6. The nurse is planning care for a client who has a subarachnoid
Question6. The nurse is planning care for a client who has a subarachnoidhemorrhage. Which of the following interventions should the nurse include in the client’s plan of care: A). Keep the head of the bed flat B). Implement patient precautions C). Administer enemas as needed to prevent constipation D). Place the client in a room closest to the nurses station 7. The nurse is planning care for a client with a traumatic brain1. The nurse is caring for a client who had a liver biopsy 30 minutes ago. Which of the following would be essential to follow up: A. There is discomfort with inspiration B. Change in heart rate from 94 to 80 C. Lying on the right side of the bed flat D. 2.5 cm area of serosanguineous drainage present Ordered Response / Drag and DropThe nurse is inserting a peripheral intravenous catheter. Place each action in the correct order.1. Tape and secure the IV site.2. Apply tourniquet and palpate a vein for insertion.3. Clean the skin with approved solution.4. Apply pressure above the insertion site and connect the IV tubing.5. Puncture the skin and vein with the stylet.6. Observe for blood return and advance the catheter.7. Stabilize the vein below the insertion site ( digital tractionThe nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats per minute. Which nursing action is most appropriate?1. Notify the primary health care provider (PHCP).2. Continue monitoring the fetal heart rate.3. Encourage the client to continue pushing with each contraction.4. Instruct the client’s coach to continue to encourage breathing techniques.2. The nurse is caring for a client with a pleural effusion who had a thoracentesis 30 min ago. Which of the following findings would be a priority to follow up: A. Small amount of pleural – fluid drainage at the puncture site dressing B. Vesicular breath sounds auscultated over most of the lung field. C. Productive cough with pink tinged sputum. D. Soreness at the needle entry site. 4. The nurse is assessing a client with acute pancreatitis. Which of the following would be a priority to follow up: A). Decreased urine output B). Temperature of 100.4 C). Blood pressure 148/82 D). left upper quadrant pain radiating to the back. 5. The nurse is assessing a routine physical examination. Which of the following would require follow up. A). Constriction of the right pupil when light is directed toward the left pupil. B). Harsh, hollow, tubular sounds auscultated in the diaphragm of the stethoscope as it is placed over the trachea. C). A swooshing sound as the diaphragm is placed over the base of the neck. D). Elevation of the uvula of the soft palate when the client says “Ah” tongue is depressed 7. The nurse is planning care for a client with a traumatic brain injury. Which of the following interventions should be included in the client’s plan of care: A). Keep the head of the client’s bed elevated at least 15 degrees B). Monitor the client’s vital signs for widening pulse pressure C). Suction the client’s airway path three consecutive times D). Notify the primary care provider if the clients ICP is less than 10 mmHg 8. The nurse is caring for a client who exhibits facial muscle contractions when the facial nerve in front of the ear is tapped; which of the following lab values should be obtained A) Serum Magnesium level B). Serum Potassium level C).Serum Sodium level D). Serum Chloride level 9. The nurse is planning care for a client with heart failure who is at risk for pulmonary edema. Which of the following interventions should the nurse include in the client’s plan of care. A). Notify the primary health care provider if the client has a daily weight gain of one pound. B). Instruct the client about a low cholesterol diet C). Place the client in a high fowler’s position with edematous legs down D). Auscultate the client’s lungs q. 8 hours 10. The nurse is caring for a client who has SIADH Which of the following would indicate that the client’s treatment regimen has been effective: A). Serum Sodium level of 137 meq/L B). Urinary output of 48 mL in 2 hours C). Absence of peripheral edema D). Weight gain 11. The nurse is caring for assigned clients. Which of the following would indicate that the client equipment is malfunctioning and would require intervention: A). The reservoir bag of a patient’s non-rebreathing mask remains deflated during inspiration. B). There is water in the ventilator tubing of a client who is receiving mechanical ventilation. C). There is continuous bubbling in the water seal chamber of a client’s closed chest drainage system D).The alarm sounds on a clients IV pump when the client bends his arm containing the IV catheter 14. The nurse is caring for a client with Disseminated intravascular coagulation (DIC). Which of the following findings requires immediate follow up. A). Urine output of 250 ml for the past 4 hours. B). Headache rated as a 7 on a scale of 0 – 10 C). Hypoxia and is receiving 4L of oxygen nasal cannula D). Temperature of 100.7 F 15. The nurse is assessing a client with suspected acquired HIV. Which of the following would support a finding of AIDS. A). Polycythemia B). Lymphadenopathy C). Urinary urge incontinence D). Vesicular lesions 16. The nurse has taught a client with primary hypertension about strategies to prevent CVA. Which of the following statements by the client would require follow up: A. I will learn stress management techniques B. I will walk briskly for at least 30 minutes a day C. I will maintain a low potassium, low sodium diet D. I will limit my intake of alcoholic beverages 19. The nurse is talking with a client who has hypertrophic cardiomyopathy. Which of the following statements by the client would require follow up: A). I drink two liters of fluid daily. B). I schedule rest periods throughout the day C). I take my prescribed antiarrhythmic medication with a meal. D). I try to participate in games with my soccer league once a week 20. The nurse is teaching clients at a community healthcare center about risk factors of coronary artery disease. Which of the following statements by a participant would indicate a correct understanding of the teaching. A). I can reduce my risk for CAD by switching to low nicotine filtered cigarettes. B). Eating a high protein low carbohydrate diet is essential for reducing the risk of CAD C). Physical exercise for 30 minutes at least three times a week will eliminate my risk for CAD D). I inherited a predisposition for an elevated low density lipoprotein level from my parents who had CADGY 21. The nurse is assessing a client’s pulmonary system. Which of the following would indicate correct assessment technique: A. Asking the client to repeat a word or phrase while auscultating the client’s trachea. B. Telling the client to take a deep breath and hold their breath while percussing along the lower intercostal border. C. Asking the client to breathe through the nose while auscultating the posterior chest wall with the bell of the stethoscope. D. Placing the hands on the client’s posterior chest wall with the thumbs touching and watching for separation of the hands while the client inhales. 23. The nurse is assessing a client with bronchial asthma who was admitted four hours ago with status asthmaticus. Which of the following findings would require immediate follow up: A). Pulse of 88 B). Absence of wheezing C). Dyspnea upon exertion D). Respirations of 22 bpm 24. The nurse has taught a client about the use of peak expiratory flow rate. Which of the following statements by the client would indicate a correct understanding of the teaching: A). I should exhale forcibly and deeply before placing the mouth piece in my mouth. B). I should blow into the mouth piece for 8 – 10 seconds when measuring my peak flow. C). I should record the highest volume from 3 consecutive readings from the meter. D). I should notify my primary care provider if my pace flow measurement indicates I am in the green zone. 25. The nurse is assessing a client that has bacterial pneumonia. The client’s oral temperature is 39.4 Celsius (102.8 F) Which of the following actions would be appropriate for the nurse to take: A). Administer a dose of the client’s anti-infective IV one hour early. B). Encourage the client to drink increased amounts of liquids C). Give the client a sponge bath with cold water D). Ask the respiratory therapist to administer the respiratory treatment prescribed PRN 26. The nurse is admitting an 81 year old client with type 2 diabetes whose blood glucose is 385 g/dl.it would be a priority to follow up if the client has.A). Decreased peripheral vision B). Numbness and tingling of the hands and feet C.) Had nausea, vomiting and diarrhea for the past two daysD). had a weight gain of 2.3 kg in the past one month 27. The nurse prescribed regular insulin, Humulin-R, SQ to a client at 8:00a. Which of the following times should the nurse expect the medication to peak: A). 14:00 (2p) B). 08:30 (8:30a) C). 11:00 (11a) D. 16:00 (4p) 28. The nurse is planning a staff education meeting about hypothyroidism. Which of the following information should the nurse include in the conference. A). Provide the client with a high caloric diet B). Monitor the client for photophobia C). Encourage the client to increase fluid intake D). Maintain the client’s room temperature as cool as possible. 30. The nurse is assessing a client with Botulism. Which of the following findings would require immediate follow up A). Bile colored emesis of 300 ml B). Difficulty articulating words C). Blood streaked diarrhea D). Ancillary deep tendon reflexes of one 31. The nurse is reviewing discharge instructions with a client who had a total knee arthroplasty 2 days ago. Which of the following statements by the client would indicate a correct understanding of the teaching: A). If I develop swelling in my legs, I will contact my primary care provider. B). I will begin performing Quadriceps Sets and Gluteal Sets exercises one week after surgery C). I will apply warm, moist heat to my knee to control the pain D). If I notice clear drainage from the drain site, I will obtain a prescription to treat the infection32. The nurse is teaching a client who is scheduled for an EEG. Which of the following information should the nurse include: A). You will experience mild pain during the EEG B). You should not eat for 12 hours before the EEG C). You should wash your hair the night before the EEG D). You will feel electrical impulses pass through your body during the EEG33. The nurse is assessing a client who has been receiving prescribed TPN, through a central catheter peg for the past one month. Which of the following findings would be essential to follow up: A. Blood pressure 106/72 B. Capillary Blood Glucose 130 mg / dL C. White blood cell count 9,000 per mcL D. Weight loss of 1.8 kgs (4 lbs) in the past one week 34. The nurse has taught a client, who has hemorrhoids about a sitz bath. Which of the following statements by the client would indicate a correct understanding of the teaching A. A sitz bath should last for 40 minutes. B. I should immerse my body from the waist down into the water. C. I will receive a portable device that fits on my toilet. D. The water temp should be 48.9 degrees Celsius. 35. The nurse is caring for a client who has hydronephrosis. Which of the following lab test results would be a priority to follow up: A). Increase serum phosphate B). Serum Sodium level 136 meq/L C). Decrease serum ALT D). Serum Potassium level of 4.9 meq/L 36. The nurse is planning care for a client with chronic renal failure. It would be most important for the nurse to monitor the clients: A). Hematocrit level B). White blood cell count C). Serum Amylase levels D). Eosinophil count 37. The nurse is talking to a client who had an illegal conduit created one week ago. Which of the following statements by the client would be a priority to follow up: A). I have to increase my fluid intake to 2 Liters each day B). I occasionally have strings of mucus in my urine C). I will cut a hole in the appliance and the hole is slightly larger than the stoma D). I use warm water and alcohol when cleansing the area around the stoma 38. The nurse on the Women’s Health Unit, has just received a report on the following four clients. The nurse should plan to first assess the client who: A). Had an abdominal hysterectomy 2 hours ago and has a prescription for Morphine via an epidural catheter had has a pulse ox of 92% B). Had a C- Section 2 days ago and is having difficulty breastfeeding the baby C). Had a vaginal birth 2 hours ago, has a fundus that is firm and reports perineum pain D). Has a 4th degree tear with a 9 lb baby and is reporting abdominal cramping while breastfeeding. 39. The nurse is preparing several small group discussions for clients in different age groups. Which of the following would be an age appropriate topic for the nurse to consider: A). Reviewing self testicular examinations with a group of 15 to 18 year old males. B). Demonstrating self examination of the breast with a group of 10 to 12 year old females C). Discussing promotion of independent tooth care with a group of children between the ages of 4 and 5 years of age. D). Teaching water safety to toddlers between the ages of two and three years of age. 40. :The nurse has prepared a class about infant nutrition. Which of the following statements by another parent indicates a correctA). I can add string vegetables to my baby’s understanding of the teaching diet at 4 months of age. B). I will mix my baby’s cereal with strained fruits at 5 months of age. C). I can introduce finger foods to my baby at 9 months of age. D). I must use low fat milk rather than whole milk in my baby’s bottle at 10 months of age. 41. The nurse in a client care center has assessed the following clients. It would be a priority for the nurse to follow up with a client who is: A). I am 4 month old. Does not vocalize and whose head bobs forward while sitting. B). 17 month old. Falls often running and who has a temper tantrum during examination. C). A 3 year old who is not toilet trained and speaks in three and four word sentences D). A 5 year old has no permanent teeth and can print 3 or 4 different letters42. The nurse is caring for a 5 year old, whose mother has recently died. The nurse should inform the family members that the child will respond to his mother’s death by: A). Insisting that a plate be at the table so that he can eat with the parent. B). Asking several times a day why a parent died. C). Throwing items that the parent has used such as shoes, into a trashcan. D). Telling others that his behavior caused the parent to die 43. The nurse is preparing a staff education conference about newborn care, which of the following instructions would be appropriate for the nurse to include in the conference? A. Administer prescribed Aquamephyton to the newborn’s right leg. B. Place a newborn who has pyloric stenosis in a prone position for one hour after feeding. C. Wear sterile gloves when obtaining a blood sample from the newborn’s heel. D. Isolate from other newborns, a newborn whose mother has a positive test result for the HIV virus. 44. A nurse is preparing a newborn for discharge 48 hours after delivery, the nurse observes small yellow papules over the newborn’s face and diaper area. The lesions are firm and raised with pink halos. It would be appropriate for the nurse to define this as: A. Erythema toxicum B. MiliaC. Acne neonatorum D. Petechiae 45. A three week old client is receiving Gavage, released by gravity infusion. When preparing to administer the feeding, The nurse should: A). Position the client on the left side. B). Aspirate stomach contents and discard the residual. C). Instill 2ml of 0.95 Sodium chloride and ascultate tube placement. D). Warm the formula to room temperature. 46. The nurse is assessing a full term male newborn who has been delivered one hour ago. Which of the following would be an expected age related findings. A). Cyanosis of the hands and feet B). Abundant thick hair on the shoulders C). Undescended testicles with scrotal rugae. D). Extension of the arms and legs while awake 48. A three year old has an order for a cleansing enema. Just prior to administering this enema the nurse should: A. Give the client a coloring book with pictures of equipment of enemas. B. Have the client watch a video tape of someone receiving an enema. C. Encourage the client to give an enema to a doll. D. Show the client a picture book about the administration of the procedure. 49. The nurse has taught a parent of an 18 month old client with gastroenteritis who is receiving oral rehydration therapy. Which of the following statements by the parent would indicate a correct understanding of the teaching: A). I will weigh my child at the same time each day and notify the primary healthcare provider if my child loses weight. B). I will give my child water to drink for the next 24 hours and then begin to give my child fruit juice C). I will check my child’s rectal temperature every 12 hours for the next 48 hours. D). I should not feed my child solid foods until my child no longer has diarrhea50. A one year old baby is receiving supplemental oxygen in a tent. Which of the following if seen by the nurse upon entering the room would indicate a violation of oxygen safety principles: A). Nylon sleepwear on the baby B). Transistor radio at bedsideC). Plastic blocks stacked in the baby’s crib D). Suction machine at the bedside 51. The charge nurse in a long term care facility is observing a client who has had 3 falls during the past 2 days sitting in a wheelchair with restraints in place. The facility has a restraint free policy. Which of the following actions should the nurse take first: A. Demonstrate safe restraint usage at a staff meeting. B. Remove the client from the restraint. C. Complete submit an incident report. D. Evaluate previous interventions. 52. The nurse is assessing the coping strategies of a family member with severe Alzheimer’s Disease. Which of the following statements by a family member would be a priority for follow up: A). It is so sad to think my family members will never get better. B). There seems to be no happiness in my life these days. C.) I live the closest so all her care is left up to me. D). I know I should not be angry but I just can’t help it. 53. The nurse is caring for a client with Rheumatoid arthritis (RA) with hip and knee involvement. Which of the following actions taken by the client would need follow up: A). Sitting comfortably in an overstuffed chair to nap B). Using a straight back chair while ironing C). Using a barstool at the kitchen sink D). Placing a bed board under the mattress The nurse is assessing assigned clients. Which of the following should the nurse assess for being at highest risk for suicide: A). A 75 year old Caucasian male who has recently retired from the police force. B). A 73 year old African American who recently had a sibling move out of State. C). A 15 year old Native American female who has just been diagnosed with Osteoarthritis. D). A 67 year old female who is aging and has chronic insomnia. 58. The nurse on an inpatient psychiatric support unit is leading a support group for a client. It would be a priority for the nurse to intervene in a client: A). Who has bipolor disorder. Moving their legs and looking around the room restlessly B). A client with borderline personality disorder is saying that another group member is too disturbed to be attending this session. C). A client with major depression is listening quietly and looking downward D). A client with Schizophrenia is rocking in place and mimicking what other people are saying in the group. 59. The nurse is preparing a teaching session with a group of adults about interventions that may help prevent the development of cataracts.Which of the following would be appropriate for the nurse to include: A). Wearing sunglasses to reduce exposure to UV light. B). Managing hypertension to prevent constriction of blood vessels. C). Preventing eye infection to decrease intraocular pressure. D). Avoiding eye strain to minimize refractive error. 0). The nurse is planning a staff education program about Meniere’s disease. Which of the following information would be appropriate for the nurse to include: A). Cranial Nerve II Optic is commonly affected B). Maintaining adequate peripheral tissue perfusion as a treatment goal C). Client’s may report a roaring sound in the ear D). Short wind edema is started with OCD and appears from the onset. 61.. The nurse is caring for a client with expressive aphasia. Which of the following strategies would best facilitate communication with a client. A). Using exaggerated facial expressions when speaking with a client. B). Facing the client directly when speaking C). Encouraging the client to point to direct objects. D). Asking the family members to interpret the client’s speech 62. The nurse is preparing a plan of care for a client with a nursing diagnosis of a risk for injury related to left homonymous hemianopsia. Which of the following interventions would be most appropriate for the nurse to include in the plan of care. A). Explaining the location of items and placing them near the client B). Reminding the client to turn their head to scan their complete range of vision C). Ensuring that the client’s room is brightly lit D). Placing visual stimuli on the clients affected side63. The nurse has attended a staff education conference about infection control precautions. Which of the following statements by the nurse would indicate a correct understanding of the teaching: A. I will wear a surgical mask when entering the room of a client with impetigo. B. I will wear sterile gloves when taking the blood pressure of a client with streptococcal meningitis. C. I will wear a protective gown and sterile gloves when changing an IV tubing of a client with cytoplasmic pneumonia. D. I should wear a protective gown and gloves when assisting a client with a VRE infection with a bath. 64. The nurse is caring for a client who has scabies, which of the following infection control precautions should the nurse include: A. Place the client in a private room. B. Remove gloves after leaving the clients room. C. Keep the door to the room closed at all times. D. Place a surgical mask on the client during transport. 65. The nurse has attended a staff education conference about infection control precautions. Which of the following statements by the nurse would indicate a correct understanding of the conference: A. A client that has measles should be placed in a private room B. A surgical mask should be put on before entering the room of a client who has TB C. A protective gown should be worn before bathing a client who has streptococcal pneumonia D. A client who has C-diff should wear a surgical mask when being transported outside the assigned room. 66. The nurse is teaching a staff education conference about skin lesions. Which of the following information should the nurse include in the conference: A. Client should be placed on contact precautions B. There is an overgrowth of tissue at the site of the incision C. The lesions grow the longer the client stays in bed D. Clients should avoid scratching the lesion to prevent infecting other areas of the body. 67. The nurse is conducting a staff education program about infection control precautions. Which of the following information should the nurse include: A. Adolescents with pelvic inflammatory disease should stay home from school until all the prescribed anti-infective medications have been taken. B. Children with chicken pox can return to school within 24 hours after the rash has appeared. C. A client with pustular psoriasis is contagious until crusted over. D. Ringworm can be transmitted via articles of clothing. 68. The nurse is planning a new assignment for a client scheduled to be admitted during the shift. The charge nurse should assign the only available private room to a client with: A). COPD who has a productive cough of clear sputum. B). Acute glomerulonephritis who has pressure ulcers 3rd degree. C). Hepatitis C who has hepatic encephalopathyD). Acute pancreatitis who has viral conjunctivitis 69. The nurse has developed a staff conference on infection control guidelines. Which of the following actions by a staff member would indicate a correct understanding of the conference: A). Placing a client who has meningitis in a room with a client who has hepatitis B. B). Wearing a protective mask and gown when entering a clients room with pertussis. C). Placing a surgical mask on a client with measles before transporting the client to another department. D). Wearing a surgical mask when changing the dressing who has a wound infected with VRE. The nurse is caring for a client with C-Diff. Which of the following infection control precautions should the nurse implement? A). Initiate droplet precautions for the client B). Wear clean gloves when entering the client’s room C). Provide the client with disposable eating utensils for meals. D). Place the client in a private room with negative air pressure. 71. The nurse is assessing a client who has a urine culture sensitivity test result that is positive for MRSA. Which of the following infection control precautions should the nurse implement: A). Keep the door of the client’s room closed B). Provide the client with disposable eating utensils C). Wear a surgical mask when emptying the client’s bedpan D). Place a disposable stethoscope in the room for the client’s use only 71. The nurse is assessing a client who has a urine culture sensitivity test result that is positive for MRSA. Which of the following infection control precautions should the nurse implement: A). Keep the door of the client’s room closed B). Provide the client with disposable eating utensils C). Wear a surgical mask when emptying the client’s bedpan D). Place a disposable stethoscope in the room for the client’s use only 72. The nurse is assigned as a preceptor to a newly hired nurse. Which of the following if preformed first by the newly hired nurse, would indicate his/her ability to prioritize. A, Obtaining a blood glucose level for a client with a history of hyperglycemia who recently returned from surgery. B. Performing a neurological check on a client with primary hypertension who is reporting right sided weakness. C. Assessing the pain of a client who had a thyroidectomy 2 hours ago and is reporting a sore throat. D. Checking for the return of a gag reflex of a person who returned from surgery 15 minutes ago from a bronchoscopy and is NPO. 73. The nurse has received the following information about assigned clients. Whom should the nurse assess first? A. A 66 year old client with pneumonia and a fever of 100.7 B. A 56 year old client who had an abdominal cholecystectomy 12 hours ago and is restless. C. A 43 year old client with Ulcerative Colitis who had 4 episodes of blood tinged diarrhea in six hours. D. A 24 year old client who had an open reduction. And internal fixation of a fractured femur and is requesting a dose of a prescribed medication. 74. The nurse has received a change of shift report on the following client. The nurse should first assess the client: A. With Sickle – Cell Crisis who has a hemoglobin of 9 gm/dL B. With pneumonia who has an oral temp of 38.8 C / 101.8 F C. Who had a femoral phlebitis graph bypass surgery and is reporting slightly more pain than before the surgery.D. Not discussed 75. The nurse has received the following information about assigned clients. The nurse should first assess the client with: A). COPD who has a pulse ox of 92% B). Diabetes type 1 who is reporting pain in the legs C). Primary hypertension who has a blood pressure of 160/90 D). Lung cancer who has a paradoxical pulse 76. The nurse has received the following information about assigned clients. The nurse should first assess the client: A). With prostate cancer and metastasis who has developed numbing and tingling in the legs. B). Who had a total knee replacement 2 days ago and is reporting pain in the effected knee after physical therapy. C). With COPD who is using purse – lipped breathing after taking a shower. D). Who had an appendectomy 2 days ago and has not had a bowel movement since surgery. 77. The nurse has been assigned to the following client situations. The nurse should first assess the client who has: A). A CVA 48 hours ago and is receiving oxygen at 24% via venture mask and has a PaCo2 at 55 B). Open reduction and internal fixation of a left hip fracture 12 hours and is reporting incisional pain rated an 8 on a scale of 1 to 10 C). A chest tube inserted 12 hours ago for a hemothorax and a 100 ml of dark colored drainage in the collection chamber of a closed chest drainage system. D). An appendectomy 18 hours ago and has a temperature of 101.5 78. The nurse is observing a staff member caring for assigned clients. It would require immediate attention if a staff member is observed: A). Instructing a client who just had a liver biopsy to maintain a left sided lying position for 2 hours. B). Administering Digoxin to a client who’s most recent serum potassium level is 4.9 mg/dl C). Getting the client signature on a consent form for an HIV blood test after the primary health care provider has left the room. D). Informing a client that has diabetes type 2 the a Glycated hemoglobin level of 14% indicates poor glycemic control 79. The nurse is caring for the following clients. It would be a priority for the nurse to follow up with a client who: A). Scheduled for a renal transplant in 2 hours and has a platelet count of 150,000 B). Is scheduled for an abdominoperineal resection in 1 hour and has a blood urea of 47 c).Had a left lung lobectomy 8 hours ago and has 200 ml of serosanguineous drainage in the closed chest tube drainage system. D. Had a right hip replacement 12 hours ago and has drained 60 ml of drainage in the closed wound drainage system in the past 2 hours I). 80. The nurse is assessing a client with heart failure who is receiving prescribed IV Dopamine (Intropin). Which of the following statements by the client would be a priority to follow up: A). My IV site is painful B). My heart rate is increased C). I have developed a headacheD). I have urinated twice in 4 hours 81. The nurse is caring for the following clients. It would be a priority to initiate a referral to a Social Worker for a A). A 32 year old client recently diagnosed with Huntington’s Disease who is a single parent of a 10 year old child. B). A 40 year old client who has an external fixation device applied for fractured tibia and fibia and lives alone C). A 54 year old client with breast cancer who had a bilateral mastectomy and lives with her spouse. D). A 68 year old client who had an MI and lives with a sibling 82. The nurse has been made aware of the following client situations. The nurse should first see the: A). The 28 year old client with pneumonia who is expectorating blood tinged mucus and is reporting chest pain upon inspiration. B). A 36 year old client with a pulmonary embolism who is receiving prescribed heparin sodium infusion and has a PT which is one and one half times the control value. C). A 40 year old client with MS who has ectopia and is experiencing urinary incontinence D). A 47 year old client who just had a thyroidectomy one day post op and is reporting that the dressing feels tight. 83. The nurse is assessing a 72 year old client who has a blood pressure of 182/92 mmHg. Which of the following findings would be a priority to follow up: A). His ability to recall a 24 hour diet history B). Double vision and a unsteady gait C). Numbness and tingling in the fingers D). Episodes of urinary frequency 84. The nurse has been made aware of the following client situations. The nurse should first assess the client who: A). Is being treated for gastointestional bleeding and is reporting having a tarry stool B). Has not voided since an indwelling catheter was removed 6 hours ago C). Is confused and has unfastened the prescribed vest restraint to go to the bathroom D). Has not had a bowel movement since a prescribed oil retention enema was given an hour ago. 85. The nurse has received the following information about assigned clients. The nurse should first assess the client: A). With Ulcerative Colitis who is reporting having bloody diarrhea B). With lung cancer who is reporting expiratory rust colored sputum C). Who had Percutaneous Transluminal Angioplasty (PTA) 4 hours ago and is reporting flank pain D). Who had a partial thyroidectomy 3 hours ago and is reporting incisional pain at a level of 6 on a scale of 0 – 10 86.. The nurse is participating in an external disaster. The nurse should first see: A). A 27 year old client with chest contusions who has muffled heart sounds and has a blood pressure of 105/90 B). A 43 year old client with abrasions on the face and lacerations on the forehead who has a glascow coma scale of 10 C). A 54 year old client with abdominal pain who has hyperactive bowel sounds and nausea D). A 64 year old client with an open fracture of the left lower extremity who has diminished sensation in his left lower extremity. 87. The nurse enters a clients room and observes a fire in the waste basket. Place in the correct order: A). Remove the client from the immediate danger B). Use a fire extinguisher and put out the fire C). Activate the fire alarm per the facility protocal D). Contain the fire by closing the door to the clients room. 88.. The nurse has attended a staff education conference about emergency defibrillation. Which of the following statements by the nurse would indicate a correct understanding of the conference: A). Defibrillation can used to treat both A – fib and V – fib B). Monophasic defibrillators deliver successful shocks at lower energy than biphasic devices C). Defibrillation depolarizes mycardial cells and thereby allows the SA Node to resume the role of pacemaker of the heart D). Electrical current is synchronized with the clients cardiac cycle prior to delivering the shock during defibrillation. 89. The nurse is preparing a staff education conference about spirituality. Which of the following information should the nurse include: A. Physical pain often causes spiritual distress B. Spirituality is a personal experience unaffected by cultural contacts in development C. Nurses should avoid praying with clients since privacy during prayer is a universal need D. Nurses should clearly state their own beliefs about spirituality.90. The nurse is preparing for a staff meeting about developing strategies for improving multi disciplinary team collaboration. Which of the following would be important for the nurse to do first at the meeting: A. Suggest methods to increase communication between team members. B. Provide information for possible changes in team members. C. Identify one team member to coordinate the client’s care. D).Discuss the strengths and weaknesses of each team member. 91. The nurse is caring for the following clients. It would be a priority for the nurse to initiate a multidisciplinary conference. A. An 18 year old client who is newly diagnosed with type 1 diabetes. B. A 29 year old client who sustained a spinal cord injury at C- 4 2 days ago. C. A 50 year old with COPD in his lungs. D. A 72 year client with right – sided heart failure who was admitted with thombophlebitis 92. The nurse is caring for a group of clients. It would be most appropriate to initiate a multidisciplinary approach with a client: A). Had a total hip replacement 2 days ago and is refusing to use the prescribed passive range of motion exercises. B). With AIDS who is scheduled to be transferred to a long term care facility.C). Who had a total hip replacement 5 days ago and is being discharged with a recommendation for a home health nurse. D). With heart failure and is being admitted for the fourth time in the past 3 months. 93. The nurse has attended a staff education meeting on continuing quality improvement. Which of the following statements by the nurse would indicate a correct understanding of the information presented. A). The goal of CQI is cost effectiveness B). The problem-solving approach is internalized in CQI. C). The educational needs of the staff determine the CQI program D). The standards of CQI are determined by managed care 94.. The nurse is planning a staff development conference about intentional torts that may be committed in health care settings. Which of the following information should the nurse include. Select all that apply: A. Threatening a client with frightening consequences for actions deemed undesirable by a nurse can constitute assault. B. Performing surgery without the client’s written consent can constitute battery. C. Submitting an unsubstantiated written statement criticizing a supervisor’s action can constitute liable. D. Retaining a client in a healthcare facility against their will constitutes false imprisonment. E. Practicing nursing without a license can constitute malpractice. 95. The nurse is preparing a staff education conference about involuntary admissions. The nurse should understand that the client: A). The client cannot file a writ of habeas corpus if the client has been involuntarily committed. B). Cannot refused to take prescribed medication if the client has been involuntarily committed. C). Can be committed without a written consent if the client is found to be unable to met basic needs. D). Can be committed for a duration of six months without consent. In six months the case is fully reviewed. 96.. The nurse is planning a staff development conference about confidentiality. Which of the following information should the nurse include? A). Client health information can be released without the clients consent for research purposes only. B). Serious breaches in client confidentiality cannot result in the revoking of a nursing license C). The nurse protects the clients health information because the nurse is the client’s advocate I). Health information about the client is not made public without the client’s consent 97. The nurse has attended a staff education conference about Digoxn. Which of the following statements by the nurse would require follow up: A. Hyperkalemia can cause lanoxin toxicity B. Visual disturbances can be a sign of lanoxin toxicity. C. The medication is available in oral and intravenous forms. D. The medication works by increasing the force of heart muscle contractions. 98. The nurse has taught a client who is receiving newly prescribed Flagyl(Metronidazole). Which of the following statements by the client would demonstrate an understanding of the teaching. A. “I should limit my alcohol intake to one glass of wine or beer per week.” B. “I can use sugarless gum if I experience dry mouth while taking the medication.” C). “I can discontinue the medication when I have been symptom free for one week.” D). ” I should notify my primary care provider if my urine appears dark yellow.” 99. The nurse is reviewing new prescriptions for assigned clients. Which of the following prescriptions should the nurse clarify. A). Byetta (Lantus) for a client with Diabetes type 2. B). Cialis (Tadalafil) for a client with erectile dysfunction. C). Zoloft (Sertraline) for a client with panic disorder. D). Calan (Verapamil) for a client with alopecia 100. The nurse has taught a client who is receiving newly prescribed Zyrtec (Cetirizine). Which of the following statements by the client would demonstrate an understanding of the teaching. A). ” I can take the medication without regard to food”. B). “I will exercise in the sunlight at least 30 minutes a day”. C). “I should limit my alcohol intake to one glass of wine per day”. D). “I can expect to experience an increase in oral secretions while taking this medication”. 101. The nurse is caring for a client who is receiving newly prescribed Viagra (sildenafil citrate). Which of the following statements by the client would require follow up: A). I can take over the counter aspirin to relieve headaches. B). I will not take more than one dose of the medication in a 24 hour period. C). I should continue taking Cardura to control hypertension. D. I may split the medication tablet if I have trouble swallowing the medication. 102. The nurse has received a change of shift report about the following clients. The nurse should first see the client with: A). Angina endocarditis who is receiving Tridil infusion and is reporting a headache B). Primary hypertension who is receiving Vasotec and has a blood pressure of 140/80 C). COPD who is receiving Theo-Dur and is using pursed – lip breathing while ambulating. D). Heart failure who is receiving prescribed Lasix and has crackles/rales during expiration. I). 103. The nurse has taught a client who is receiving L-dopa. Which of the following statements by the client would indicate a correct understanding of the teaching: A). The medication acts as a neurotransmitter. B). The medication should be taken one hour before eating. C). I should feel better one week after starting the medication. D). I may develop muscle twitching as a side effect of the medication. 104. The nurse is preparing to administer prescribed medications to a client. Which of the following actions should the nurse take to correctly identify the client. Select all that apply. A). Check the client’s name and room number posted on the client’s bed. B). Insure that an informative response is given when the nurse states the client’s name C). Compare the client’s medication administration record to the medication administration record of the previous day. D). Ask the client to state their name and date of birth and then compare this information to the medication administration record.E). Compare the client’s name and medical identification number on the MAR to the client’s identification bracelet (not done yet) 105. The nurse is preparing to administer prescribed Lithium to a client. Which of the following would require follow up before administering the medication. A). The client drank 2 Liters of water in the past 24 hours. B). The client ate a hamburger for lunch. C). The client report dizziness D). The client reports tremors 106. The nurse has taught a client who is receiving prescribed Remeron. Which of the following would indicate a correct understanding of the teaching. A). I will have a blood specimen obtained to check my serum phosphate level. B). I will take the medication before bedtime because it may cause drowsiness. C). I may experience a decrease in appetite while taking the medication D). I should take the medication one hour prior to meals. 107. The nurse has taught a client with bipolar disorder about newly prescribed Lithium which of the following statements by the client would indicate a correct understanding of the teaching. A). I may experience weight loss B). I should avoid food high in Tyramine C). I will have my serum phosphorus checked weekly D). I will notify my primary healthcare provider if I experience muscle weakness 108. The nurse is planning care for a client with mild hemophilia type A who is changing prescribed Desmopressin Which of the following interventions should the nurse include in the plan of care: A). Monitor intake and output to prevent over – hydration B). Administer intravenous dose 30 minutes before surgery C). Administer ASA for pain D). Monitor blood pressure for hypertension 109. The nurse is preparing to administer a corticosteroid medication inhaler without a spacer to a client. Select in correct order the steps that the nurse should take A). Assist the client to rinse the mouth B). Shake the inhaler C). Advise the client to breathe in while pressing down firmly on the canister of the inhaler D). Position the inhaler 1 – 2 inches away from the mouth E). Instruct the client to hold their breath for approximately 10 seconds 110. The nurse is teaching a client who is receiving newly prescribed Catapres TTS. Which of the following information should the nurse include in the teaching: A). Apply the transdermal patch once every 7 days B). Cut the transdermal patch based on the dosage prescribed C). Place the transdermal patch on the side to enhance absorption D). take the trandermal patch off when you shower and then reapply the patch 111. The nurse is assessing a client with cocaine abuse. Which of the following is consistent with cocaine abuse:A. Aplastic anemia, altered level of consciousness and respiratory depression. B. Poor motor coordination, flushed face and decreased mental alertness. C. Slurred speech, decrease in blood pressure and constricted pupils. D. Increased heart rate increased euphoria and anorexia 112. The nurse is caring for a client who has a prescription for Neoral (Cyclosporine) 2.5 mg/kg/day po in 2 divided doses. The client weights 160 lbs. The nurse has Neoral (Cyclosporine) 100 mg/mL available. How many mL should the nurse administer with each dose? Write your answer using one decimal place. 1. 113. How many mL in an 8 hour shift did this infant produce? Emesis 300 mL Diarrhea 200 mL first wet diaper weighed 300 mg; second wet diaper weighed 200 mg. I dry diaper weighs 160 mg. 114. The nurse is calculating a client’s intake and output for an 8 hour shift. The client has had the following intake throughout the shift. 0.9% Sodium Chloride infusing at 125 mL/hr. 6 oz of chicken broth. 8 oz of apple juice. 4 oz of ice cream and 12 oz of carbonated beverages. How many mL should the nurse record as the clients fluid intake for the shift. 115. A client with deep vein thrombosis is receiving an IV infusion of heparin sodium at 1,500 units/hr. The concentration in the bag is 25,000 units/500ml. How many milliliters should the nurse document as intake from this infusion for an 8 hour shift? Record your answer using a whole number. 116. The nurse is caring for a 10 year old client who has a prescription for Ancef 7mg/kg po twice daily. The client weighs 66 lbs. The nurse has Ancef 125 mg / 5ml solution available. How many mL’s should the nurse administer with each dose? (Record your answer using a whole number) 117. The home health nurse is visiting a client with leukemia who has received prescribed chemotherapy, to observe the spouse performing client care. Which of the following actions by the spouse would cause the nurse to intervene: A. Flossing the client’s teeth after eating a meal to promote oral hygiene. B. Administering a stool softener to prevent constipation. C. Providing the client with canned fruit as a between meal snack to increase caloric intake. D. Administering Tylenol to the client for a headache. 118. The nurse is teaching a client about the proper use of an electric heating pad. Which of the following statements by the client would require follow up: A.”I should place a waterproof covering over the heating pad.” B. “I will keep the temperature constant if the heating pad feels less warm over time.” C. “I will remove the heating pad if I notice an increase skin redness.” D. “I should place the heating pad under the affected body part when laying in bed.” 119. The nurse is caring for a client who is reporting trouble sleeping. Which of the following would be a priority for the nurse to follow up: A). I watch television before bedtime to go to sleep.B). I take Tylenol PM prior to the time I go to sleep. C). I sleep sitting up in a recliner if I cannot get comfortable in bed. D). I eat a light snack before bedtime. 120. The nurse has attended a staff education conference about Hospice Care. Which of the following statements by the nurse would indicate a correct understanding of Hospice Care. Select all that apply. A). The goal of Hospice Care is to facilitate a dignified death for the client B). Hospice Care includes pain medications and symptom management for the client C). The Hospice team includes a social worker D). Hospice services terminate when the client dies. E). Hospice services begin as soon as the client exhibits a life threatening condition 121. The home health nurse is assigned to the following clients who live within 3 miles of each other. The nurse should first see the client who has a A). A peg tube whose family member will administer the first feeding today. B). A central venous access device for chemotherapy and is reporting burning with urination. C). Pressure stage I ulcer and is reporting that the hydrochloride dressing has fallen off. D). A transverse colonoscopy and will be changing the colostomy bag for the first time today 122.. The home health nurse is talking with a spouse of a client who has a positive result for the HIV virus. It would be a priority to follow up if the spouse is reporting: A). Red, itchy lesions in the antecubital space. B). Silver scaly patches on the elbows and knees C). painful, fluid pustules on the right thorax D). Flat brown spots on the back of the hands. Health ScienceScienceNursingShare Question
