1. The nurse observes client care on a geriatric unit. The nurse should
intervene inwhich situation?
a. A student nurse assist the client out of bed
... [Show More] toward the clients strong
side.
b. A student nurse assist the client to sit on the side of the bed by lifting
the client’sshoulders and swinging the client’s legs over the edge of the
bed.
c. A student nurse assists the client to stand from a sitting position by
grasping theclient’s elbows.
d. Two student nurses use a draw sheet to turn a client in the bed.Answer:
C
2. The nurse evaluates the results of the client’s purified protein derivative
(PPD) 2 ½ days after the injection. The nurse noted the induration is 4 mm.
which action by the nurseis most appropriate? a. Inform the client the
results are negative
b. Obtain the names of the client’s closest contacts.
c. Determine the HIV status of the client.
d. Wait and additional 24 hours to read the
results.Answer: A
3. The nurse cores for the client with a history of schizophrenia. The nurse
expects tonote which speech pattern?
a.
b.
c.
d.
questions.Answer: A
Repetition of the words used by the nurse.
Rapid, coherent conversation about unrelated topics.
Immediately answering questions appropriately. Slow,
purposeful answers to the nurses
4. The nurse cares for a 6-month-old infant. The parents report that the
infant hadsevere diarrhea for twelve hours. The nurse anticipates
which finding? a. Normal skin elasticity.
b. Depresses anterior fontanel.
c. Pale yellow urine.
d. Absent bowel
sounds.Answer: B
5. The nurse cares for a client receiving hydrocodone every 6 hours prn for
pain. The client reports pain at 1600. The nurse notes that the hydrocodone
was last administered at1200, and the nurse proceeds to administer
hydromorphone at 1615. After discovering theerror, how should the nurse
record the occurrence?
a. “Wrong pain tablet given early. Client will be monitored closely. Asleep
now.”
b. “Hydromorphone given instead of hydrocodone. Nursing supervisor
aware of error.”
c. Hydrocodone tablet ordered every 6 hours; pain medication given after
4 hours.Health care provider notified.”
d. “Hydromorphone given at 1615; health care provider notified. B/P
122/80, RR 16.”Answer: D
6. The male client asks the nurse, “Why am I experiencing erectile
dysfunction (ED)?”The nurse reviews the client’s medications. The nurse
recognizes that which classification increases the risk for ED? a. Non-
steroidal anti-inflammatory drugs.
b. Antihypertensive medications.
c. Anticoagulant medications.
d. Histamine H2
inhibitors.Answer: B [Show Less]