A female client with a nasogastric tube attached to low suction states that she is
nauseated. The nurse assesses that there has been no drainage through
... [Show More] the
nasogastric tube in the last 2 hours. Which action should the nurse take first?
A. Irrigate the nasogastric tube with sterile normal saline.
B. Reposition the client on her side.
C. Advance the nasogastric tube 5 cm.
D. Administer an intravenous antiemetic as prescribed. - CORRECT ANSWER B. The
priority is to determined if the tube is functioning correctly, which would relieve the
client's nausea. The least invasive intervention is to reposition the client (B), should be
attempted first, followed by (A & C) if these are unsuccessful then (D).
When assigning clients on a medical-surgical floor to a RN and a LPN, it is best for the
charge nurse to assign which client to the LPN?
A. A child with bacterial meningitis with recent seizures.
B. An older adult client with pneumonia and viral meningitis.
C. A female client in isolation wiht meningococcal meningitis.
D. A male client 1 day post-op after drainage of a brain abscess. - CORRECT ANSWER
B. Is the most stable. A, C, D have an increased risk for elevated ICP.
Which description of symptoms is characteristic of a client with diagnosed with
trigeminal neuralgia (tic douloureux)?
A. Tinnitus, vertigo, and hearing difficulties.
B. Sudden, stabbing, severe pain over the lip and chin.
C. Unilateral facial weakness and paralysis.
D. Difficulty in talking, chewing, and swallowing. - CORRECT ANSWER B. Trigeminal
neuralgia is characterized by paroxysms of pain, similar to an electric shock, in the area
innervated by one or more branches of the trigeminal nerve. A. Characteristic of
Meniere's
C. Characteristic of Bell palsey D. Characteristic of disorders of the hypoglossal (12th
cranial nerve)
Which abnormal lab finding indicates that a client with diabetes needs further evaluation
for diabetic nephropathy?
A. Hypokalemia
B. Microalbuminauria
C. Elevated serum lipids
D. Ketonuria - CORRECT ANSWER B. Microalbuminuria is the earliest sign of
nephropathy and indicates the need for follow-up evaluation. Hyperkalemia (A) is
associated with end stage renal disease caused by diabetic nephropathy. (C) may be
elevated in end stage renal disease. (D) may signal the onset of DKA.
5) An older male client comes to the geriatric screening clinic complaining of pain in his
left calf. The nurse notices a reddened area on the calf of his right leg that is warm to
touch and the nurse suspects that the client may have thrombophlebitis. Which addition
assessment is most important for the nurse to perform?
A. Measure calf circumference.
B. Auscultate the client's breath sounds.
C. Observe for ecchymosis and petechiae.
D. Obtain the client's blood pressure - CORRECT ANSWER B. Since the client may
have a pulmonary embolus secondary to the thrombophlebitis. A. Would support the
nurses assessment. C. Least helpful since bruising is not associated with
thrombophlebitis. D. Less important then auscultation.
The nurse know that a client taking diuretics must be assessed for the development of
hypokalemia, and that hypokalemia will create changes in the client's normal ECG
tracing. Which ECG change would be an expected finding in the client with
hypokalemia?
A. Tall, spiked T waves
B. A prolonged QT interval
C. A widening QRS complex
D. Presence of a U wave - CORRECT ANSWER D. A U wave is a positive deflection
following the T wave and is often present with hypokalemia. A, B, C indicate
hyperkalemia.
An older client is admitted with a diagnosis of bacterial pneumonia. The nurse's
assessment of the client will most likely reveal which S/SX?
A. Leukocytosis and febrile.
B. Polycythemia and crackles.
C. Pharyngitis and sputum production.
D. Confusion and tachycardia. - CORRECT ANSWER D. The onset of pneumonia is
the older may be signaled by general deterioration, confusion, increased heart rate or
increased respiratory rate. (A, B, C) are often absent in the older with bacterial
pneumonia.
The nurse observes ventricular fibrillation on telemetry and upon entering the clients
bathroom finds the client unconscious on the floor. What intervention should the nurse
implement first?
A. Administer an antidysrhythmic medication.
B. Start cardiopulmonary resuscitation.
C. Defibrillate the client at 200 joules.
D. Assess the client's pulse oximetry. - CORRECT ANSWER B. Ventricular fibrillation
is a life-threatening dysrhythmia and CPR should be started immediately. A & C are
appropriate but B is the priority. D does not address the seriousness of the situation.
An older female client with dementia is transferred from a long term care unit to an
acute care unit. The client's children express concern that their mother's confusion is
worsening. How should the nurse respond?
A. "It is to be expected that older people will experience progressive confusion."
B. "Confusion in an older person often follows relocation to new surroundings."
C. "The dementia is progressing rapidly, but we will do everything we can to keep your
mother safe."
D. "The acute care staff is not as experienced as the long-term care staff at dealing with
dementia." - CORRECT ANSWER B. Relocation often results in confusion among older
clients and is stressful to clients of all ages. [Show Less]