NURSING NUR34653kaplan CAT 3 KAPLAN (3)
1. The nurse auscultates crackles throughout all lung fields and measures a heart rate of 132 bpm, a
respiratory ... [Show More] 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.
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.
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 is an acceptable pain level.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.) [Show Less]
