1. A male client develops oral candidiasis. He has MRSA-positive sputum, is dyspneic, and is receiving oxygen per facemask and linezolid (Zyvox) 600 mg BID... [Show More] IV.
In planning care for this client, the nurse identifies which factor as the probable cause of the stomatitis?
A. Antibiotic therapy.
2. A 38-year-old male client collapsed at his outside construction job in Texas in July.
His admitting vital signs to ICU are: BP 82/70, heart rate 140 beats/minute, urine output 10 ml/hr, skin cool to the touch. Pulmonary artery (PA) pressures are: PAWP 1, PAP 8/2, RAP -1, SVR 1600. What nursing action has the highest priority?
A. Increase the client’s IV fluid rate to 200 ml/hr.
3. A one-year-old child with neuroblastoma is crying continuously and is curled into a fetal position. What action is most important for the nurse to implement?
A. Give a prescribed analgesic.
4. A client diagnosed with major depression is being allowed a weekend pass from the psychiatric unit. Which instruction should the nurse provide to the client’s
A. Involve the client in usual at-home activities.
5. The nurse is evaluating an asthmatic client’s response to an inhaled corticosteroid
medication. What assessment finding indicates that the medication has been effective in controlling the asthma symptoms? The client has increased
A. Peak flow meter rates.
6. In reviewing the goals of “Healthy People”, the nurse determines that the community has a significant problem in preventing dental caries among children. To bring about change that addresses this identified community health problem, where
is the best place to initiate a prevention program?
A. WIC program intake offices.
7. A client with a permanent pacemaker develops loss of capture resulting in symptomatic sinus bradycardia at a rate of 38/minute. Which intravenous medication
should the nurse prepare to administer immediately?
A. Atropine sulfate (Atropine).
8. A 25-year-old female client reports to the nurse that she has a throbbing headache over her left eye that began early yesterday right after experiencing dark spots in her vision. Movement makes her nauseous, but lying still in a dark room does provide
some relief. Over-the-counter pain medications have not helped. This client is describing which type of headache?
A. Classic migraine.
9. A client with acute renal failure has a daily urine output of 1000 mL per day and is experiencing nausea, vomiting, diarrhea, and weakness. Which
action would help the client at this time?
A. Remove potassium from intravenous fluids.
10. A client is being evaluated for sciatica. What will the nurse most likely assess in this client?
A. Pain in the buttock that radiates down the leg.
11. When instructing an elderly client on insulin self-administration the
client says “my daughter is going to give me the shots every day.” Which
action would the nurse take at this time?
A. Continue teaching the client.
12. A client complains of feeling tired and not sleeping well during the night. What will the nurse include when assessing the effectiveness of this
client’s sleep pattern?
A. Number of hours of sleep each night.
13. Thirty-six hours after a cesarean delivery, a client complains of nausea and bloating. Assessment reveals a distended abdomen and no bowel movement since
delivery. What intervention should the nurse implement first
A. Auscultate the abdomen
14. The nurse who is performing blood sugar and cholesterol screenings at a community health fair determines that a female client’s blood sugar is 59 mg/dl at 10:00 a.m. Which nursing intervention is most important for the nurse to implement
A. Ask the client how she is feeling
15. The nurse is responding to telephone messages at a psychiatric day clinic. Which client situation requires immediate intervention by the nurse
A. The wife of a client with post-traumatic stress syndrome reports that her husband is threatening to kill her
16. Following vaginal delivery of a 10 lb infant, nurse assesses new mother’s vaginal
bleeding and finds that she has 2 pads in 30 min and boggy uterus. What action?
A. Perform fundal massage until firm
17. Angina experiences chest pain after morning care. First?
A. Administer a nitro tab
18. Gravida 3, Para 2 at 31 wks gestation admitted to hosp with suspected HELLP syndrome. CC- N/V malaise, epigastric pain, BP 116/74. What assessment?
A. Evaluate for thrombocytopenia
19. 60 yr old male admitted complaining of R knee pain for past week; knee and calf are warm and edematous, history of diabetes and arthritis. What info obtain?
20. Neurovascular status of lower extremities
21. A male client with hepatitis A is admitted with elevated hepatic enzymes and jaundice. Which intervention should the nurse implement
A. Meticulous hand washing after each client contact
22. The nurse observes that a client with COPD is exhibiting fingernail clubbing. What action should the nurse take
A. Document the assessment finding in the nurses’ notes
23. The nurse is assessing a 4-year-old girl with eczema. Her skin is dry and scaly, and the mother reports that she frequently scratches her skin to the point of causing
bleeding. Which guideline is indicated for care of this child [Show Less]