1. A client in the second stage of labor has a fully dilated cervix and says that she feels like she has to move her bowels. What should the nurse respond
... [Show More] to the client?
A. “That means it is time for you to start pushing.”
2. The nurse is assessing a client for testing to diagnose meningitis. Which finding suggests to the nurse that the client is experiencing this health problem?
A. Negative Kernig sign
3. A 59 yr old male client is brought to the emergency room where he is assessed to have a Glasgow Coma Scale of 3. Based on this assessment, how should the nurse characterize the client’s condition?
A. He is in a coma, and has a very poor prognosis
4. A client who has a prescription for fluid restriction asks the nurse for a mid-afternoon snack. What is the best snack to bring to the client
A. Custard
5. A client arrives in the ED with slurred speech and right-sided weakness
A. Onset of symptoms
6. An elderly client is admitted with an enlarged liver and jugular vein distention. The nurse realizes these manifestations are most likely associated with which disease process?
A. Right heart failure.
7. A client experiencing pink frothy sputum is having a brain natriuretic
peptide level (BNP) drawn. How will this laboratory test help guide the care this client needs at this time?
A. The BNP level will be low if the cause for the pink frothy sputum is respiratory failure.
8. At a community health fair, a 50 yr old woman tells the nurse she has an annual physical exam that includes a clinical breast exam and an annual mammogram. How should the nurse respond?
A. Ask the woman if she also performs monthly breast self-exams
9. The nurse is developing a teaching plan for a client who was recently diagnosed with pernicious anemiaand requires vitamin B12 replacement therapy. Which precaution is most important for the nurse to include in the clients plan of care.
A. Schedule daily rest periods to minimize fatigue
10. The community mental health nurse is planning to visit 4 clients with schizophrenia..see first
A. The father who took his children from school because aliens were after them
11. The wife of a client with terminal cancer gives the nurse a copy of her husband’s living will.
What action should the nurse take?
A. Notify the healthcare provider of the client’s wishes.
12. An adolescent client is recovering from a spinal cord injury sustained from a motor vehicle crash. The client’s mother has been at the bedside since admission and has stopped going to work and caring for other family members. Which action should the nurse take at this time?
A. Spend time with the mother to find out what her needs are.
13. While performing a physical examination of a 10-month-old infant, the nurse notes raw moist weeping macules and papules of skin on the child’s genitals, upper thighs and bottom. How should the nurse document this finding?
A. Diaper dermatitis
14. Which assessment finding should indicate to the nurse that a client with arterial HTN is experiencing a cardiac complication?
A. Complaints of shortness of breath on exertion
15. In preparing to administer an intravenous medication, the nurse notes that the drug is listed in drug reference guide as being incompatible with the currently infusing intravenous solution of Ringer’s Lactate. What action should the nurse take?
A. Flush the line with a compatible solution before and after administering the medication
16. A 7-year-old child is admitted to the hospital with acute glomerulonephritis (AGN). When obtaining the nursing history, which finding should the nurse expect to obtain
A. A recent strep throat infection
17. A client with a fractured femur is placed in traction to immobilize the fracture. When transporting this client to another room, how should the nurse handle the traction?
A. Leave the weights in place for the full duration of the transport.
18. A client recovering from a spinal cord injury is experiencing a spastic neurogenic bladder. Which action should the nurse teach the client to stimulate reflex voiding?
A. The antipyretic medication was effective.
19. A college student who is Dx with a vaginal infection and vulva irritation describes the vaginal discharge as having a “cottage-cheese” appearance. Which prescription should the nurse implement first?
A. Instill the first dose of nystatin (Mycostatin) vaginally per applicator
20. A client with an overactive bladder receives a prescription Oxybutynin (Ditropan) an anticholinergic agent. Which information should the nurse include in this client teaching plan.
A. Sugar free hard candies may relieve dry mouth
21. Beginning with the vena cava, what is the normal sequence of blood circulation through the heart (arrange from entry of the heart on top to exit of the heart on the bottom)
A. Right atrium, tricuspid valve, right ventricle, pulmonary semilunar valve, left atrium, mitral valve, left ventricle, aortic semilunar valve
22. A client with type 2 diabetes mellitus is prescribed daily insulin injections however has limited manual dexterity. What can be done to ensure the client’s compliance with this medication?
A. Recommend that insulin be prescribed through the use of a pen.
23. The healthcare provider prescribed triazolam (Halcion) 500 mcg for a client with insomnia. The pharmacy supplies Halcion in 0.25 mg tablets. How many tablets should the nurse administer? (Enter numeric value only.)
A. 2
24. An 18-month-old pediatric client with neuroblastoma is crying. The nurse realizes that the source of this crying is probably because
A. The client is in pain.
25. A client in acute renal failure has a serum potassium of 7.5 mEq/L. Based on this finding the nurse should anticipate implementing which action?
A. Administer a retention enema of Kayexalate
26. A female client who is receiving chemotherapy asks the nurse if she can have a fresh green salad because she is nauseated. Which response should the nurse provide.
A. Canned vegetables are recommended while taking chemotherapy [Show Less]