Bundle
FLORIDA UNIVERSITY PEDIATRICS NUR 416 CAT 1,2& 3 KAPLAN 2 LATEST 2021/2022,100% CORRECT
3 Items
FLORIDA UNIVERSITY PEDIATRICS NUR 416 CAT 3 KAPLAN 2 LATEST 2021/2022,100% CORRECT New
FLORIDA UNIVERSITY PEDIATRICS NUR 416 CAT 3 KAPLAN 2 LATEST 2021/2022 1. The nurse auscultates crackles throughout all lung fields and measures a heart ra... [Show More] te of 132 bpm, a respiratory rate of 30, and blood pressure of 102/54 mm Hg in a client recovering from an esophagectomy. Which action will the nurse take first? 1. Place the client on continuous pulse oximetry. 2. Monitor the client for changes in blood pressure. 3. Notify the health care provider. 4. Assist the client to use the incentive spirometer. Ans: 3 2. The nurse assigns a client diagnosed with cancer who is receiving chemotherapy to a nursing assistive personnel (NAP). Which instruction is most important for the nurse to include? 1. Perform hand hygiene frequently. 2. Wear a mask when entering the room. 3. Monitor the roommate for signs of infection. 4. Monitor the amount of protein the client eats. Ans: 1 3. The nurse provides care for a client diagnosed with a bone infection. The client was given intravenous morphine 3 hours ago and cannot have another dose for an hour. The client reports pain that is rated as 6 out of 10. The nurse implements several nonpharmacological approaches. The client’s pain level is now a 3 out of 10. Which action should the nurse take next? 1. Notify the health care provider. 2. Administer the morphine early. 3. Instruct the client that the next dose cannot be given for an hour. 4. Ask the client what an acceptable pain level is. Ans: 4 4. The nurse provides care for a client who was in a car accident as the result of falling asleep at the wheel. The client reports only being able to sleep 3 to 4 hours a night over the past month, due to stress. The client reports waking up frequently during the night. Which outcome is most appropriate for the nurse to include in the client’s plan of care? 1. Client will verbalize a plan to implement a sleep promoting program within the next week. 2. Client will fall asleep with less difficulty over the next 2 weeks. 3. Client will achieve a more normal sleep pattern within 2 to 4 weeks. 4. Client will achieve an improved sense of adequate sleep over the next 4 weeks. Ans: 1 5. The nurse reviews medications prescribed for a client recovering from surgery. Which prescription causes the nurse the most concern? 1. Diphenhydramine 50 mg PO at bedtime, as needed. 2. Furosemide 40 mg IV q.d. 3. Morphine sulfate 2 mg IV every hour, as needed, for pain. 4. Oxygen at 2 L/min via nasal cannula. Ans: 2 6. The nurse reads the result of a tuberculosis (TB) skin test on a client with no known risk factors for TB. Which finding will the nurse interpret as a positive result? 1. Erythema of 5 or more millimeters. 2. Induration of 5 or more millimeters. 3. Induration of 10 or more millimeters. 4. Induration of 15 or more millimeters. Ans: 4 7. The nurse provides care to an older adult client suspected of being a victim of physical abuse. Which action is appropriate for the nurse to implement when providing care to the client? (Select all that apply.) 1. Place the client in a single room near the nurses’ station. 2. Assess the client for bilateral injuries in ankles or wrist. 3. Identify, collect, and preserve physical evidence of abuse. 4. Take photographs to document signs of physical abuse. 5. Use standardized tool to screen for elder mistreatment. Ans: 2, 3, 5 8. A client receiving an enema reports cramping and discomfort when the nurse releases the clamp and places the container 12 inches above the client’s hip level. Which action will the nurse take next? 1. Instruct the client to take deep breaths. 2. Discontinue the enema. 3. Clamp the tubing. 4. Lower the enema bag below the level of the hips. Ans: 3 9. The nurse assesses clients waiting to be seen by the health care provider. Which client does the nurse identify to be seen first? 1. Client with myasthenia gravis reporting double vision and drooping of the right eye lid. 2. Client with a flat 9 mm induration area at the site of a tuberculin skin test placed 48 hours ago. 3. Client with a mean arterial pressure of 80 mm Hg. 4. Client with lung disease reporting dyspnea after walking up stairs. Ans: 2 10. A client experiences wide QRS complexes on telemetry, numbness of the feet, and tingling of both hands. Which medication will the nurse question before administering to this client? 1. Diltiazem. 2. Furosemide. 3. Spironolactone. 4. Metoprolol tartrate. Ans: 3 11. The nurse provides care for a client diagnosed with leukemia. The nurse notes the client has vomited a large amount of bloody emesis. Which action should the nurse take first? 1. Measure the vomitus before dumping it. 2. Assess the client’s last platelet count. 3. Notify the health care provider. 4. Complete a head to toe assessment. Ans: 3 12. The nurse is teaching a client who has undergone a cataract extraction with intraocular implant. Which instruction does the nurse include in the discharge teaching? (Select all that apply.) 1. Avoid activities that require bending over. 2. Place an eye shield on the surgical eye at bedtime. 3. Avoid lifting anything over 5 pounds. 4. Contact the surgeon if eye scratchiness occurs. 5. Take acetaminophen for minor eye discomfort. Ans: 1, 2, 3, 5 13. An infant diagnosed with pertussis is being discharged home with the parents. Which information will the nurse include in the parents’ teaching plan? (Select all that apply.) 1. Hand hygiene using an alcohol-based hand rub is effective against pertussis. 2. Family members and others in close contact with the infant should be vaccinated. 3. Airborne isolation precautions are required for 5 days after the start of antibiotic therapy. 4. Pertussis is most severe for the elderly. 5. Even if a person’s immunization status for pertussis is unknown, it is safe to immunize again. Ans: 1, 3, 5 14. The nurse reviews the care needs for assigned clients. Which client will the nurse assess first? 1. Client with ulcerative colitis who reports rectal bleeding. 2. Client with an acute kidney injury with a urine output of 100 mL over the past 6 hours. 3. Client with angina pectoris who reports a headache after receiving a dose of prescribed nitroglycerin. 4. Client with a radioactive implant for cervical cancer who is in the bathroom. Ans: 4 15. The nurse teaches a client how to self-administer nasal drops. Which statement is part of these instructions? 1. “Occlude one nostril prior to instilling the drops.” 2. “Store the medication vial in the refrigerator between doses.” 3. “Shake the medication vial for several minutes before opening.” 4. “Sit with the neck flexed backward for 5 minutes after instilling the drops.” Ans: 4 16. The nurse assists the code team treating a client with asystole. Cardiopulmonary resuscitation (CPR) is in process. Which direction by the code team leader requires the nurse to intervene? 1. “Push hard and push fast during compressions.” 2. “Give atropine 1 mg followed by an NS flush.” 3. “Give epinephrine 1 mg every 3 to 5 minutes.” 4. “Continue CPR for 2 minutes and then check rhythm.” Ans: 2 17. The nurse provides care to a 10-month-old infant. For which statement made by the parent will the nurse intervene? (Select all that apply.) 1. “My child has a two-word vocabulary.” 2. “My child gained 1 ounce this week.” 3. “My child cannot walk unless I hold under the arms.” 4. “My child cries and spreads the arms in and out when I bump the crib.” 5. “My child’s soft spot on top of the head is still open.” Ans: 2, 4 18. The charge nurse assigns several clients to a novice nurse who is fresh off unit orientation. Which client will the charge nurse assign the novice nurse to provide care during this shift? (Select all that apply.) 1. A client on airborne precautions for newly diagnosed tuberculosis (TB). 2. A client diagnosed with chronic obstructive pulmonary disease (COPD) discharging tomorrow. 3. A client diagnosed with acute pneumonia on a bilevel positive airway pressure (BiPAP) machine. 4. A client status postoperative for a vaginal hysterectomy done earlier in the day. 5. A toddler diagnosed with respiratory syncytial virus (RSV) admitted an hour ago. Ans: 2, 4 19. The nurse teaches a group of nursing students about cultural competency. Which strategy will the nurse include to improve the students' cultural competency? (Select all that apply.) 1. Participate in continuing education classes about culturally congruent care. 2. Develop culturally competent approaches to care. 3. Talk with clients about their cultural views of health. 4. Assess own skill level and seek improvement. 5. Realize that personal preferences can influence the client’s preferences. Ans: 1, 2, 3, 4 20. The nurse manager is concerned about increased instances of client confusion and disorientation in the intensive care unit (ICU). Which nursing intervention is most effective in resolving this issue? 1. Promote daytime periods of sleep. 2. Monitor noise levels during the night. 3. Prioritize and cluster care activities. 4. Turn off TVs and unnecessary lights. Ans: 2 21. The nurse provides care to a client with asthma. Which co-morbid condition does the nurse identify as a trigger for an acute asthma episode? 1. Psoriasis. 2. Cellulitis. 3. Rheumatoid arthritis. 4. Hiatal hernia. Ans: 4 22. The nurse manager creates a discharge teaching form for clients with acquired immunodeficiency syndrome (AIDS). Which statement will the manager include on this form? (Select all that apply.) 1. Avoid children who have just gotten a live vaccine. 2. A condom is necessary during sexual activity. 3. Contact sports, such as football, must be avoided. 4. Drug paraphernalia must not be shared with others. 5. Sexual activity must be restricted to a single partner. Ans: 1, 2, 4 23. The nurse provides pain management teaching to an older adult client diagnosed with osteoarthritis (OA). Which medication does the nurse discuss as the initial treatment of choice for OA pain? 1. Morphine. 2. Acetaminophen. 3. Ibuprofen. 4. Cyclobenzaprine. Ans: 2 24. The nurse prepares teaching materials to review chest physiotherapy with the parents of a pediatric client diagnosed with cystic fibrosis (CF). Which observation indicates to the nurse that additional teaching is needed? (Select all that apply.) 1. Blood pressure 110/68 mm Hg. 2. Pulse oximetry 88% on room air. 3. Respiratory rate 24 breaths/min. 4. Ecchymosis over the back and lateral chest. 5. Complaint of pain with deep inspiration. Ans: 2, 4, 5 25. The nurse receives a verbal prescription from a health care provider (HCP) during a client emergency. Which action does the nurse take to ensure client safety? (Select all that apply.) 1. Record the prescription in the client’s medical record. 2. Read back the prescription to verify the accuracy of the prescription. 3. Date and time the prescription that was issued during the emergency. 4. Record the HCPs prescriber number. 5. Document the nurse’s own name and title. Ans: 1, 2, 3 26. A client in the postanesthesia care unit (PACU) reports nausea to the nurse. Which medication will the nurse given intravenously for this client's problem? (Select all that apply.) 1. Hydroxyzine. 2. Promethazine. 3. Ondansetron. 4. Aluminum hydroxide. 5. Sucralfate. Ans: 1, 2, 3 27. After being notified that a client is seeking legal counsel about care received while hospitalized, the nurse manager investigates a staff nurse’s performance regarding the client’s care. Which nursing action will concern the nurse manager? (Select all that apply.) 1. The nurse mailed prescriptions to the client after discharge. 2. The nurse consulted the wound care nurse for the client’s area of skin breakdown. 3. The nurse found a referral for home care with laboratory results faxed after the client was discharge. 4. The nurse delegated sterile wound care to nursing assistive personnel (NAP). 5. The nurse administered an oral pain medication when an intramuscular dose was prescribed. Ans: 1, 3, 4, 5 28. The nurse provides care for an infant who has a fractured femur. Which statement regarding pain in an infant is accurate? (Select all that apply.) 1. Infants cannot feel pain. 2. Infants cannot express pain. 3. Infants have the same sensitivity to pain as older children. 4. Pain scales do not work well with infants. 5. Absorption of pain medication is faster in an infant than an adult. Ans: 3, 5 29. The nurse provides care for a client diagnosed with new onset atrial fibrillation. The client’s health care provider prescribes a transesophageal echocardiogram (TEE). What reason will the nurse give to the client as the primary reason for performing a TEE? 1. To measure the cardiac index. 2. To rule out thrombus in the heart. 3. To estimate the ejection fraction. 4. To observe ventricular wall motion. Ans: 2 30. The nurse provides care for a pediatric client suspected of having the respiratory syncytial virus (RSV). Which transmission-based precaution does the nurse initiate once influenza and adenovirus are ruled out for this client? 1. Airborne precautions. 2. Droplet precautions. 3. Reverse precautions. 4. Contact precautions. Ans: 4 31. The nurse develops a teaching plan for a client with hyperlipidemia. Which lifestyle change will the nurse include in the plan? (Select all that apply.) 1. Consume a diet low in saturated fat. 2. Engage in regular, high-intensity aerobic activity. 3. Stop tobacco use by any possible means. 4. Avoid exposure to second-hand smoke. 5. Consume a diet low in soluble fiber. Ans: 1, 3, 4 32. The nurse who is a practicing Muslim requests to wear a hijab while working. Which action will the nurse manager take next? 1. Decline the request. 2. Make the accommodation. 3. Advocate for modification of the organization’s dress code. 4. Review the organization’s dress code policy. Ans: 4 33. The nurse provides care for a client diagnosed with insomnia. Which intervention does the nurse include in the nursing care plan? 1. Encourage afternoon naps. 2. Provide dairy products 30 minutes before bedtime. 3. Advise the client to vary retire and awake times. 4. Limit naps to less than 60 minutes. Ans: 2 34. The nurse is proving care for several clients. Which client need will the nurse address first? 1. Client with a stroke needing a hand splint reapplied. snack. 2. Client with diabetes and a fasting blood glucose of 78 mg/dL requesting a 3. Client with diarrhea needing the bedside commode emptied. 4. Client with emphysema requesting assistance with ambulation. Ans: 4 35. The nurse provides care to a newly admitted client. At which time will the nurse conduct a medication reconciliation? (Select all that apply.) 1. At every clinic appointment. 2. At the pharmacy. 3. Upon discharge to home. 4. Upon entry into the unit. 5. Upon transfer to a skilled unit. Ans: 1, 3, 4, 5 36. The nurse provides care for a client experiencing a fever who also reports bone pain, redness, and swelling. The client asks the nurse which treatment will likely be prescribed by the health care provider (HCP). Which response from the nurse is the most accurate? 1. “Usually a few days of bed rest and antibiotics are needed.” 2. “You will need surgery and then antibiotics for a few weeks.” 3. “Antibiotics will be prescribed for several weeks, which you can take at home.” 4. “If the area improves with rest and warm compresses, you might just need pain medication.” Ans: 3 37. The nurse assesses a newborn. Which finding alerts the nurse that the newborn is at risk for hyperbilirubinemia? 1. Caput succedaneum. 2. Hyperglycemia. 3. Petechiae. 4. Cephalhematoma. Ans: 4 38. Which safety measure is appropriate for the nurse to use to prevent the development of a pressure injury when providing care to clients? (Select all that apply.) 1. Encourage dorsiflexion exercises of the foot. 2. Limit the client’s intake of caffeinated fluids. 3. Encourage the client to hold the breath and try to exhale when moving up in bed. 4. Use a turning or lift sheets or devices to turn or transfer clients. 5. Avoid a strong massage over bony prominences. Ans: 4, 5 39. A client sues the nurse and the hospital for malpractice. Which resource will the nurse refer to determine if the client’s suit is legitimate? 1. Medical record. 2. Standards of care. 3. American Nurses Association Code of Ethics. 4. The Joint Commission standards. Ans: 2 40. A client who takes alendronate asks the nurse when the medication can be stopped. Which response by the nurse is best? 1. “People usually have to take this medication for a few months.” 2. “Unfortunately, you will need to take this medication for the rest of your life.” 3. “After a few doses, the frequency and need to take this medication will be reevaluate” 4. “A scan will be repeated in 3 years, and if your bone mass stabilizes, it can be discontinued.” Ans: 4 41. The nurse provides care for a client admitted to the hospital for an ischemic cerebrovascular event. The nurse is scheduled to administer clopidogrel, aspirin, and dexamethasone to the client. Which action should the nurse take? (Select all that apply.) 1. Send a stool specimen to the hospital laboratory to test for occult blood. 2. Ask the client if there is any history of gastrointestinal bleeding or stomach ulcers. 3. Administer the medications and write a note documenting the nurse’s concern. 4. Hold the medications until the health care provider is expected to visit the client. 5. Notify the health care provider that the client is at risk for a medication interaction. Ans: 2, 5 42. While conducting an abdominal assessment the nurse palpates a small round mass above the client’s symphysis pubis. Which action will the nurse take first? 1. Auscultate the mass. 2. Ask the client to void. 3. Apply pressure to the mass. 4. Ask if the client is experiencing pain. Ans: 2 43. The nurse receives report on assigned clients. Which client will the nurse assess first? 1. Client who had a myocardial infarction 3 hours ago and is experiencing two to three premature ventricular contractions per minute. 2. Client who had a lumbar puncture 2 hours ago and is reporting a headache rated as an 8 on a pain rating scale of 0 to 10. 3. Client who had a permanent pacemaker inserted 12 hours ago and is reporting dizziness. 4. Client who had a total hip replacement 8 hours ago and is in a semi- Fowler position. Ans: 3 44. A nurse works to establish a nurse-client relationship with a client who is new to the mental health unit. Which task does the nurse perform during the introductory phase of the nurse-client relationship? (Select all that apply.) 1. Discuss confidentiality with the client. 2. Assist the client to explore feelings. 3. Clarify the client’s problem. 4. Summarize the client’s success. 5. Identify the tasks the client should accomplish. Ans: 1, 3, 5 45. The nurse provides care for a client who reports a lack of appetite, nausea, and passing a small amount of liquid stool throughout the day for several days. Which action does the nurse do next? 1. Administer prescribed medication for constipation. 2. Consult with the dietitian regarding client’s diet. 3. Perform a digital rectal exam. 4. Obtain a stool sample from the client. Ans: 3 46. While assessing an adolescent for a sore throat and fatigue, the nurse notes multiple wounds in different levels of healing on both of the client’s arms. Which action will the nurse take first? 1. Inquire as to how the wounds occurred. 2. Ask about a history of sexual abuse. 3. Assess the wounds for healing and signs of infection. 4. Report the findings to the nursing supervisor. Ans: 3 47. The nurse performs triage at a mass casualty incident. Which client will the nurse recommend receive treatment first? 1. Adolescent client with abdominal bleeding and confusion. 2. School-aged child with lacerations on the face and scalp. 3. Older adult client with a chest wound who is apneic. 4. Adult client with an open fracture of the humerus with present radial pulses. Ans: 1 48. A female client received 2 units of packed red blood cells (PRBCs) for gastrointestinal bleeding. Which finding indicates to the nurse that the client may need an additional transfusion? (Select all that apply.) 1. Pulse rate 115 beats/minute. 2. Blood pressure 82/40 mm Hg. 3. Hemoglobin 13 g/dL (130 g/dL). 4. Hematocrit 28%. 5. Red blood cell count 4 X 106 cells/µL (4.4 X 1012 cells/L). Ans: 1, 2, 4 49. The nurse notes the client’s electrocardiogram (ECG) rhythm is torsades de pointes. Which assessment does the nurse complete after a normal sinus rhythm is restored? 1. Monitor for ST segment depression. 2. Monitor for QT interval prolongation. 3. Monitor for PR interval prolongation. 4. Monitor for narrow QRS complexes. Ans: 2 50. The nurse manager reviews the importance of using best evidence when planning client care during a nursing staff meeting. Which nursing staff response indicates additional information is required regarding evidence-based practice? (Select all that apply.) 1. “I’m glad that standardized care plans are gone.” 2. “Care plans now will be customized and useful.” 3. “I always liked research and now we can do it with our clients.” 4. “A software program to help search for information will be helpful.” 5. “Now we know that interventions for care will work for our clients.” Ans: 1, 3 .................DOWNLOAD FOR FULL PAPER TO QUESTIONS 150............... [Show Less]
- Exam
- $17.45
- 0
- 392
FLORIDA UNIVERSITY PEDIATRICS NUR 416 CAT 2 KAPLAN 2 LATEST 2021/2022,100% CORRECT New
FLORIDA UNIVERSITY PEDIATRICS NUR 416 CAT 2 KAPLAN 2 LATEST 2021/2022
- Exam
- $17.45
- 0
- 330
FLORIDA UNIVERSITY PEDIATRICS NUR 416 CAT 1 KAPLAN 2 LATEST 2021/2022,100% CORRECT New
FLORIDA UNIVERSITY PEDIATRICS NUR 416 CAT 1 KAPLAN 2 LATEST 2021/2022 1. The nurse performs an assessment on a full-term newborn. Which finding does the n... [Show More] urse report to the health care provider? 1. The client's blood pressure of 70/44 mm Hg. 2. The umbilical cord is whitish gray in color. 3. Bowel sounds cannot be auscultated in the abdomen. 4. The big toe dorsiflexes when the side of the foot is stroked. Ans: 3 2. The nurse in an antepartum clinic has several phone messages from clients. Which client does the nurse call first? 1. The client who is 10 weeks pregnant and reports vomiting after dinner for the past 5 days. 2 days. 2. The client who is 18 weeks pregnant and reports a headache in the evening for the past 3. The client who is 32 weeks pregnant and reports that her feet are swollen in the morning. 4. The client who is 37 weeks pregnant and reports that her membranes have ruptured. Ans: 4 3. The nurse prepares a medication in a prefilled syringe and notes that the syringe does not have a label with the client's name. What action will the nurse take? 1. Notify the pharmacy. 2. Call the health care provider. 3. Label the syringe. 4. Administer the medication. Ans: 1 4. The nurse plans to teach a local community group about chronic obstructive pulmonary disease (COPD). Which information does the nurse include? (Select all that apply.) 1. Uncontrolled COPD can lead to cardiac disease. 2. Asthma in childhood leads to COPD later in life. 3. Cigarette smoking is the leading COPD risk factor. 4. More females are affected by COPD than males. 5. Co-existing illness may cause COPD exacerbation. Ans: 1, 3,5 5. The nurse notes that a client requires protective isolation. Which additional client will the nurse safely pair with the client in protective isolation? 1. Client with a urinary tract infection. 2. Client with a stage 3 sacral pressure ulcer. 3. Client with unstable diabetes mellitus. 4. Client recovering from surgery for a perforated bowel. Ans: 3 6. A client who is pregnant asks the nurse what an elevated serum alpha-fetoprotein (AFP) level indicates. Which information does the nurse provide to the mother? 1. Gestational diabetes. 2. A neural tube defects. 3. Trisomy 21 (Down syndrome). 4. Lack of lung maturity. Ans: 1 7. The nurse notes that a toddler-age client has burn marks in various stages of healing and is fearful of male health care professionals. Which action will the nurse take next? 1. Document the findings in the chart. 2. Talk to the nursing supervisor. 3. Ask the client what happened. 4. Discuss the findings with the health care provider. Ans: 1 8. The nurse mentors a nursing student. The student asks which organization requires all clients to be assessed for pain. Which response by the nurse is correct? 1. The National Council of State Boards of Nursing (NCSBN). 2. The American Nursing Association (ANA). 3. The Joint Commission. 4. The National League of Nursing (NLN). Ans: 3 9. The nurse provides care for several clients. Which task does the nurse delegate to the nursing assistive personnel (NAP)? (Select all that apply.) 1. Determine client’s pain level. 2. Perform walker use training. 3. Assist with meal trays. 4. Bathe a client with wounds. 5. Obtain routine vital signs. Ans: 3, 4, 5 10. A client receives an antibiotic every 8 hours. The antibiotic has an onset of action of 2 hours and a duration of action of 8 hours. The client is prescribed a peak blood level. If the medication is provided at 1000, at which time will the nurse schedule the peak level to be drawn? 1. 1100. 2. 1200. 3. 1400. 4. 1800. Ans: 3 11. The nurse provides care to a client at risk for hypercalcemia. Which action is most appropriate for the nurse to take? 1. Encourage strict bed rest. 2. Limit dietary fiber. 3. Encourage oral fluids. 4. Hold prescribed zoledronate. Ans: 3 12. The nurse provides care for several clients in Buck traction. Which client is at greatest risk for skin breakdown? 1. An elderly client with severe Alzheimer disease. 2. An elderly client with a history of atrial fibrillation. 3. An elderly client with chronic bronchitis. 4. An elderly client with diverticulosis. Ans: 1 13. The charge nurse reviews the medical records of several clients. Which documentation from a staff nurse requires the charge nurse to follow-up? 1. “Returned from radiology department following a chest X-ray. Requesting lunch but remains nothing by mouth until seen by the health care provider as prescribed.” 2. “Late – entry. Ambulated from bed to doorway without assistance. No shortness of breath or diaphoresis noted. Vital signs remained within baseline after ambulating.” 3. “Intravenous catheter site in left antecubital space is red and warm to touch. Intravenous solution infusing slowly. Catheter removed intact. New catheter placed in right forearm.” 4. “Found client sitting on floor. All four side rails were in upright position. Client reports no pain. No abrasions or bleeding noted. Health care provider notified. Incident report completed.” Ans: 4 14. The nurse delegates vital sign measurement to the nursing assistive personnel (NAP). Which statement provides the best information for the nurse to give when delegating this task? 1. “Please obtain blood pressure, heart rate, respiratory rate, temperature, and pulse oximetry. Let me know if anyone’s systolic blood pressure is <100 or >160, heart rate <60 or >100, respiratory rate <12 or >20, temperature >100.50F (40.60C), or pulse oximetry <95%." 2. “Please obtain blood pressure, heart rate, respiratory rate, temperature, and pulse oximetry. Report any readings outside the normal ranges." 3. “Please obtain blood pressure, heart rate, respiratory rate, temperature, pain rating, and pulse oximetry. Let me know if anyone’s systolic blood pressure is <100 or >160, heart rate <60 or >100, respiratory rate <12 or >20, temperature >100.50F (40.60C), pain level >5/10, or pulse oximetry <95%." 4. “Please obtain blood pressure, heart rate, respiratory rate, temperature, and pulse oximetry. Let me know if anyone’s blood pressure is <100 or >160, heart rate <50, respiratory rate <12, temperature >100.50F (45.60C), or pulse oximetry <93%." Ans: 1 15. A client takes a beta 2 afrenergic agonist. Which finding indicates to mthe nurse that the client is experiencing and adverse reaction? 1. Drowsiness 2. Dysphagia 3. Palpitation 4. Paresthesias Ans: 3 16. The nurse notes that a client's laboratory values are blood urea nitrogen (BUN) 55 mg/dL (19.64 mmol/L) and creatinine 3.5 mg/dL (309.4 µmol/L). For which acid-base imbalance will the nurse assess the client? 1. Respiratory acidosis. 2. Respiratory alkalosis. 3. Metabolic acidosis. 4. Metabolic alkalosis. Ans: 3 17. The nurse performs a nitrazine test on a client at 38 weeks' gestation. Which color change indicates that membranes have likely ruptured? 1. Yellow. 2. Olive-green. 3. Olive-yellow. 4. Blue green. Ans: 4 18. A client develops ventricular tachycardia (VT). Which action does the nurse take next when providing care to this client? 1. Auscultate breath sounds. 2. Check pulse for a full minute. 3. Establish responsiveness. 4. Start cardiac compressions. Ans: 3 19. The nurse notes that a client who follows Judaism has roast beef and whole milk on the dinner tray. Which action will the nurse take first? 1. Ask the nutrition department to replace the roast beef with pork. 2. Deliver the food tray to the client. 3. Ask the nutrition department for a new tray. 4. Replace the whole milk with skim milk. Ans: 3 20. The nurse provides care for a client with face, ear, and neck burns. Which is the best position for the client? 1. Prone with a small pillow under the head. 2. Supine with padding on the affected side. 3. Supine without pillows or padding. 4. Prone without extra padding around the head. Ans: 3 21. The nurse provides care for a client who requests testing for human immunodeficiency virus infection (HIV). Which intervention is most important for the nurse to perform before administering testing? 1. Discuss prevention practices to prevent the transmission of HIV to others. 2. Explain that all tests must be repeated twice to be valid. 3. Ask the client to identify all sexual partners. 4. Determine when the client thinks the exposure to HIV occurred. Ans: 4 22. The nurse provides care to a client diagnosed with a clostridium difficile (C. diff) infection. Which precaution will the nurse take? (Select all that apply.) 1. Wear a protective gown when entering the client’s room. 2. Put on a particulate respirator mask when administering medications to the client. 3. Wear gloves when feeding the client a meal. 4. Ask the client’s visitors to wear a surgical mask when in the client’s room. 5. Wear sterile gloves when removing the client’s wound dressing. Ans: 1, 3 23. The nurse provides care for a client diagnosed with type 2 diabetes. The health care provider has ordered exenatide for the client. When will the nurse administer this medication? 1. Twice a day within 1 hour before morning and evening meals. 2. Once a day before bedtime. 3. Twice a day within 2 hours before morning and evening meals. 4. Twice a day within 1 hour after morning and evening meals. Ans: 1 24. The nurse provides care for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which finding indicates that the treatment has been effective? 1. Serum osmolality is decreased. 2. Serum sodium is decreased. 3. Urinary output is increased. 4. Urine osmolality is increased. Ans: 3 25. The nurse provides care for four clients. Which client will benefit the most from a multidisciplinary conference? 1. A 3-month-old client with intussusception who is vomiting, has colicky abdominal pain, and is having jelly-like stools. 2. A 2-month-old client with respiratory syncytial virus (RSV), who is wheezing and has moderate subcostal retractions and copious nasal discharge. 3. A 3-day-old client with developmental dysplasia of the hip, who has unequal leg length, limited abduction of the left hip, and asymmetry of the gluteal folds. 4. A 2-day-old client with body tremors and hyperirritability, who has intermittent episodes of sneezing and whose mother abused substances while pregnant. Ans: 4 26. The nurse provides care to a client who is unconscious. Which form of medication will the nurse safely administer to this client? (Select all that apply.) 1. Topical cream. 2. Subcutaneous injection. 3. Oral liquid. 4. Rectal suppository. 5. Intravenous infusion. Ans: 1, 2, 4, 5 27. A client says, “I promise not to touch the intravenous catheter anymore because I don’t want to be slapped again.” Which action does the nurse take first? 1. Complete a neurological assessment. 2. Ask the nursing assistive personnel (NAP) if the client was slapped when providing care. 3. Ask the client where the slap occurred and under what conditions. 4. Document the client’s statement and report it to the nurse manager. Ans: 3 28. The nurse provides care for a client who reports waking up with heartburn every night. Which client statement requires the nurse to provide further education to the client? 1. “I eat 3 meals a day.” 2. “I do not eat 2 hours before going to bed.” 3. “I will work on losing weight.” 4. “I will elevate the head of my bed 6 to 12 inches.” Ans: 1 29. The nurse provides for a client who is being evaluated for possible thrombolytic therapy. Which lab value would cause the nurse the most concern? 1. Blood glucose of 160 mg/dL (8.88 mmol/L). 2. International normalized ratio (INR) of 1.2. 3. Platelets of 90,000/mm3 (90 X 109/L). 4. Hemoglobin of 9 g/dL (90 g/L). Ans: 3 30. The nurse provides care for a client diagnosed with cutaneous Kaposi sarcoma lesions. The nurse notes that the lesions are open and draining small amounts of serous fluid. Which personal protective equipment (PPE) does the nurse use when bathing and changing the linens for this client? 1. Gloves. 2. Gown and gloves. 3. Gown, gloves, and mask. 4. Gown and gloves to change the linens; gloves when bathing. Ans: 2 31. A client in her third trimester of pregnancy asks the nurse how to differentiate between true labor and false labor. Which is the best explanation by the nurse to describe false labor to the client? 1. The intensity, frequency, and duration of contractions do not change. 2. Discomfort begins in the back and radiates to the abdomen. 3. Contractions are accompanied by pink mucus from the vagina. 4. Progressive effacement and dilation of the cervix begin to occur. Ans: 1 32. The nurse provides an older client, who was recently widowed, with a list of activities available at a local library. For which nursing diagnosis is this action most appropriate? 1. Risk for loneliness. 2. Risk for ineffective coping. 3. Risk for complicated grieving. 4. Risk for situational low self-esteem. Ans: 1 33. The nurse provides care for a client that reports difficulty falling asleep several nights a week. The nurse reviews the client’s bedtime pattern. Which client statement requires an intervention by the nurse? 1. “I turn the TV off about an hour before bed and try to read.” 2. “I will go to bed when I am wide awake and relax in bed.” 3. “I will drink some herbal tea to help me wind down for the night.” 4. “I will limit my naps to 20 minutes a day.” Ans: 2 34. The nurse prepares a client for surgery. Which task is appropriate for the nurse to delegate to the nursing assistive personnel (NAP)? (Select all that apply.) 1. Performing a clean catch urinalysis. 2. Collecting vital signs. 3. Monitoring lung sounds. 4. Applying compression stockings. 5. Educating on incentive spirometer use. Ans: 1, 2, 4 35. The nurse is teaching the parent of a 2-year-old client on how to correctly administer ear drops. Which action by the parent indicates to the nurse a need for further education? 1. Pulls the pinna up and back. 2. Directs the drops along the side of the ear canal. 3. Removes the ear drops from the fridge 30 minutes before giving. 4. Keeps the child lying down for 5 to 10 minutes before administering drops in the other ear. Ans: 1 36. The nurse provides care to a client with severe hypothermia. Which assessment will the nurse perform first? 1. Determine presence of shivering. 2. Assess the skin for mottling. 3. Examine cardiac monitor for dysrhythmias. 4. Review laboratory values for a low calcium level. Ans: 3 37. A client with transient confusion coughs constantly while being fed by nursing assistive personnel (NAP). Which action will the nurse take first? 1. Auscultate breath sounds. 2. Offer the client sips of water. 3. Direct the NAP to stop feeding the client. 4. Assess the oral cavity for pocketing of food. Ans: 3 38. A client experiences a fever, headache, photophobia, and neck stiffness. Which transmission-based precaution will the nurse implement for this client? 1. Contact. 2. Airborne. 3. Droplet. 4. Standard. Ans: 3 39. An older client with Medicare insurance asks the nurse to explain the “donut hole” in prescription drug coverage. Which response by the nurse is best? 1. It is a $20 co-payment for all prescriptions. 2. It is a temporary limit on what the drug plan will pay for covered drugs. 3. There is 20% decrease in prescription payment after six prescriptions per year. 4. There is no prescription drug coverage after age 85. Ans: 2 40. The nurse provides care to a client diagnosed with asthma who suddenly develops wheezing. Which class of medications does the nurse give first? 1. Methylxanthines. 2. Corticosteroids. 3. ß2-adrenergic agonist. 4. Anticholinergics. Ans: 3 41. The nurse provides care for a client experiencing acute anxiety. It is most important for the nurse to assess the client for which acid-base imbalance? 1. Respiratory alkalosis. 2. Respiratory acidosis. 3. Metabolic alkalosis. 4. Metabolic acidosis. Ans: 1 42. The nurse assesses a newborn’s penis 2 days after a circumcision. The nurse notes a yellow exudate around the head of the penis. Which is the appropriate nursing intervention? 1. Wash the penis with soap and a warm washcloth. 2. Take the newborn’s temperature to determine if an infection is present. 3. Leave the area alone, as this is a normal finding. 4. Report the finding to the health care provider. Ans: 3 43. The nurse plans to delegate a task to a new nursing assistive personnel (NAP). The nurse discovers that the NAP has never performed the task and changes the assignment. Which right of delegation does the nurse follow in this scenario? 1. Right supervision. 2. Right person. 3. Right circumstance. 4. Right direction. Ans: 2 44. A client claims to feel ugly because of hair lost after receiving chemotherapy for breast cancer. Which statement does the nurse make to help the client cope with these feelings? 1. “Let’s see how you look with a scarf or hat.” 2. “Your hair will grow back after your treatments are over.” 3. “Many women choose to shave their head when this starts to happen.” 4. “Just think how much easier it will be to not have to do your hair every day.” Ans: 1 45. The nurse provides care for an unconscious client. The nurse finds a stage 2 pressure injury on the client’s elbow. Which statement indicates the best understanding of the client’s perception of pain? 1. There will be a behavioral response if pain is perceived. 2. The client is not able to perceive pain. 3. The area will be treated as a painful lesion, using gentle cleaning and dressing. 4. The client will be medicated with an opioid before a dressing change. Ans: 3 46. The nurse provides preoperative teaching for a client having surgery. Which type of anesthesia does the nurse explain as altering the level of consciousness? (Select all that apply.) 1. General anesthesia. 2. Regional anesthesia. 3. Local anesthesia. 4. Conscious sedation. 5. Topical anesthesia. Ans: 1, 4 47. While changing a client's bed linen, the nurse sustains a needlestick injury from a syringe left in the bed. After washing the injury with soap and water, which action does the nurse take next? 1. Send the needle to the laboratory for testing. 2. Interview the client about infection status. 3. File an incident report according to protocol. 4. Notify the nurse manager as soon as possible. Ans: 4 48. A nurse prepares to administer medication to a client. Which information should the nurse use as client identifiers? (Select all that apply.) 1. The client’s birth date. 2. The client’s room number. 3. The client’s provider’s name. 4. The client’s medical record number. 5. The client’s first and last name. Ans: 1, 4, 5 49. The nurse provides care for a client who sustained a burn injury. The nurse notes that the client has absent bowel sounds, abdominal distention, belching, mild nausea, and a reduced appetite. Which complication should the nurse suspect the client has developed? 1. Curling ulcer. 2. Paralytic ileus. 3. Large bowel obstruction. 4. Translocation of bacteria. Ans: 2 50. The nurse delegates care of a stable client to nursing assistive personnel (NAP). Which right of delegation is the nurse following? 1. Right supervision. 2. Right circumstance. 3. Right person. 4. Right direction/communication. Ans: 2 ..........DOWNLOAD FULL PAPER UPTO 150 QUESTIONS.......... [Show Less]
- Exam
- $17.45
- 0
- 200
Purchase the bundle to get the full access instantly
- 3 Million+ Study Documents
- 100% Money Back Guarantee
- Immediate Download Access
Add To Cart
Reviews 0
Bundle Details
$32.45
- Trusted by 800,000+ Students
- 24/7 Money Back Guarantee
- Download is directly available
168
0
Seller Details
