1. A nurse is caring for a client who have a lower extremity fracture and a
prescription for crutches. Which of the following client statements indicate
... [Show More] that client is
adapting to the role of change?
-I will need my partner to take over shopping for groceries
2. A nurse is assessing a client who has a new diagnosis of colon cancer. Which of
the following findings should the nurse expect?
a) hematochezia (I think this is the answer (defined as bright red blood in the stool, the
colon or rectum)
b) weight gain
C) elevated hemoglobin (incorrect either because it should be decreased)
D) Steatorrhea don’t choose this answer it was wrong…
3. A nurse is caring for a client who is receiving TPN. The prime infusion is almost
complete and the new solution is not available. Which of the following actions should the
nurse take?
Infuse dextrose 10% in water
4. A nurse is reviewing a cardiac rhythm strip of a client who has atrial flutter.
Which of the following findings should the nurse expect?
A saw tooth pattern
5. A nurse is caring for a client admitted with a skull fracture. Which of the
following assessment findings should be the greatest concern to the nurse?
Glasgow coma scale score changes from 14 to 9
6. A nurse is completing an assessment of an older adult client and notes redness
areas over the bony prominences, but the client’s skin is intact. Which of the following
interventions should the nurse include in the plan of care?
Support bony prominences with pillows
7. A nurse is caring for a client who is receiving a blood transfusion. The nurse
observes the client had bounding peripheral pulses, hypertension, and distended jugular
vein. The nurse should anticipate administering which of the following prescribed
medications?
Furosemide
8. A nurse is caring for a patient who has a sealed radiation implant. Which
of the following actions should the nurse take?
Limit family member visits to 30 mins/day
9. A nurse is providing discharge teaching for a client who is receiving treatment
for genital herpes. Which of the following statements by the client indicates
effectiveness of the teaching?
I should expect my lesions to heal in 6 weeks
10. A nurse is caring for a client who has a traumatic brain injury. The client,
who has been quiet and cooperative, becomes agitated and restless. Which of the
following assessments should the nurse perform first?
A. Blood glucose
B. Blood pressure
C. Urinary output
D. Motor responses *wrong answer*
11. A nurse is reviewing the medical record of a client who is to undergo open heart
surgery. Which of the following findings should the nurse report to the provider as a
contraindication for receiving heparin?
Thrombocytopenia
12.A charge nurse receives a call from the house supervisor requesting room assignments for
four new clients. Based on the admission diagnoses, which of the following clients
requires a private room?
A client who reports having fever, night sweats, and cough for 2 days
13. A nurse is planning to teach a client whose provider has prescribed a low purine
diet. The nurse should plan to instruct the client that he can include which of the
following foods in his diet. SATA
-sardines -apricots -nuts -liver -scallops
14. A nurse is assessing a client following the insertion of a central venous
catheter. Which of the following findings indicates a pneumothorax?
Diminished breath sounds
15. A nurse is caring for a client who has pancreatitis and has been receiving total
parenteral nutrition. Which of the following laboratory tests should the nurse monitor
for overall nutritional status?
Prealbumin
16. A nurse is caring for a client in diabetic ketoacidosis. Which of the following is the
priority intervention by the nurse?
Check potassium levels
17. A nurse is preparing to administer furosemide to a client who has acute heart
failure. Which of the following laboratory results should the nurse identify as a
contraindication for receiving the medication?
Potassium 3.2
18. A nurse in the emergency department is preparing a client for emergency surgery. The
client’s alcohol level is 180. Which of the following action is the nurse priority?
Insert an NG Tube
19. A nurse is caring for a client who has bladder cancer and a WBC of 900.
Which of the following action should the nurse take?
Use Contact isolation while providing care
20.AA nurse is teaching a client who has asthma about the use of a peak flow meter. After
setting the meter to the zero baseline, what is the sequence of steps the nurse should
instruct the client to take? (Use all steps) *this is the correct steps… I found the correct
sequence. *
1. “Stand upright.”1
b. “Fill your lungs with a deep breath.”3
c. “Seal your lips around the mouthpiece.”2
d. “Exhale forcefully and quickly.”4
e. “Record the highest of three consecutive readings.”5
21. A nurse is preparing to perform ocular irrigation for a client following a chemical
splash to the eye. Which of the following actions should the nurse plan to take?
A. Collect information about the irritant that caused injury
B. Administer proparacaine eyedrop into the infected eye
C. Place a strip of ph paper onto the colder sac of the infected eye
D. Instill 0.9% sodium chloride into the affected eye *do not choose this*
22. A nurse is providing instructions about foot care for a client who has
peripheral arterial disease. The nurse should identify that which of the following
statements by the client indicates an understanding of the teaching?
I rest in my recliner with my feet elevated for about an hour every afternoon
23. A nurse is caring for older client with dementia, which of the following finding
questions should the nurse ask to assess the clients abstract thinking?
A. Can you tell me the state where you were born?
B. Can you count backwards?
C. what does the phrase “---- ” mean
D. ?? didn’t give the answer choice
24. A nurse is caring for a client who is scheduled for an abdominal paracentesis. The nurse
should plan to take which of the following actions?
Ask client to empty his bladder prior to the procedure
25. A nurse is caring for a client who has hypotension, cool and clammy skin,
tachycardia, and tachypnea. In which of the following positions should the nurse place
the client?
a. Reverse Trendelenburg *do not choose this. Got it wrong*
b. Side Lying
c. High Fowlers
d. Feet elevated *I think this correct. Patient is in cardiogenic shock. Feet
should be elevated above the heart… [Show Less]