1. A Nurse is contributing to the plan care of a care to promote a restful night’s sleep for a client who has Alzheimer’s disease. Which of the
... [Show More] following interventions should the nurse include in the plan?
Encourage stimulating activities after dinner Encourage a late afternoon nap
Offer a small snack at bedtime Offer hot chocolate at bedtime
2. A nurse if reinforcing teaching with a client who has chronic kidney disease about disease management. Which of the following statements by the client indicates an understanding of the teaching?
I will add a banana to my morning cereal
I will decrease my intake of carbohydrates I will limit my daily intake of protein
I will season my food with a salt substitute
3. A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following findings should the nurse report to the provider?
Absent gag reflex Blood tinged mucus
Diminished breath sounds Oxygen saturation 95%
4. A nurse is caring for a client who begins to have a seizure while ambulating in the hall. Identify the sequence of actions the nurse should follow. (Move the steps the nurse should take into the box on the right placing them in order of performance. Use all the steps.
Lower the client to the floor
Place a pad beneath the client’s head Loose the clothing around the client’s neck Time the length of the client’s seizure Reorient and reassure the client
5. A nurse is reinforcing teaching with a client who has a new diagnosis of genital herpers. Which of the following information should the nurse include in the teaching?
Use condoms when lesions are present
Look for lesions that have a wart-like appearance The virus can be transmitted without lesions present
The lesion resolves in 2 weeks and usually do not recur
6. A nurse is planning care for a group of clients after receiving change-of-shift report. Which of the following clients should the nurse plan to see first?
A client who had a colectomy 2 days ago and has a nasogastric tube Jackson-Pratt drain and indwelling urinary catheter.
A client who is dehydrated has mental confusion and was found getting out of bed several times during the night.
A client who had a right lower lobe lobectomy 4 days ago and has a chest tube set to continuous suction. A client who has pneumonia and an oral temperature of 38.7°C (101.7°F)
7. A nurse is caring for a client who is receiving a continuous tube feeding of 60 mL/hr at 1.2 cal/mL. How many calories will the client receive in 12 hrs? (Round the answer to the nearest whole number)
8. A nurse is caring for a client who is in Buck's traction for a fractured hip. The client reports increased pain at the site of the fracture. Which of the following actions should the nurse take?
Massage the area Remove the weights Loosen the ropes Reposition the client
9. A nurse is reinforcing teaching with a client who is taking levothyroxine. Which of the following statements by the client indicates an understanding of the teaching?
I will need to take the medication until my thyroid function returns to normal The medication should be taken before I eat breakfast every morning
The medication might lower my blood sugar
I will take the medication with an antacid if it gives me heartburn
10. A nurse is delegating the task of repositioning a client who is in skeletal traction to an assistive personnel (AP). Which of the following instructions should the nurse give the AP?
Allow the weights to hang freely Release the tension of the ropes
Remove the weights when rewrapping bandages
Manually lift the weights when moving the client up in bed
11. A nurse is reinforcing teaching about pursed-lip breathing with a client who has a new diagnosis of COPD. The nurse should identify which of the following client statements indicates an understanding of the teaching?
I should perform pursed-lip breathing exercises before going to be When I’m fatigued, I should inhale slowly through pursed-lips Pursed-lip breathing works best for activities like walking up stairs
I will exhale through my nose after breathing in through pursed-lips
12. A nurse is admitting a client who is suspected of having active tuberculosis (TB). Which of the following actions should the nurse take first?
Administer anti-tuberculosis medication Institute airborne precautions
Obtain sputum cultures Auscultate breath sounds
13. A nurse is preparing a client for a cardiac catheterization. Which of the following actions should the nurse take first?
Verify the client has given informed consent Administer preoperative medication
Make the location of the pedal pulses Have the client void
14. A nurse is assisting in the plan of care for a client who had a recent left hemispheric stroke. Which of the following actions should the nurse include in the plan?
Observe for impulsive behavior Approach the client from the right side
Use simple verbal cues when directing tasks
Place the client in low-fowler’s position during meals
15. A nurse is assisting with an educational program for clients who have been newly diagnosed with diabetes mellitus. Which of the following instructions should the nurse include in the program regarding insulin?
Store unopened insulin vials in the freezer for up to 1 month Opened insulin can be stored on a cool countertop away from light Roll discolored insulin gently to mix before use
Use refrigerated insulin immediately after removing it from the refrigerator
16. A nurse is caring for a client who reports shortness of breath and has an oxygen saturation of 90%. Which of the following actions should the nurse take?
Prepare for intubation of the client Administer opioid medication Administer oxygen via nasal cannula Place the client in low-fowler’s position
17. A nurse is preparing to insert a double-lumen gastric (Salem) sump tube for a client who has peptic ulcer disease and has developed gastrointestinal bleeding. Which of the following images indicates the tube that the nurse should select?
18. A nurse is contributing to the plan of care for a client who has pericarditis. In which of the following positions should the nurse plan to place the client to decrease pain?
Semi Fowler’s
Supine with lower extremities elevated Upright leaning forward
Side-lying with knees bent
19. A nurse is reviewing the medication record of a client who is taking digoxin. Which of the following medications should the nurse identify as increasing the risk for the client to develop digoxin toxicity?
Potassium Chloride Famotidine Levothyroxine Furosemide
20. A nurse is reinforcing a teaching to a client about preventing osteoporosis. Which of the following client statements indicates an understanding of the teaching?
I will eat more bananas
I will walk for 20 minutes 3 days a week I will limit my coffee intake
I will take a calcium supplement at bed time
21. A nurse is reinforcing discharge teaching with a client who has Crohn’s disease. Which of he following sttements should the nurse include in the teaching?
Increase your intake of dietary fat Maintain a low residue diet
Avoid taking antidiarrheal medication Plan to weight yourself weekly
22. A nurse is collecting data from an older adult client who has several concerns. Which of the following concerns should the nurse recognize as a normal change associated with aging?
I sweat more than I used to
Sometimes I can’t remember my kids names
I seem to have more loose stools than I used to My food tastes bland even after I add seasoning
23. A nurse is caring for a client who is suspected of having a myocardial infarction. Which of the following actions should the nurse take to prepare the client for an ECG?
Position the client in Sims’ position before electrode placement Ensure that each electrode is dry before application
Cleanse the client’s skin prior to electrode placement Place the electrodes on the client’s abdomen and back
24. A nurse is reviewing the medication administration record of a client who has osteoarthritis. Which of the following analgesic prescriptions should the nurse expect to administer when the client reports pain?
Methotrexate Acetaminophen Gabapentin Etanercept
25. A nurse is caring for a client who has dementia due to Alzheimer’s disease. Which of the following actions should the nurse take to reduce the client’s confusion?
Restrict visitors to three at a time Avoid touching the client during care
Encourage reminiscence of past experiences Give the client multiple options for daily events.
26. A nurse is contributing to the plan of care for a client who had a cerebrovascular accident (CVA). For which of the following interdisciplinary team member should the nurse recommend a referral prior to initiating oral intake for the client?
Occupational therapist Speech-language pathologist Physical therapist
Case manager
27. A nurse is reviewing the laboratory reports of a client who reports chest pain. Which of the following laboratory results indicates the client is experiencing a myocardial infarction?
Decreased lipase
Decreased erythrocyte sedimentation rate (ESR) Elevated creatinine
Elevated troponin
28. A nurse is caring for a client who is 2 hr postoperative following an amputation of the foot. Which of the following actions should the nurse take first?
Obtain the client temperature Observe for phantom pain Measure urinary output Check the incisional dressing
29. A nurse is caring for a female client who is being treated for dehydration due to nausea and vomiting. Which of the following findings should the nurse report to the provider
Hemoglobin 13 g/dL
Blood pressure 110/55 mm Hg Heart rate 120/min
Potassium 3.6 mEq/L
30. A nurse is reviewing the chart of a client who is experiencing an adrenal crisis. Which was precipitated by the client not taking her medication for several days. The nurse should identify that withdrawal from which of the following medications potentiated the adrenal crisis?
Metoprolol Methimazole Furosemide Prednisone
31. A nurse is contributing to the plan of care for a client who has just transferred to the medical-surgical unit from the PACU following a right total knee arthroplasty. Which of the following interventions should the nurse include in the plan?
Massage both lower extremities to promote comfort
Begin the client on a regular diet when the gag reflex returns
Encourage the client to use the incentive spirometer every 4 hr while awake Assist the client to change position at least every 2 hr.
32. A nurse is changing the dressing for a client who has an abdominal incision and a Hemovac drain. Which of the following actions should the nurse take?
Secure the drainage tube to the clients bedding Wear sterile gloves to empty the drainage system
Cut an absorbent gauze dressing to fit around the drainage tube Cleanse the drainage plug with alcohol swabs
33. A Nurse is monitoring a client who has a wrist cast and reports intense itching underneath the cast. Which of the following actions should the nurse take?
Blow cool air into the cast using a blow dryer on a cool setting Obtain a prescription for pregabalin
Ask the provider to bivalve the cast
Provide the client with a tongue blade to rub the skin under cast
34. A nurse is caring for a client following a thyroidectomy. Which of the following findings should alert the nurse to the possibility of parathyroid gland injury?
Anorexia Hoarseness Muscle twitching Blurred vision
35. A nurse is caring for a client who has a new cast on her left forearm and reports severe pain in the affected arm with numbness in the fingers. The nurse finds the skin is pale and cold with sluggish capillary refill. Which of the following fracture complications should the nurse suspect?
Compartment syndrome Fat embolism
Deep vein thrombosis Osteomyelitis
36. A nurse is caring for a client who has restricted movements of the chest due to a burn injury. The nurse should anticipate preparing the client for which of the following procedure?
Fasciotomy Escharotomy Skin grafting
Hyperbaric oxygen therapy
37. A nurse is caring for a client who is postoperative following a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigation. The nurse notes decreased output from the urethral catheter. Which of the following provider prescriptions should the nurse expect?
Clamp the urethral catheter for 30 min.
Place the urethral catheter drainage bag at the client’s heart level Slow the bladder irrigation flow rate
Irrigate the urethral catheter with 0.9% sodium chloride
38. A nurse is reviewing the medical record for an older adult client who is experiencing nausea and vomiting. Based on the client data. Which of the following actions should the nurse take? (click on the exhibit button for additional client information. There are three tabs that contain separate categories of data?)
Exhibit 1 Exhibit 2 Exhibit 3
Diagnostic results Nurses notes Graphic record
Sodium 142 mEq/L 1200 alert and oriented x3 temperature
Potassium 4.2 mEq/L Lungs clear to auscultation 0800: 37.7° C (99.9° F)
BUN 36 mg/dL
Creatinine 1.4 mg/dL Decreased skin turgor
Dry mucous membranes 1200: 37.2° C (99.0° F)
Pulse
0800: 96/min
1200 20/min
Respiration rate
0800: 18/min
1200: 20/min
Blood pressure
0800: 118/62 mm Hg
1200: 104/65 mm Hg
Encourage the client to ambulate Administer an antipyretic medication
Notify the charge nurse of the client’s BUN level Keep the temperature in the client’s room warm
39. A nurse in a health clinic is reinforcing teaching with a client who has tuberculosis (TB) about transmission of the disease. Which of the following clients statements indicates an understanding of the teaching?
I inhaled the infected droplets that were in the air I must have touched someone who had TB
I probably caught this disease from a mosquito bite I developed TB from having unprotected sex
40. A nurse is reinforcing teaching with the parent of a toddler who has type I diabetes mellitus and whose prescription has been changed from regular insulin to lispro insulin. Which of the following information should the nurse include in the teaching?
Lispro is given once a day
Lispro should be given before eating Lispro cannot be given with other insulin Lispro does not cause hypoglycemia
41. A nurse is preparing to administer an influenza vaccine to a client. Which of the following statements by the client should cause the nurse to postpone administration of the vaccine?
I am allergic to shrimp
I am allergic to latex balloons
I had a tuberculosis skin test 2 days ago I had a low fever this morning
42. A nurse is repositioning a client who has lower back pain. Which of the following positions is appropriate for the client?
Semi-fowler’s with knees flexed Orthopneic
Dorsal recumbent Prone with legs straight
43. A nurse is caring for a client who has prescription for digoxin 0.25 mg PO daily. While taking the client’s apical pulse, the nurse notes a rate of 58/min. which of the following actions should the nurse take?
Give the dose as prescribed
Use a different route to administer the medication Administer half of the prescribed dose
Withhold the dose
44. A nurse is reinforcing teaching about insulin injections with an adult client who weights 45.4 kg (100lb). which of the following statements by the client indicates an understanding of the teaching?
I should insert the needle at a 90-degree angle I should give my shot in my belly tissue
I will pull back on the syringe plunger to look for blood before I push the medication in
I will use the side of my hand to pull my skin to the side prior to administering the insulin
45. A nurse is caring for a client who has end-stage liver disease and just underwent an abdominal paracentesis. For which of the following manifestations should the nurse monitor as an adverse effect of the procedure?
Changes in the client’s sputum Decreased blood pressure Changes in neurological status Increased urinary output
46. A nurse is reinforcing teaching with a client about testicular self-examination. Which of the following instructions should the nurse include in the teaching?
Perform testicular self-examination after taking a warm shower Examine both testicles at the same time
Use the palm of your hand to palpate for abnormalities Perform testicular self-examination every 6 months
47. A nurse is reviewing the plan of care for older adult client who is 1 day postoperative following a total hip arthroplasty. Which of the following interventions should the nurse contribute to the plan of care?
Check neurovascular status on the extremity every 8 hr Have the client perform incentive spirometry every 4 hr Keep an abduction pillow between the client’s legs
Maintain the client on bed rest until the third postoperative day
48. A nurse is reinforcing teaching with an older adult client who has osteoporosis. Which of the following instructions should the nurse include in the teaching?
Place throw rugs on wooden floors at home Supplement your diet with vitamin E
Swim laps for 20 minutes twice per week Take calcium supplements with meal
49. A nurse is providing information regarding transmission-based precautions for a client who has clostridium difficile to an assistive personnel (AP). Which of the following instructions should the nurse include? (select all that apply)
Provide the client with disposable utensils and dishes for meals Leave blood pressure equipment in the client’s room
Clean contaminated surfaces with a bleach solution Use an alcohol-based hand sanitizer after client care Wear a face ask when in the client’s room
50. A nurse is caring for a client following a gastrectomy. Which of the following actions should the nurse take to decrease episodes of dumping syndrome?
Place the client in the supine position after meals Administer pancreatic enzymes before meals
Encourage the client to drink 240 mL (8oz) of fluids with meals Offer the client three meals daily
51. A nurse is contributing to the plan of care for a client who has a head injury and is at risk for increased intracranial pressure (ICP). Which of the following actions should the nurse include in the plan?
Measure rectal temperature every 4hr Remind the client to cough as needed Use a turn sheet to reposition the client Apply wrist restraints
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