medication," E. "I can continue my current alcohol intake." F. "I should notify my provider if I start taking new over-the-counter or prescription medications." G. "I will need to have a repeat Mantoux test in 4 weeks." 121) A nurse is caring for an adult client who has chronic anemia and is scheduled to receive a transfusion of 1 unit of packed RBCs. Which of the following actions should the nurse take? A. Administer the blood via a 21-gauge IV needle. B. Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion. C. Check the client's vital signs from the previous shift prior to the initiation of the transfusion. D. Set the IV infusion pump to administer the blood over 6 hr. 122) A nurse is teaching the parents of a school-age child who is newly diagnosed with Juvenile Idiopathic arthritis. Which of the following Interventions should the nurse Include in the teaching? A. Have the child take a tub bath each morning. B. Apply splints to the child's extremities during the day. C. Keep the child on bedrest as long as pain persists. D. Encourage the child to take naps during the day. 123) A nurse is providing discharge teaching for a client who has a new implantable cardioverter defibrillator (ICD). Which of the following client statements demonstrates understanding of the teaching? A. "I will avoid using my microwave oven at home because of the ICD." B. "I will wear loose clothing over my ICD." C. "I can hold my cell phone on the same side of my body as the ICD." D. "I will soak in the tub rather than showering." 124) A nurse is teaching a client about family planning using the basal body temperature method. Which of the following Instructions should the nurse include in the teaching? A. "Take your temperature immediately after waking and before getting out of bed." B. "Take your temperature 1 hour after getting out of bed." C. "Take your temperature every night before going to bed." D. "Take your temperature within 30 minutes after your first morning void." 125) A community health nurse is working with a group of clients. The nurse practices the ethical principle of distributive Justice by performing which of the following tasks? A. Ensuring that a client who is homeless receives preventive medical care B. Being honest with the parents of a child about the need to report suspected abuse C. Accepting the decision of an older adult client to live alone in her home D. Keeping a promise to visit with a client who is housebound after the delivery of care 126) A nurse is evaluating the laboratory values of a client who is receiving epoetin alfa. Which of the following findings indicates a therapeutic response to the medication? A. Increased platelet count B. Increased hemoglobin level C. Increased neutrophil count D. Increased erythrocyte sedimentation rate 127) A nurse is caring for a client who presents to the emergency department. Exhibits A nurse is reviewing the client's record. Which of the following client findings indicate the need for further evaluation? Select all that apply. Exhibit 1 History and Physical Day 1: Client reports, "I have a cough." History of present illness: 38-year-old client presents to the ED with a 4-day history of cough, often productive. Client reports fatigue, night sweats, and a low-grade fever. Client reports "blood-tinged sputum." Client also reports, "I used to weigh 167 pounds. Now I weigh 162 pounds." Client reports a decreased appetite along with the 2.26 kg (5 lb) weight loss over the last week. Client states they have been trying to stay hydrated. Family history: Child has asthma. All other family members healthy. Social history: Heavy alcohol use (4 to 5 drinks/day), denies tobacco or illicit drug use. Recently traveled to visit their family in South Africa and stayed for 3 weeks. Exhibit 2 Vital Signs Day 1: Temperature 38.1° C (100.5° F) Blood pressure 112/88 mm Hg Heart rate 98/min Respiratory rate 24/min Oxygen saturation 98% on room air A. Blood pressure B. Temperature C. Heart rate D. Oxygen saturation E. Travel history F. Weight G. Sputum characteristics H. Report of cough 128) A nurse is planning a community health program about Parkinson's disease. Which of the following interventions should the nurse Include as a tertiary prevention strategy? A. Educate clients who are at risk for Parkinson's disease about maintaining a low- cholesterol diet. B. Provide screenings for community members to identify early manifestations of Parkinson's disease. C. Provide daily exercise classes to improve ambulation for clients who have Parkinson's disease. D. Educate clients about common techniques used to diagnose Parkinson's disease. 129) A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis following a stroke. Which of the following actions by the nurse best promotes communication among staff caring for the client? A. Recording the client's progress in the nurses' notes B. Noting changes in the treatment plan in the client's medical record C. Having interdisciplinary team meetings for the client on a regular basis D. Posting swallowing precautions at the head of the client's bed 130) A nurse is making an Initial postpartum home visit. Which of the following client statements should the nurse Identify as a manifestation of Increased risk for child abuse? A. "I have several friends who come by to help out with the baby." B. "I want to meet other parents to see if they are going through the same things." C. "I think the baby should be sleeping through the night by now." D. "I try to respond to the baby quickly so she doesn't cry very long." 131) A charge nurse is observing a newly licensed nurse provide care for a client who is postoperative. The newly licensed nurse tells the client that she will insert a urinary catheter if the client will not vold. Which of the following torts should the charge nurse Identify as having occurred? A. Negligence B. Battery C. Assault D. Libel 132) A nurse is caring for a client who has an NG tube with intermittent suction. Which of the following actions should the nurse take? A. Flush the tube with 0.9% sodium chloride. B. Replace the NG tube every 24 hr. C. Position the client supine in bed. D. Increase the suction pressure as tolerated. 133) A nurse is reviewing home recommendations with a client who is postoperative following knee surgery. Which of the following recommendations should the nurse make? A. Place a towel on the floor outside of the shower. B. Ensure that all area rugs are rubber-backed. C. Wear slippers with cloth soles. D. Place a handrail in the entryway of the house. 134) A nurse is positioning a client for a cesarean birth. To prevent a compromise in placental blood flow during the intraoperative period, which of the following actions should the nurse take? A. Position the client in reverse Trendelenburg. B. Assist the client into the lithotomy position. C. Insert a pillow under the client's knees. D. Place a wedge under one of the client's hips. 135) A nurse is caring for a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia? A. Chorioamnionitis B. Fetal anemia C. Maternal hypoglycemia D. Maternal fever 136) A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage? A. Eat a meal. B. Complete oral hygiene. C. Use an albuterol inhaler. D. Take pancrelipase. 137) A nurse is preparing to administer levothyroxine 50 micrograms to a client. Available is levothyroxine 0.025 mg/tablet. How many tablets should the nurse administer per dose? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) Answer: 2 138) A nurse is caring for a client who is experiencing Increased Intracranial pressure following a head Injury. In which of the following positions should the nurse place the client? A. Sims B. Supine C. Left lateral D. Low-Fowler's 139) A nurse has identified tasks to delegate to a group of assistive personnel (AP) after receiving change-of-shift report. Identify the sequence of steps the nurse should follow when delegating tasks to the APs. (Move the steps, placing them in the selected order of performance. Use all the steps.) B: Review the skill level and qualifications of each AP. C: Communicate appropriate tasks to the APs with specific expectations. A: Monitor progress of task completion with each AP. D: Evaluate the APs' performance of each task IN THIS ORDER 140) A nurse is caring for a client who has heart failure. Which of the following manifestations should the nurse expect? A. Tachycardia B. Weight gain C. Decreased thirst D. Thready pulse 142) A nurse is assessing a client who is in skeletal traction for a fractured left tibia. The nurse should identify that which of the following findings indicates altered tissue perfusion of the affected extremity? A. Warm skin temperature distal to pin site B. Faint pedal pulse of left leg C. Pain with movement of the left great toe D. Purulent drainage at the pin site 143) A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan? A. Encourage the client to lie down in a quiet room. B. Avoid eye contact with the client. C. Ask the client directly what he is hearing. D. Refer to the hallucinations as if they are real. 144) A nurse is giving an intramuscular injection to a newborn who was delivered at 38 weeks of gestation. Which of the following pain scales should the nurse use to assess the newborn's pain? A. Neonatal Infant Pain Scale (NIPS) B. FACES pain rating scale C. Visual analog scale (VAS) D. Premature Infant Pain Profile (PIPP) 145) A nurse is caring for a client who has Graves' disease and is experiencing a thyroid storm. Which of the following actions is the nurse's priority? A. Provide a cooling blanket. B. Monitor the client's cardiac rhythm. C. Administer 0.9% sodium chloride IV. D. Obtain the client's blood glucose. 146) A nurse is assessing the peripheral catheter insertion site of a client who is receiving an infusion. The nurse notices redness and warmth to the touch around the insertion site. The nurse should document the finding as which of the following complications? A. Circulatory overload B. Extravasation C. Phlebitis D. Infiltration 147) A nurse is discussing treatment options with a client who is experiencing nicotine withdrawal. Which of the following Information should the nurse include in the teaching? A. Use up to 40 nicotine lozenges per day. B. Substitute tobacco use with an electronic cigarette. C. Limit use of nicotine gum to 6 months. D. Use progressively larger nicotine patches. 148) A nurse is updating the plan of care for a client who has amyotrophic lateral sclerosis with dysphagia. Which of the following interprofessional team members should the nurse identify as the priority to consult? A. Physical therapist B. Occupational therapist C. Speech-language pathologist D. Dietitian 149) A nurse is preparing to administer PRN pain medication to a client who has cholelithiasis and is experiencing moderate abdominal pain. Which of the following medications should the nurse plan to administer? A. Ketorolac B. Omeprazole C. Metoclopramide D. Acetaminophen 150) A nurse is completing an admission assessment for a client who has narcissistic personality disorder. Which of the following findings should the nurse expect? A. Suspicious of others B. Preoccupied with aging C. Exhibits separation anxiety D. Ritualistic behavior 151) A nurse is providing teaching to a client who is undergoing radiation therapy and has stomatitis. Which of the following responses by the client indicates an understanding of the teaching? A. "I should limit my intake of dairy products to prevent nausea." B. "I should use a soft-bristle toothbrush to clean my teeth after meals." C. "I should moisten my lips with lemon-glycerin swabs," D. “I should gargle with an alcohol-based mouthwash to kill germs." 152) A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? (Select all that apply.) A. Keep objects in the client's room in the same place. B. Approach the client from the side. C. Ensure there is high-wattage lighting in the client's room. D. Allow extra time for the client to perform tasks. E. Touch the client gently to announce presence. 153) A nurse is providing teaching to a client who is to begin external radiation therapy for cancer. Which of the following information should the nurse include? A. "Use rubbing alcohol to remove the ink markings." B. "You might experience altered taste sensations." C. "Wear a binder over the radiation site." D. "Wash your skin thoroughly with a washcloth after each treatment." 154) A nurse is assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect? A. Fever B. Drooling C. Tinnitus D. Steatorrhea 155) A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make? A. "Your name cannot be removed once you are listed on the organ donor list." B. "Your desire to be an organ donor must be documented in writing." C. "I cannot be a witness for your consent to donate." D. "You must be at least 21 years of age to become an organ donor. 156) A nurse is preparing to administer dopamine hydrochloride 4 mcg/kg/min via continuous infusion. Available is dopamine hydrochloride in a solution of 800 mg in a 250 mL bag. The client weighs 80 kg. The nurse should set the IV infusion to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies.) A. 6 mL/hr. B. 25 mL/hr. C. 30 mL/hr. D. 35 mL/hr. 157) A nurse is caring for a client in an emergency department. Exhibits Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress Exhibit 1 Day 1 0400: Client brought in by emergency medical services (EMS) after being found roaming around the college and yelling. Client ran from EMS shouting, "No, you are not going to kill me," and only agreed to seek assistance when another student agreed to accompany the client to the emergency department. Acquaintance reports hearing rumors that the client had odd behaviors like mumbling and talking when no one else was there and always seemed suspicious of everyone. Client appears disheveled and states, "I feel hot." Informed client that they were in the emergency department. Assisted client in changing into a hospital gown. Client was cooperative and appears less anxious. 0415: Client tearfully agreed to be admitted to the mental health unit. Day 2 1000: Client states, "I feel a bit better. I get these thoughts sometimes when I am stressed. Smoking sometimes helps, but not yesterday. I have not been sleeping well." Client reports recent job loss and concern about having money for food. Reports first episode at age 19 as a freshman in college, which lasted for a few days. After several episodes, they dropped out of school. Client states, "My parent told me they had episodes like this years ago and were glad I didn't have brain problems too. But maybe I do." Exhibit 2 0445: Blood alcohol 0 mg/dL (0 to 50 mg/dL) Sodium 140 mEq/L (136 to 145 mEq/L) Potassium 3.5 mEq/L (3.5 to 5.0 mEq/L) Chloride 100 mEq/L (98 to 106 mEq/L) BUN 18 mg/dl (10 to 20 mg/dl) WBC count 5,500/mm3 (5,000 to 10,000/mm3) Glucose 94 mg/dL (74 to 106 mg/dL) C-reactive protein 0.8 mg/L (less than 1.0mg/dL) Exhibit 3 0415: Temperature 37° C (98.6° F) BP 128/66 mm Hg Heart rate 88/min Respiratory rate 20/min Oxygen saturation 98% room air BOW TIE Question Actions to take Choices -Reduce External Stimuli -Engage with the client several times each day to establish trust Potential Condition Choices -Brief psychotic order Parameters to Monitor Choices -ability to care for self -Suicide risk 158) A nurse is planning care for a client who was recently admitted to the medical- surgical unit. Exhibits Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Vital Signs Temperature 38.4° C (101.1° F) Heart rate 82/min Respiratory rate 20/min BP 138/74 mm Hg Oxygen saturation 97% on room air Day 1: WBC count 4,500/mm3 (5,000 to 10,000/mm3) RBC count 3.2 million/mm3 (4.2 to 5.4 million/mm3) Hgb 11 g/dL (12 to 16 g/dL) Hct 46% (37% to 47%) Platelet count 145,000/mm3 (150,000 to 400,000/mm3) Erythrocyte sedimentation rate 40 mm/hr (up to 20 mm/hr) Urinalysis: pH 5.0 (4.6 to 8.0) Specific gravity 1.0 (1.010 to 1.025) Protein 10 mg/dL (0 to 8 mg/dL) Glucose negative (Negative) WBC casts 2 (0 to 4 per low-power field) Admission Assessment Client reports new onset of fever and discomfort in their joints and increase malaise. No relevant medical history. Client is alert to person, place, time, and situation. Reports generalized pain as 4 on a scale of 0 to 10. Macular rash present on cheeks bilateral. Lungs clear anterior and posterior. Bowel sounds active in all 4 quadrants. Last bowel movement 1 day ago. Skin warm, dry, and intact. Capillary refill less than 3 seconds. A 20 gauge IV saline lock inserted in back left hand. BOW TIE Question Actions to take Choices - Ensure that client has intake of at least 200 ml/hr -Encourage client to avoid direct sunlight Potential Condition Choices -Systemic Lupus Erythematosus Parameters to Monitor Choices -Erythrocyte sedimentation rate -Vital Signs Every 4 hours 159) A nurse is caring for a recently admitted 18-year-old client. Exhibits Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Exhibit 1 Nurses’ Notes 1000: Client admitted to behavioral health unit for prolonged weight loss and refusal to eat. Client collapsed at school. The client's parents were called. They contacted the primary care provider, who arranged for a direct admission. Weight 37.2 kg (82 lb). Height 157.5 cm (62 inches). BMI 15. 1200: Client observed during noon meal. Client pushed food around the plate. Intake 10% of meal. Offered nutritional supplement. Client declined. Reports feeling anxious due to admission and mealtime. Client states, "I cannot eat this with you watching me.". 1500:. Snack provided. Client observed throwing snack into the trash can. When realized they had been observed, they admitted to their action and asked for a second snack. Client ate 10% of their snack. Exhibit 2 Laboratory results 1130: Sodium 145 mEq/L (136 to 145 mEq/L) Potassium 2.8 mEq/L (3.5 to 5.0 mEq/L) Chloride 110 mEq/L (98 to 106 mEq/L) BUN 20 mg/dL (10 to 20 mg/dL) Magnesium 1.2 mEq/L (1.3 to 2.1 mEq/L) Total calcium 9.5 mg/dL (9.0 to 10.5 mg/dL) Phosphate 3.2 mg/dL (3.0 to 4.5 mg/dL) Glucose 74 mg/dL (74 to 106 mg/dL) Total protein 4.8 g/dL (6.4 to 8.3 g/dL) Albumin 2.7 g/dL (3.5 to 5.0 g/dL) Exhibit 3 Admission Assessment Skin dry and flakey, lanugo. Lips dry and chapped. Hair thin and dull, buccal mucosa dry. Diminished bowel sounds. Abdomen swollen and bloated. Lungs clear to auscultation. Respirations regular and unlabored. Heart rate regular 50/min. Client reports no menstrual cycle for past 3 months. Client reports feeling depressed. Reports starting diet 6 months ago because they "felt fat" compared to the "popular kids at school.". Exhibit 4 Vital Signs 1000:. Temperature 36.1° C (97° F). Heart rate 50/min. Respiratory rate 16/min. BP 90/62 mm Hg. Oxygen saturation 98% room air. 1400: Temperature 36.2° C (97.2° F). Heart rate 48/min. Respiratory rate 16/min. BP 88/60 mm Hg. BOW TIE Question Actions to take Choices - Provide structured meal environment -Focus on the client’s underlying feelings of dysphoria and lack of control Potential Condition Choices -Anorexia Nervosa Parameters to Monitor Choices -Monitor weight on a daily basis -Cardiac function with ECG 160) A nurse in labor and delivery is caring for a client who is at 30 weeks of gestation. Exhibits Select 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing (drop down) due to (drop down) Exhibit 1 Assessment Client is Gravida 1 Para 0 and reports headache, nausea, vomiting, and right upper abdominal pain. Client is alert and oriented, appears restless. Client has gained 0.68 kg (1.5 lb) within the last week. Slight facial edema is present. Heart rate regular and without murmur. Respirations even, non-labored. Lungs clear to auscultation. Abdomen gravid. Fundal height measurement 29 cm. 1+ dependent edema noted bilaterally. Deep tendon reflex (DTR) is 3+ bilaterally, Applied external fetal heart monitor. No contractions noted. Fetal heart rate 140/min. Exhibit 2 Vital Signs 1000: Temperature 37.4° C (99.3° F) Heart rate 90/min Respiratory rate 20/min Blood pressure 148/94 mm Hg Oxygen saturation 95% on room air The client is at risk for developing (Placenta Abruption) due to (Hypertension) 161) A nurse is caring for a client at a clinic. Exhibits Complete the following sentence by using the lists of options. The client is at risk for developing Exhibit 1 Admission Assessment 1 week ago: Client reports that manifestations of hopelessness and disinterest are lessened, but present. Sleep disturbance continues. Provider increased paroxetine to 30 mg daily. Return to clinic in 1 week. 2 weeks ago: Client with a history of generalized anxiety disorder and major depressive disorder. Client presents with increased hopelessness, disinterest, and a change in sleep and appetite over several months. Client is currently taking fluoxetine 20 mg daily for the past year. Fluoxetine discontinued and paroxetine 10 mg daily started. Return to clinic in 1 week. Exhibit 2 Nurses’ Notes Client presents to the clinic with reports of restlessness, abdominal pain, disorientation, and fever for the past 12 hr. States, "I don't know what is wrong with me." Client denies recent illness. Denies fatigue and chills. Reports falling yesterday but didn't hit their head. Reports taking ibuprofen for muscle soreness. Client reports continued sleep disturbances, feelings of hopelessness, and a disinterest in activities. The client is at risk for developing (Serotonin Syndrome) due to (Adverse Effects of Paroxetine) 163) A nurse is caring for a postpartum client in an outpatient setting. Exhibits Complete the following sentence by using the lists of options. Exhibit 1 History and Physical G1P1, spontaneous vaginal delivery with median episiotomy at 39 weeks of gestation.  Newborn 4,508 g (9 lb 15 oz). APGARS: 8 at 1 min, 9 at 5 min. Group B streptococcus B-hemolytic positive (negative) Received 2 doses of intravenous penicillin G while in labor. Exhibit 2 Nurses’ Notes Discharge from acute care facility notes 2 days postpartum: Client discharged to home with newborn. Fundus firm, midline, and measures two fingerbreadths below umbilicus. Lochia scant rubra. Episiotomy site well approximated. Mild labial edema present. Voiding without difficulty. Breastfeeding newborn every 2 to 3 hr. Denies any pain with breastfeeding, nipples intact. Reports increased firmness in breasts. Outpatient setting notes 2 weeks postpartum: Client seen for postdelivery check. Unable to palpate uterus. Denies abdominal pain. Reports perineal discomfort as 2 on a pain scale of 0 to 10. Small amount of whitish- yellow vaginal discharge. Continues to breastfeed. Verbalizes nipple discomfort throughout feeding. Visible crack noted on left nipple. The client is at risk for developing (Mastitis) due to (Cracked nipple)