1) A nurse is suctioning the airway of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following findings should
... [Show More] the nurse identify as an indication that the suctioning has been effective?
• Presence of a productive cough
• Decrease peak inspiratory pressure
• Flattening of the artificial airway cuff
• Thinning of mucus secretions
2) A nurse is caring for a client who is in a seclusion room following violent behavior. The client continues to display aggressive behavior. Which of the following actions should the nurse take?
• Speak assertively to the client
• Express sympathy for the client's situation
• Confront the client about this behavior
• Stand within 30 cm of the client when speaking with them
3) A nurse is caring for a client who is immediately postoperative following an adrenalectomy to treat Cushing's disease. Which of the following actions is the nurse's priority?
• Monitor the client’s fluid and electrolyte status
• Observe for any indications of infection
• Reposition a client for comfort every 2 hours
• Document amount and color of the incision and drainage
4) A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first?
• Notify the provider
• Report the incident to the nurse manager
• Monitor vital signs
• Fill out an incident report
5) A nurse is caring for a client who is scheduled for a surgical procedure and states I don't want to have the surgery anymore. Which of the following responses should the nurse make?
• You have the right to refuse the procedure
• Your doctor thinks the surgery is necessary
• Let me review the procedure so you can understand what is going to happen
• We can manage your care following the procedure without complications ‘
6) A nurse is evaluating a client who has borderline personality disorder. Which of the following behaviors indicates an improvement in the client's condition?
• Decreased clinging behavior
• Impulsive behaviors
• Lability of mood
• Dependent behavior
7) A nurse is teaching a group of school-age children about healthy snack options. Which of the following snacks should the nurse include?
• Air popped popcorn
• Baked potato chips
• Milkshake made with whole milk
• Cheesecake
8) A nurse is caring for a client who wears glasses. Which of the following actions should the nurse take?
• Store the glasses in a labeled case
• Clean the glasses with hot water
• Clean the glasses with a paper towel
• Store the glasses on the bedside table.
9) A nurse is caring for a client who has fibromyalgia and requested pain medication. Which of the following medications should the nurse plan to administer?
• Pregabalin (Lyrica) - Nerve Pain Med
• Lorazepam
• Colchicine
• Codeine
10) A nurse is caring for a client who has congestive heart failure and is receiving furosemide and digoxin. Which of the following laboratory values indicates that the client is at risk for developing digoxin toxicity?
• Potassium 3.1
• Glucose 150
• Magnesium 1.3 (Magnesium is 1.7 to 2.2)
• Sodium 134
11) A nurse is caring for a client who has an embolic stroke and has a new prescription for alteplase. Which of the following in the client's history should the nurse identify as a contraindication to receiving alteplase?
• Hip arthroplasty one week ago
• Acute kidney failure 6 months ago
• Obstructive lung disease
• Retinal detachment
12) A nurse is providing discharge teaching for a client who has a new implantable cardioverter-defibrillator ICD. Which of the following client statements demonstrates understanding of the teaching?
• I will wear loose clothing over my ICD
• I can hold my cell phone on the same side of my body as ICD
• I will avoid using my microwave oven at home because of the ICD
• I will soak in the tub rather than showering
13) A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 ml an hour. Which of the following interventions should the nurse anticipate?
• Obtain a urine specimen for culture and sensitivity
• Initiate continuous bladder irrigation
• Administer a fluid bolus
• Clamp the catheter tubing for 30 minutes
14) A nurse is caring for a client who has experienced a stillbirth. Which of the following actions should the nurse take during the initial grieving process?
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• Avoid talking to the client about the newborn
• Discourage the client from allowing friends to see the newborn
• Assured a client that she can have additional children
15) A nurse is caring for a client who has a major burn injury. Which of the following actions is the nurse's priority to prevent wound infection?
• Maintain consistent hand washing by the staff
• Place a client in protective isolation
• Use sterile dressing for wound care
• Apply topical antibiotics to the client's wounds
16) A nurse is planning care for a client who sustained a major burn over 20% of the body. Which of the following interventions should the nurse include is important to support the client’s nutritional requirements?
• Schedule meals at 6 hr
• Keep a calories amount for foods and beverages
• Provide low-protein, high carbohydrates diet
• Maintain the calories intake as 1,500 per day
17) A nurse is speaking with a caregiver of a client who has Alzheimer's disease. The caregiver states, providing consistent care is very stressful and is affecting all areas of my life. Which of the following actions should the nurse take?
• Assist the caregiver to arrange for daycare program for the client
• Recommend allowing the client to have time alone in their room throughout the day
• Discuss methods of how to communicate with the client about resolving problem behaviors
• Suggest that the caregiver seek a prescription for an antipsychotic medication for the client
18) A nurse is caring for a client who is one hour postpartum and is unable to urinate. Which of the following actions should the nurse take?
• Place the clients hands in warm water
• Administer a benzodiazepine
• Performing a fundal massage
• Place an ice pack on a client's perineum
19) A nurse in a medical-surgical unit is performing medication reconciliation for a newly admitted client. Which of the following actions should the nurse take?
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20) A nurse is preparing to administer betamethasone to a client who is at 25 weeks of gestation and has preterm labor. Which of the following findings should the nurse identify as an adverse effect of this medication?
• Hyperglycemia [Show Less]