A nurse is caring for a client who has a new RX for antihypertensive medication. Prior to
administering the medication, the nurse uses an electronic
... [Show More] database to gather information about
the medication and the effects it might have on this client. Which of the following components of
critical thinking is the nurse using when he reviews the medication information?
A) Knowledge
B) Experience
C) Intuition
D) Competence - CORRECT ANSWER A) Knowledge
A client who has an indwelling catheter reports a need to urinate. Which of the following actions
should the nurse take?
A) Check to see whether the catheter is patent.
B) Reassure the client that it is not possible for her to urinate.
C) Recatheterize the bladder with a larger-gauge catheter.
D) Collect a urine specimen for analysis - CORRECT ANSWER A) Check to see whether the
catheter is patent.
A nurse is caring for a client who has a RX for a 24-hr urine collection. Which of the following
actions should the nurse take?
A) Discard the first voiding
B) Keep the urine in a singe container at room temp
C) Ask the client to urinate and pour the urine into a specimen container
D) Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen
container. - CORRECT ANSWER A) Discard the first voiding
A newly licensed nurse is reporting to the charge nurse about the care she gave to a client. She
states, "The client said his leg pain was back, so I checked his medical record, and he last
received his pain med 6 hr ago. The prescription reads every 4 hours PRN for pain, so I decided
he needs it. I asked the unit nurse to observe me preparing and administering it. I checked with
the client 40 minutes later, and he said his pain is going away." The charge nurse should inform
the newly licensed nurse that she left out which of the following steps of the nursing process?
A. Assessment
B. Planning
C. Intervention
D. Evaluation - CORRECT ANSWER A. Assessment
A nurse is contributing to the plan of care for a client who is being admitted to the facility with a
suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of
care? (SATA)
A. Place the client in a room that has negative air pressure of at least six exchanges per hour.
B. Wear a mask when providing care within 3 ft of the client.
C. Place a surgical mask on the client if transportation to another department is unavoidable.
D. Use sterile gloves when handling soiled linens.
E. Wear a gown when performing care that may result in contamination from secretions. -
CORRECT ANSWER B. Wear a mask when providing care within 3 ft of the client.
C. Place a surgical mask on the client if transportation to another department is unavoidable
E. Wear a gown when performing care that may result in contamination from secretions.
A nurse is caring for a client who had an amphetamine overdose and has sensory overload.
Which of the following interventions should the nurse implement?
A. Immediately complete a thorough assessment
B. Put the client in a room with a client who has hearing loss
C. Provide a quiet room and limit stimulation
D. Speak at a higher volume to the client and encourage ambulation. - CORRECT ANSWER C.
Provide a quiet room and limit stimulation
A nurse is caring for a client who reports difficulty hearing. Which of the following assessment
findings indicate a sensorineural hearing loss in the left ear? (SATA)
A. Weber test showing lateralization to the right ear
B. Light reflex at 10 o'clock in the left ear
C. Indications of obstruction in the left ear canal
D. Rinne test showing less time for air and bone conduction
E. Rinne test showing air conduction less than bone conduction in the left ear - CORRECT
ANSWER A. Weber test showing lateralization to the right ear
D. Rinne test showing less time for air and bone conduction
A nurse is caring for a client who has several risk factors for hearing loss. Which of the
following medications, that the client currently takes, should alert the nurse to a further risk for
ototoxicity? (SATA)
A. Furosemide
B. Ibuprofen
C. Cimetidine
D. Simvastatin
E. Amiodarone - CORRECT ANSWER A. Furosemide
B. Ibuprofen
A nurse is reviewing instructions with a client who has a hearing loss and has just started
wearing hearing aids. Which of the following statements should the nurse identify as an
indication that the client understands the instructions?
A. "I use a damp cloth to clean the outside part of my hearing aids."
B. "I clean the ear molds of my hearing aids with rubbing alcohol."
C. "I keep the volume of my hearing aids turned up so I can hear better."
D. "I take the batteries out of my hearing aids when I take them off at night." - CORRECT
ANSWER D. "I take the batteries out of my hearing aids when I take them off at night."
A nurse is caring for an adolescent who client who is 2 days post-op following an appendectomy
and has type I DM. The client is tolerating a regular diet. He has ambulated successfully around
the unit with assistance. He requests pain medication every 6 to 8 hr while reporting pain at a 2
on a scale of 0 to 10 after receiving the medication. His incision is approximated and free of
redness, with scant serous drainage on the dressing. The nurse should recognize that the client
has which of the following risk factors for impaired wound healing? (SATA)
A. Extremes in age
B. Impaired circulation
C. Impaired/suppressed immune system
D. Malnutrition
E. Poor wound care - CORRECT ANSWER B. Impaired circulation
C. Impaired/suppressed immune system
A nurse is collecting data from a client who is 5 days post-op following abdominal surgery. The
surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the
nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of
the following findings should the nurse expect? (SATA)
A. Increase in incisional pain
B. Fever and chills
C. Reddened wound edges
D. Increase in serosanguineous drainage
E. Decrease in thirst - CORRECT ANSWER A. Increase in incisional pain
B. Fever and chills
C. Reddened wound edges
A nurse educator is reviewing the wound healing process with a group of nurses. The nurse
educator should include in the information which of the following alterations for wound healing
by secondary intention? (SATA)
A. Stage III pressure ulcer
B. Sutured surgical incision
C. Casted bone fracture
D. Laceration sealed with adhesive
E. Open burn area - CORRECT ANSWER A. Stage III pressure ulcer
E. Open burn area
A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in
his surgical incision. The nurse checks the surgical wound and finds it separated with viscera
protruding. Which of the following actions should the nurse take? (SATA)
A. Cover the area with saline-soaked sterile dressings.
B. Apply an abdominal binder snugly around the abdomen.
C. Use sterile gauze to apply gentle pressure to the exposed tissues.
D. Position the client supine with his hips and knees bent.
E. Offer the client a warm beverage, such as herbal tea. - CORRECT ANSWER A. Cover the
area with saline-soaked sterile dressings.
D. Position the client supine with his hips and knees bent.
A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of
the following interventions should the nurse use to help maintain the integrity of the clients skin?
(SATA)
A. Keep the head of the bed elevated 30 degrees.
B. Massage the client's bony prominences frequently.
C. Apply cornstarch liberally to the skin after bathing.
D. Have the client sit on a gel cushion when in a chair.
E. Reposition the client at least every 3 hr while in bed. - CORRECT ANSWER A. Keep the
head of the bed elevated 30 degrees.
D. Have the client sit on a gel cushion when in a chair [Show Less]