• The client with infective endocarditis must be assessed frequently by the home health
nurse. Which finding suggests that antibiotic therapy is not
... [Show More] effective, and must be
reported by the nurse immediately to the healthcare provider?
A) Nausea and vomiting
B) Fever of 103 degrees Fahrenheit (39.5 degrees Celsius)
C) Diffuse macular rash
D) Muscle tenderness
The correct answer is B: Fever of 103 degrees F (39.5 degrees C)
• A client in a long term care facility complains
of pain. The nurse collects data about
the client’s pain. The first step in pain assessment is for the nurse to
A) have the client identify coping methods
B) get the description of the location and intensity of the pain
C) accept the client’s report of pain
D) determine the client’s status of pain
The correct answer is C: Accept the client''s report of pain
• An 85 year-old client complains of
generalized muscle aches and pains. The first action by the nurse should be
A) Assess the severity and location of the pain
B) Obtain an order for an analgesic
C) Reassure him that this is not unusual for his age
D) Encourage him to increase his activity
The correct answer is A: Assess the severity and location of the pain
• A 20 year-old client has an infected leg
wound from a motorcycle accident, and the
client has returned home from the hospital. The client is to keep the affected leg elevated
and is on contact
precautions. The client wants to know if visitors can come. The appropriate response
from the home health nurse is that:
A) Visitors must wear a mask and a gown
B) There are no special requirements for visitors of clients on contact precautions
C) Visitors should wash their hands before and after touching the client
D) Visitors
The correct answer is C:Visitors should wash their hands before and after touching the
client
• A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal
meningitis. Which admission orders should the nurse do first?
A) Institute seizure precautions
B) Monitor neurologic status every hour C) Place in respiratory/secretion precautions
D) Cefotaxime IV 50 mg/kg/day divided q6h
The correct answer is C: Place in respiratory/secretion precautions
• Which of these nursing diagnoses of 4 elderly
clients would place 1 client at the greatest risk for falls?
A) Sensory perceptual alterations related to decreased vision
B) Alteration in mobility related to fatigue
C) Impaired gas exchange related to retained secretions
D) Altered patterns of urinary elimination related to nocturia The correct answer is D: Altered patterns of urinary elimination related to nocturia
• A nurse who is reassigned to the emergency
department needs to understand that gastric lavage is a priority in which situation?
A) An infant who has been identified to have botulism
B) A toddler who ate a number of ibuprofen tablets
C) A preschooler who swallowed powdered plant food
D) A school aged child who took a handful of vitamins
The correct answer is A: An infant who has been identified to have botulism
• A newly admitted adult client has a diagnosis of
hepatitis
A. The charge nurse should
reinforce to the staff members that the most significant routine infection control strategy,
in addition to hand washing, to be implemented is which of these?
A) Apply appropriate signs outside and inside the room
B) Apply a mask with a shield if there is a risk of fluid splash
C) Wear a gown to change soiled linens from incontinence
D) Have gloves on while handling bedpans with feces The correct answer is D: Have gloves on while handling bedpans with feces
• A client who had a vasectomy is in the
post recovery unit at an outpatient clinic.
Which
of these points is most important to be reinforced by the nurse?
A) Until the health care provider has determined that your ejaculate doesn't contain
sperm, continue to use another form of contraception.
B) This procedure doesn't impede the production of male hormones or the production of
sperm in the testicles. The sperm can no longer enter your semen and no sperm are in
your ejaculate.
C) After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If
your work doesn't involve hard physical labor, you can return to your job as soon as you
feel up to it. The stitches
generally dissolve in seven to ten days.
D) The health care provider at this clinic recommends rest, ice, an athletic supporter or over-the-counter pain medication to relieve any discomfort. The correct answer is A: Until the health care provider has determined that your ejaculate
doesn't contain sperm, continue to use another form of contraception.
• A client who is to have antineoplastic
chemotherapy tells the nurses of a fear of being sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture?
A) Some needles go as deep as 3 inches, depending on where they're placed in the body
and what the treatment is for. The needles usually are left in for 15 to 30 minutes.
B) In traditional Chinese medicine, imbalances in the basic energetic flow of life —
known as qi or chi — are thought to cause illness.
* C) The flow of life is believed to flow through major pathways or nerve clusters in your body.
D) By inserting extremely fine needles into some of the over 400 acupuncture points in
various combinations it is believed that energy flow will rebalance to allow the body's
natural healing mechanisms to take over.
The correct answer is C: The flow of life is believed to flow through major pathways or
nerve clusters in your body.
• The nurse is discussing with a group of students the disease Kawasaki.
What statement
made by a student about Kawasaki disease is incorrect?
A)It also called mucocutaneous lymph node syndrome because it affects the mucous
membranes (inside the mouth, throat and nose), skin and lymph nodes. B)In the second phase of the disease, findings include peeling of the skin on the hands
and feet with joint and abdominal pain
C) Kawasaki disease occurs most often in boys, children younger than age 5 and children
of Hispanic descent
D) Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to2 weeks
The correct answer is C: Kawasaki disease occurs most often in boys, children younger
than age 5 and children of Hispanic descent
• A client has viral pneumonia affecting 2/3 of the right lung. What would be the best
position to teach the client to lie in every other hour during first 12 hours after admission?
A) Side-lying on the left with the head elevated 10 degrees
B) Side-lying on the left with the head elevated 35 degrees
C) Side-lying on the right wil the head elevated 10 degrees
D) Side-lying on the right with the head elevated 35 degrees The correct answer is A: Side-lying on the left with the head elevated 10 degrees
• A client has an indwelling catheter with
continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago.
Which finding
at this time should be reported to the health care provider?
A) Light, pink urine
B) occasional suprapubic cramping
C) minimal drainage into the urinary collection bag
D) complaints of the feeling of pulling on the urinary catheter The correct answer is C:
minimal drainage into the urinary collection bag
• A nurse is performing CPR on an adult who went into cardiopulmonary arrest.
Another nurse enters the room in response to the call. After checking the client’s pulse
and respirations, what should
be the function of the second nurse?
A) Relieve the nurse performing CPR
B) Go get the code cart
C) Participate with the compressions or breathing
D) Validate the client's advanced directive The correct answer is C: Participate with the compressions or breathing
• The nurse assesses a 72 year-old client who
was admitted for right sided congestive
heart failure. Which of the following would the nurse anticipate finding? [Show Less]