. A nurse is providing teaching about the gastrostomy tube feedings to the parents of a school age child.
Which of the following instructions should the
... [Show More] nurse take?
A. Administer the feeding over 30 min.
B. Place the child in as supine position after the feeding.
C. Charge the feeding bag and tubing every 3 days.
D. Warm the formula in the microwave prior to administration.
2. A nurse is administering digoxin 0.125 mg Po to an adult client. For which of the following findings should
the nurse report to the provider? A. Potassium level 4.2 mEq/L. B. Apical pulse 58/min.
C. Digoxin level 1 ng/ml.
D. Constipation for 2 days.
3. A nurse is caring for a client who is comatose and has advance directives that indicate the client does not
want life-sustaining measures. The client’s family want the client to have life-sustaining measures. Which of
the following action should the nurse take?
A. Arrange for an ethics committee meeting to address the family’s concerns.
B. Support the family’s decision and initiate life-sustaining measures.
C. Complete an incident report.
D. Encourage the family to contact an attorney.
4. A nurse is caring for a client who wears glasses. Which of the following actions should the nurse take? A.
Store the glasses in a labeled case.
B. Clean the glasses with hot water.
C. Clean the glasses with a paper towel.
D. Store the glasses on the bedside table.
5. A nurse is teaching a group of newly licensed nurses about measures to take when caring for a client who is
on contact precautions. Which of the following should the nurse include in the teaching?
A. Remove the protective gown after the client’s room.
lOMoARcPSD|6529866
B. Place the client in a room with negative pressure.
C. Wear gloves when providing care to the client.
D. Wear a mask when changing the linens in the client’s room.
6.A nurse is planning on care for a client who is recovering from an acute myocardial infarction that occurred
3 days ago. Which of the following instructions should the nurse include? A. Perform an ECG every 12 hr. B.
Place the client in a supine position while resting.
C. Draw a troponin level every 4hr.
D. Obtain a cardiac rehabilitation consultation.
7. The nurse is reviewing the medical record of a client who is requesting combination oral contraceptives.
Which of the following conditions in the client’s history is a contradiction to the use of oral contraceptives? A.
Hyperthyroidism.
B. Thrombophlebitis.
C. Diverticulosis.
Hypocalcemia.
8 A nurse is caring for a client who request the creation of a living will. Which of the following actions should
the nurse take?
A. Schedule a meeting between the hospital ethics committee and the client.
B. Evaluate the client’s understanding of life-sustaining measures.
C. Determine the client’s preferences about post mortem care.
D. Request a conference with the client’s family.
9.A nurse is caring for an adolescent who has sickle-cell anemia. Which of the following manifestations
indicates acute chest syndrome and should be immediately reported to the provider? A. Substernal retractions.
B. Hematuria.
C. Temperature 37.9 C (100.2 F).
D.
lOMoARcPSD|6529866
D. Sneezing.
10.A nurse is preforming a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the
.following action should the nurse take?
A. Instill 500 ml of solution through the NG tube.
B. Insert a large-bore NG tube.
C. Use a cold irrigation solution.
D. Instruct the client to lie on his right side.
11. A nurse is providing care for a client who is in the advance stage of amyotrophic lateral sclerosis. (ALS).
Which of the following referrals is the nurse’s priority?
A. Psychologist.
B. Social worker.
C. Occupational therapist.
D. Speech-language pathologist.
12.A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis. Which of the
following findings should the nurse report to the provider? A. WBC count 8,000/mm3. B. Platelets
150,000/mm3.
C. Aspartate aminotransferase 10 units/L.
D. Erythrocyte sedimentation rate 75 mm/hr
13. A nurse is caring for a client who has generalized petechiae and ecchymoses. The nurse should expect
a prescription for which of the following laboratory tests? A. Platelet count. B. Potassium level.
C. Creatine clearance.
D. Prealbumin.
lOMoARcPSD|6529866
14. A nurse is caring for a client following application of a cast. Which of the following actions should the nurse
take first?
A. Place an ice pack over the cast.
B. Palpate the pulse distal to the cast.
C. Teach the client to keep the cast clean and dry.
D. Position the casted extremity on a pillow.
15. A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take?
(Select all that apply)
A. Keep objects in the client’s room in the same place.
B. Ensure there is high-wattage lighting in the client’s room.
C. Approach the client from the side.
D. Allow extra time for the client to perform tasks.
E. Touch the client gently to announce presence.
16. A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has questions about the
disease. To research the nurse should identify that which of the following electronic database has the most
comprehensive collection of nursing (Unable to read) articles?
A. MEDLINE
B. CINAHL.
C. ProQuest.
D. Health Source.
17. A nurse in an emergency department is assessing newly admitted client who is experiencing drooling and
hoarseness following a burn injury. Which of the following should actions should the nurse take first? A.
Obtain a baseline ECG.
B. Obtain a blood specimen for ABG analysis.
C. Insert an 18-gauge IV catheter.
D. Administer 100% humidified oxygen.
Downloaded by Shanise Wise ([email protected])
lOMoARcPSD|6529866
22. A nurse is caring for a client who is in labor and requires augmentation of labor. Which of the following
conditions should the nurse recognize as a contraindication to the use of oxytocin.
A. Diabetes mellitus.
B. Shoulder presentation.
C. Postterm with oligohydramnios. (I think Maternal Newborn Chapter 15 page 100)
D.Chorioamnionitis
23. A nurse is assessing a client who has left-sided heart failure. Which of the following should the nurse
identify as a manifestation of pulmonary congestion? A. Frothy, pink sputum.
D. Jugular vein distention.
E. Weight gain.
D.Bradypnea
24. A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription
for paternal fluid therapy. The guardian asks. “What are the indications that my baby needs an IV?” Which of
the following responses should the nurse make?
A. “Your baby needs an IV because she is not producing any tears”
B. “Your baby needs an IV because her fontanels are budging”
C. “Your baby needs an IV because she is breathing slower than normal”
D. “Your baby needs an IV because her heart rate is decreasing”
25. A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which
of the following statements should the nurse make?
A. “Taking furosemide can cause your potassium levels to be high”
B. “Eat foods that are high in sodium”
C. “Rise slowly when getting out of bed”
D. “Taking furosemide can cause you to be overhydrated”
Downloaded by Shanise Wise ([email protected])
lOMoARcPSD|6529866
26. A nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder. Which
of the following interventions should the nurse take? A. Allow the client enough time to perform rituals. B.
Give the client autonomy in scheduling activities.
C. Discourage the client from exploring irrational fears.
D. Provide negative reinforcement for ritualistic behaviors.
27. A nurse is caring for a client who has depression and reports taking ST. John’s wort along with citalopram.
The nurse should monitor the client for which of the following conditions as a result of an interaction between
these substances?
A. Serotonin syndrome
B. Tardive dyskinesia C.
Pseudo parkinsonism.
D. Acute dystonia.
28. A nurse is assessing a client who is receiving packed RBCs. Which of the following findings indicate fluid
overload?
A. Low back pain.
B. Dyspnea.
C. Hypotension.
D. Thready pulse.
29. A nurse is calculating a client’s expected date of delivery. The client’s last menstrual period began on
April
. Using Nagele’s rule, what date should the nurse determine to be the client’s expected delivery date? (Use
mmdd format.)
0119 date
30. A nurse is discussing group treatment and therapy with a client. The nurse should include which of the
following as being a characteristic of a therapeutic group? A. The group is organized in an autocratic
structure. [Show Less]