Kaplan QBank Test 1 Comprehensive Study Guide Questions and Answers Latest 2022/2023
The nurse instructs a primigravida woman during the third
... [Show More] trimester about the signs and symptoms of impending labor. Which statement by the client indicates to the nurse that the teaching was effective?
1. "I will call the healthcare provider when I see pink-tinged secretions from my vagina."
2. "I will call the healthcare provider when my contractions occur every 5 minutes for an hour."
3. "I will call the healthcare provider when I pass my mucus plug."
4. "I will call the healthcare provider when I feel increased pelvic pressure."
"I will call the healthcare provider when my contractions occur every 5 minutes for an hour."
The nurse provides care for a client admitted for the surgical repair of a detached retina in the left eye. Which intervention does the nurse include in the client's postop plan of care?
1. Limit the movement of both eyes
2. Limit the amount of talking
3. Wear patches over both eyes
4. Perform self-care activities Limit the movement of both eyes 00:0301:27
The nurse provides care for a child diagnosed with a fever. The client weighs 66 pounds. The healthcare provider prescribes a total acetaminophen dose of 15mg/kg. The child's parent administered 2.5 mL (concentration 160mg/5mL) prior to arrival. How many milligrams does the nurse administer?
370 mg
The nurse manager on the unit is fiscally responsible for meeting goals related to personnel and supply expenses. To meet budget expectations, it is important for the nurse manager to take which action?
1. Share budget expectations with the personnel on the unit
2. Designate a staff nurse to assist with budget planning
3. Post the budget on the bulletin board
4. Ensure that provider needs are met
Share budget expectations with the personnel on the unit
The client reports, "I can't get warm. I'm cold all the time" to the nurse. The client's spouse reports recent behavior changes and forgetfulness. The client is unsure when daily medications were taken last. The nurse notes the client has periorbital edema and a flat affect. Vital signs reveal T: 95.6, BP: 100/60, P: 58 bpm, RR: 26. Laboratory data reveal serum pH 7.25, PaCO2 50 mm Hg, HCO3 23 mEq/L, Serum T4 is 4.2 mcg/dL, Serum TSH is 6.3 mcg/dL. Which action does the nurse take when providing client care?
1. Reorient client every 15 minutes
2. Administer oral levothyroxine sodium
3. Administer IV hydrocortison
4. Obtain a stat 12-lead ECG
5. Place client on continuous cardiopulmonary monitoring
Administer oral levothyroxine sodium & place client on continuous cardiopulmonary monitoring
The nurse receives a report on clients in the psychiatric unit. Which actions, if performed by the off-going nurse, require follow-up by the nurse? (select all that apply)
1. The nurse assessed a suicidal client every 15 minutes
2. The nurse administered ziprasidone to a violent client
3. The nurse placed a client in a dimly lit room after the client did not eat all of the provided meal
4. The nurse allowed a suicidal client to remain in street clothes
5. The nurse initiated a signed PRN prescription for physical restraints
The nurse assessed a suicidal client every 15 minutes, The nurse placed a client in a dimly lit room after the client did not eat all of the provided meal, The nurse allowed a suicidal client to remain in street clothes, & The nurse initiated a signed PRN prescription for physical restraints
The nurse provides discharge teaching to a client diagnosed with chronic kidney disease. Which client statements indicate the teaching is effective? (select all that apply)
1. "If I follow this diet, I should lose 1 to 2 pounds per week."
2. "I will notify my healthcare provider if my legs start feeling numb or weak."
3. "I should take acetaminophen instead of ibuprofen if I have a headache."
4. "I will need to take an iron supplement to prevent being anemic due to bleeding."
5. "I will keep hard candy with me for when my mouth gets dry."
6. "If I quit smoking, I'll have a better chance of getting a kidney transplant." 2, 5, 6
A client reports stabbing facial pain and twitching facial muscles a week after having a toothache. Which actions are appropriate for the nurse to implement when providing care to this client? (select all that apply)
1. Teach isometric exercises for facial muscles
2. Administer oral carbamazepine as prescribed
3. Administer IV hydrocortisone as prescribed
4. Teach to chew on opposite side of mouth
5. Perform facial massage twice daily
Administer oral carbamazepine as prescribed & Teach to chew on opposite side of mouth
The nurse provides care for a pregnant client. The client reports heartburn. Which client statement would cause the nurse to IMMEDIATELY intervene?
1. "I sit upright for 2 hours after eating."
2. "I sleep with an extra pillow."
3. "I will stop smoking."
4. "I eat every 6 hours." "I eat every 6 hours."
The nurse assesses clients for their risk for injury. Which client should the nurse determine is at risk for injury?
1. The client who flushes the percutaneous endoscopic gastrostomy (PEG) tube with 20 mL of water after medications.
2. The client who injects prescribed subcutaneous insulin into the abdomen at a 90 degree angle
3. The client with a spinal cord injury who washes the urinary catheter with soap and water between uses
4. The infant client who is receiving prescribed intramuscular injections in the dorsogluteal site The infant client who is receiving prescribed intramuscular injections in the dorsogluteal site
The nurse returns to the desk in the prenatal clinic and finds four phone messages. Which message does the nurse return FIRST?
1. A multigravida at 12 weeks' gestation experiencing heavy white vaginal discharge
2. A primigravida at 17 weeks' gestation stating that she has not felt the baby move
3. A primigravida at 22 weeks' gestation reporting feeling dizzy and clammy when lying on her back
4. A multigravida at 32 weeks gestation experiencing malaise and bilateral dependent and facial edema A multigravida at 32 weeks gestation experiencing malaise and bilateral dependent and facial edema
The nurse prepares to each a client recovering from a spinal fusion on how to move from a supine to standing position at the left side of the bed with a walker. Which direction by the nurse is appropriate?
1. Raise the HOB to sit straight up, bend the knees, and swing the legs to the side and then to the floor
2. Rock the body from side to side, going further each time until enough momentum is built up to be lying on the right side, and then raise the trunk towards the toes
3. Reach over to the left side rail with the right hand, pull the body onto the left side, bend the upper leg so the foot is on the bed, and push down to elevate the trunk
4. With the left elbow as a pivot, grasp the mattress edge with the left hand and push on the mattress with the right hand above the left elbow, and then slide the legs over the side of the mattress
With the left elbow as a pivot, grasp the mattress edge with the left hand and push on the mattress with the right hand above the left elbow, and then slide the legs over the side of the mattress
00:0201:27
The nurse provides care to a client with hypermagnesemia. What will the nurse identify as a risk factor for this electrolyte imbalance?
1. Diarrhea
2. Alcoholism
3. Renal failure
4. Intestinal fistula Renal failure
The nurse monitors a client who is recovering from coronary artery bypass graft (CABG) surgery. Which finding MOST concerns the nurse?
1. The jugular veins are distended, but the lung sounds are clear
2. The client reports sharp stabbing pain over the sternum
3. Lab values of potassium 4.6 mEq/L, calcium 9.4 mg/dL, and magnesium 1.6 mg/dL
4. The core body temperature is 97.2
The jugular veins are distended, but the lung sounds are clear
The nurse provides care for a client who sustained a fractured right femur. The client has a cast applied. Which type of exercise does the nurse assist the client to perform?
1. Passive exercises for the upper extremities
2. Active ROM of the left leg
3. Passive exercises of the right leg
4. Quadriceps setting of the right leg Quadriceps setting of the right leg
The nurse develops a client teaching brochure on health promotion. Which interventions will the nurse include as examples of primary health promotion? (select all that apply)
1. Attending a stress management class
2. Performing a testicular self-examination
3. Determining a HbA1C level
4. Taking an analgesic for a headache
5. Determining foods low in cholesterol
Attending a stress management class & determining foods low in cholesterol
The nurse provides care for clients on the psychiatric unit. Before administering medication, the nurse asks the client, "Please state your name." The client responds, "I am Jesus Christ." Which action does the nurse take?
1. Ask two nursing assistive personnel to stand by in the area
2. Request that the hospital chaplain speak to the client
3. Look at the client's armband
4. Determine if the client ate lunch Look at the client's armband
The nurse provides care for an older adult with type 1 diabetes and hypertension. The client is scheduled for a CT scan with contrast. Which action by the nurse is appropriate?
1. Hydrate the client with a 1 L bolus of normal saline
2. Monitor BP before and after the procedure
3. Instruct the client to increase oral fluids before the procedure
4. Question whether the scan must be done with contrast.
Question whether the scan must be done with contrast
The nurse changes a large abdominal wound dressing with two Penrose drains in place. Which information does the nurse MOST correctly document regarding this dressing change?
1. Condition of surrounding tissue, time used to change the dressing, type of dressing used
2. Client's tolerance of the procedure, client position in bed, amount of wound drainage
3. Client's response to the dressing change, status of Penrose drains, type of drainage from Penrose drains
4. Time dressing was changed, description of the wound, color and amount of drainage from the Penrose drains Time dressing was changed, description of the wound, color and amount of drainage from the Penrose drains
A client who is scheduled for surgery takes carbamaezepine 100 mg by mouth twice a day. Which action will the nurse expect the healthcare provider to take because of this medication?
1. Instruct to withhold the medication the morning of surgery
2. Gradually discontinue the medication 24-48 hours before surgery
3. Increase the dosage of the medication before surgery
4. Inform the anesthesiologist Inform the anesthesiologist
The nurse provides care to a client with an external fixation device to stabilize a fractured femur. Which assessment findings concern the nurse? (select all that apply)
1. Pain distal to the injury that is not relieved by opioid analgesics
2. Paresthesia distal to the area of injury
3. Reports of pain at pin insertion sites
4. Toes on affected leg edematous and cool to touch
5. Weak pedal pulses strength in affected leg 1, 2, 4, 5
The home health nurse is planning to visit four clients who live within 3 miles of each other. Which client does the nurse visit first?
1. The newborn who is 20-hours-old, is being breastfed, and has not had a stool since birth
2. The newborn who has a respiratory rate of 60 breaths/min when crying
3. The client who is at 30 weeks' gestation, has gestational diabetes mellitus, and has a blood sugar of 78 mg/dL
4. The client who is at 34 weeks' gestation with twins and is reporting intermittent low back pain The client who is at 34 weeks' gestation with twins and is reporting intermittent low back pain
The nurse overhears two nursing assistive personnel discuss a client's protected health information in a public elevator. Which action does the nurse take next?
1. Assess the elevator for visitors and non staff passengers
2. Contact the supervisor on the floor where the NAPs work
3. Instruct the NAPs to stop the conversation immediately
4. Notify the hospital risk manager and ethics committee Instruct the NAPs to stop the conversation immediately
The nurse receives report on the client who had an extensive stroke and is aphasic with a DNR prescription. Initial assessment reveals pulse is 102 beats/min, respirations 28 breaths/min, BP 82/42 mm Hg, temperature 96.7 orally, and O2 saturation of 84% on 4 L/min oxygen by nasal cannula. Which action does the nurse implement based on these data? (select all that apply)
1. Assess for advance directives
2. Contact the healthcare provider
3. Confirm the DNR prescription
4. Contact the family about impending death
5. Provide pain medication
6. Place the client in high-Fowler position 1, 2, 3, 4, 5
The nurse performs diet teaching for a client diagnosed with heart failure. Which statement by the client indicates to the nurse that further teaching is necessary?
1. "I will eat 5 to 6 servings of fresh vegetables daily."
2. "I eat salami sandwiches for lunch each day."
3. "I enjoy whole wheat toast in the morning."
4. "I drink 4 ounces of water at every meal."
"I eat salami sandwiches for lunch each day."
The nurse is providing care for a client who has been taking fluoxetine for 4 weeks. Which observation most concerns the nurse?
1. The client frequently uses sarcasm
2. The client has been giving away some possessions
3. The client has been sleeping 9 hours each night
4. The client has started waking up at 0600 every morning The client has been giving away some possessions
The nurse provides care to a client diagnosed with a negative nitrogen balance. Which dietary selection is MOST appropriate for the nurse to recommend to the client?
1. Rice cereal
2. Celery
3. Green peas
4. Salmon Salmon
A client receives intravenous doxorubicin hydrochloride. Which observation causes the nurse the MOST concern?
1. Mouth ulcer
2. Red urine
3. Alopecia
4. Fever Fever
The nurse inserts a nasogastric tube in the client. In which order does the nurse complete the steps for insertion?
1. Determine if the client is taking an anticoagulant
2. Attach the syringe to the tube and obtain gastric aspirate
3. Have the client close each nostril alternatively and breathe
4. Identify the client using two client identifiers
5. Obtain a radiograph of the client's abdomen
6. Advance the tube to the desired length as the client swallows 4, 1, 3, 6, 2, 5
The nurse monitors a client receiving the first of two units of packed RBCs. The client reports a headache and lower back pain approximately 2 hours into transfusion of the first unit. Which intervention does the nurse perform first?
1. Assess the client's vital signs and respiratory status
2. Administer acetaminophen as prescribed and monitor response
3. Stop the infusion of blood
4. Notify the healthcare provider Stop the infusion of blood
The nurse provides instructions to a client diagnosed with peptic ulcer disease receiving cimetidine. Which statement by the client indicates that teaching is successful?
1. "I should eat foods like creamed soups, oatmeal, and pudding."
2. "I should eat three meals each day."
3. "I can't eat salad or strawberries."
4. "I can drink coffee as long as it is decaffeinated." "I should eat three meals each day."
The parents of a preschooler bring their child to the emergency department during flu season. The parents state that the child has been reporting abdominal pain, is nauseated and vomiting, and refuses to eat. Which question is most important for the nurse to ask the parents?
1. "Did you child have the flu shot this year?"
2. "What new foods has your child been eating lately?"
3. "How long has your child been feeling like this?"
4. "Which came first: the pain, or the nausea and vomiting?" "Which came first: the pain, or the nausea and vomiting?"
The healthcare provider prescribes 1000mL of dextrose 5%in water to infuse at 100mL per hour for a client. The infusion is to be discontinued when completed. The nurse begins dextrose 5% in water at 0545. What time does the nurse anticipate discontinuing the IV fluids?
1545
A client is prescribed digoxin 1.25 mg by mouth STAT for digitalization. The medication is available in 0.25 mg tablets. Which number of tables will the nurse administer?
5
The nurse staff an education both during a community health fair. Which information is appropriate to provide to the parents of an older school-age client?
1. Sports safety
2. Water safety
3. Suicide prevention
4. Burn prevention Sports safety
The nurse assesses the breath sounds of a client with severe shortness of breath. Which type of assessment is the nurse completing?
1. Body systems
2. Focused
3. Comprehensive
4. Psychosocial Focused
The nurse prepares a client for diagnostic testing to determine if the client has cancer. The client seems to have difficulty concentrating, is tense, and restless. Which response by the nurse is best?
1. "You seem to be anxious. Please share your thoughts with me."
2. "You will be less anxious if you understand the diagnostic tests."
3. "Why are you so restless? Your healthcare provider is very good."
4. "You seem worried about the tests. I'm sure everything will be fine." "You seem to be anxious. Please share your thoughts with me."
A client is discharged from the emergency department after evaluation for a concussion with loss of consciousness. Which statement by the spouse indicates to the nurse that further teaching is necessary?
1. "I will wake my spouse up every 3 hours whenever sleeping and ask him his name, my name, and where he is."
2. "If my spouse complains of a headache and needs aspirin, I will give it to him no more than every 4 hours."
3. "If my spouse complains of blurry vision or has difficulty walking, I will bring him to the emergency department."
4. "I will talk to my spouse's friend about doing the coaching for the soccer team tomorrow."
"If my spouse complains of a headache and needs aspirin, I will give it to him no more than every 4 hours."
The nurse provides care for a client diagnosed with respiratory failure. Which nutrient does the nurse instruct the client to limit in the diet?
1. Protein
2. Calcium
3. Water
4. Carbohydrates Carbohydrates
A nurse in a rural community assesses residents for risk factors for heart disease. The nurse determines that which resident is at greatest risk to develop heart disease?
1. A resident who participates in a competitive weight lifting program
2. A resident diagnosed with type 1 diabetes that is poorly controlled
3. A resident whose grandfather died of heart failure at age 72
4. A resident who drinks a glass of beer every night
A resident diagnosed with type 1 diabetes that is poorly controlled
A client is recovering from a myelogram that used an oil-based contrast medium. Which action is most important for the nurse to take?
1. Apply ice packs to the puncture site
2. Ambulate the client
3. Monitor for seizures
4. Encourage oral fluids Encourage oral fluids
During the admission process, a client reports pain in the right arm and states that it has been hurting since blood was drawn earlier. The nurse discovers a tourniquet in place. Which action does the nurse take next?
1. Notify the healthcare provider
2. Assess the arm
3. Remove the tourniquet
4. Complete an incident report Remove the tourniquet
The nurse provides care for a client admitted for an adrenalectomy for treatment of Cushing syndrome. Which intervention is MOST important for the nurse to take?
1. Evaluate the client's mood
2. Monitor the client's blood glucose
3. Take the client's temperature
4. Obtain the client's weight Monitor the client's blood glucose
A client experiences a pulmonary embolism after abdominal surgery. Which information in the client's history will contraindicate the use of thrombolytic therapy?
1. Has type 2 diabetes mellitus
2. Takes medications as needed for angina pectoris
3. Is recovering from a concussion that occurred 3 weeks ago
4. Uses an inhaler for treatment of asthma
Is recovering from a concussion that occurred 3 weeks ago
The nurse provides care for a client at 29 weeks' gestation. The nurse reviews the results of the client's biophysical profile. Which fetal assessment parameters are included in the profile? (select all that apply)
1. Breathing movement
2. Weight
3. Muscle tone
4. Heart rate during contractions
5. Amniotic fluid volume
Breathing movement, muscle tone, & amniotic fluid volume
When administering preoperative medication to a client, the nurse notices a large number of small insects crawling out of the closet where the client placed his suitcase. The client refuses to allow the nurse to inspect his luggage. Which action by the nurse is MOST appropriate?
1. Notify security
2. Kill the insects
3. Inspect the client's bag
4. Double-bag the suitcase and insects Double-bag the suitcase and insects
Which information will the nurse include when teaching the client about the self-management of an implantable cardioverter/defibrillator (ICD)? (select all that apply)
1. Continue taking antidysrhthmic medications until the healthcare provider directs otherwise
2. Do not wear tight clothing or belts over the ICD generator
3. Notify the local fire department about having an ICD
4. Avoid activities that involve rough contact with the ICD
5. Report symptoms such as nausea, fainting, and weakness 1, 2, 4, 5
The client care team at a home care agency consists of a nurse, an LPN, and a nursing assistive personnel (NAP). Which client will be assigned to the LPN?
1. Client with hypertension and hypothyroidism who is returning home from the hospital
2. Client recovering from a kidney transplant and reporting a fever and tenderness over the transplant site
3. Client with regional enteritis who requires a dressing change for an abdominal abscess
4. Client recovering from a hip fracture and requiring assistance with a bath and hair washing Client with regional enteritis who requires a dressing change for an abdominal abscess
The nurse provides care for an antepartum client. Which factors, identified by the nurse on assessment, increase the risk of thrombosis? (select all that apply)
1. Vaginal birth
2. Obesity
3. Maternal age greater than 27 years
4. Varicose veins
5. Forceps use during delivery
Obesity, varicose veins, & forceps use during delivery
The nurse notes that a toddler has honey-colored crusts, vesicles, and reddish macules around the mouth. Which statement is BEST for the nurse to make to the client's parent?
1. "Your child has developed an irritation because of using a pacifier."
2. "Your child has an infection that can be treated with antibiotics."
3. "Your child has a food allergy and needs a restricted diet."
4. "Your child has been exposed to a sick child and should be isolated for a few days." "Your child has an infection that can be treated with antibiotics."
The nurse provides care for a client receiving lithium therapy. Which instruction is important for the nurse to include in client teaching?
1. Restricted-sodium diet with increased fluid intake
2. High-calorie diet with sodium and potassium restriction
3. Regular diet with normal sodium and adequate fluid intake
4. Reduced-calorie diet with reduced sodium and increased fluid intake Regular diet with normal sodium and adequate fluid intake
The nurse assesses a client diagnosed with a left colon tumor. Which characteristic symptoms of this type of tumor does the nurse ask the client about during the physical examination? (select all that apply)
1. Early satiety
2. Rectal bleeding
3. Colicky abdominal pain
4. Flat, ribbonlike stools
5. Alternating diarrhea and constipation
Rectal bleeding, flat, ribbonlike stools, & alternating diarrhea and constipation
While interviewing a young adult, the nurse learns that the individual has a history of frequent nosebleeds that require health care intervention. Which response by the nurse is BEST?
1. "Do you use nasal sprays for allergies?"
2. "Do you smoke cigarettes?"
3. "Do you take aspirin on a regular basis?"
4. "Have you been diagnosed with nasal polyps?" "Do you use nasal sprays for allergies?"
The nurse assesses the pain level of clients recovering from surgery. Which clients' pain relief are appropriate for the nurse to delegate to the LPN? (select all that apply)
1. Client who had knee arthroplasty yesterday and is scheduled for physical therapy and reports pain as 3 out of 10
2. Client who arrived post-anesthesia care unit a short while ago after an appendectomy and is dozing intermittently and reports pain as 8 out of 10
3. Client ambulating on the unit recovering from a hernia repair 2 days ago and reports pain as 4 out of 10
4. Client who had surgery to repair a hip fracture yesterday evening and is difficult to arouse, yet moans when moved
5. Client on NPO status after a colon resection 2 days ago and reports pain as 4 out of 10
6. Client who had carpal tunnel release yesterday and reports pain as 6 out of 10 1, 3, 6
The nurse in a nursing facility discovers a fire in the soiled utility room. In which order does the nurse perform the required actions?
1. Locate all of the residents
2. Pull the fire alarm
3. Move clients away from the fire
4. Close all of the fireproof doors 1, 3, 2, 4
A client receiving IV heparin 1400 units/hour is prescribed to have the dose changed to 1200 units/hour. The concentration of heparin is 25,000 units per 500 mL normal saline. At which rate, in milliliters per hour, will the nurse adjust the infusion pump to deliver the prescribed dose of 1200 units per hour?
24 mL/hour
A client, crying hysterically, calls the nurse at the prenatal clinic. The client reports that she is a few days late for her period, has a positive home pregnancy test, and just noticed a scant amount of blood on the tissue when she voided. The client is afraid that she is having a miscarriage. Which initial response by the nurse is MOST appropriate?
1. "You seem really upset. Take some slow deep breaths."
2. "A small amount of bleeding is nothing to worry about."
3. "Bleeding from implantation is expected at this time."
4. "Come to the clinic immediately. The healthcare provider will see you." "You seem really upset. Take some slow deep breaths."
The nurse performs a moist-to-dry dressing. In which order does the nurse complete the steps of this procedure?
1. On the dressing, record the date and time
2. Clean the wound with saline solution
3. Observe the appearance of the wound
4. Assess the client's comfort level
5. Remove dressing material from the wound
6. Apply moist gauze in a single layer to the wound 4, 5, 3, 2, 6, 1
The nurse counsels a client diagnosed with rheumatoid arthritis. The client asks the nurse why performing range-of- motion (ROM) exercises is required. Which is the best response by the nurse?
1. "They help make your muscles stronger."
2. "They help prevent contractures."
3. "They help keep your spirits up."
4. "They will prevent respiratory complication." "They help prevent contractures."
A client is scheduled for a colonoscopy, and the nurse is completing teaching regarding the procedure. Which client statement indicates to the nurse an appropriate understanding of the procedure?
1. "I need to not eat or drink anything by mouth 8 hours before the procedure."
2. "I need to begin a liquid diet 2 days before the procedure."
3. "I need to stop taking my oral hypoglycemic agent the day before the procedure."
4. "I need to let my healthcare provider know that I am allergic to iodine before the procedure." "I need to not eat or drink anything by mouth 8 hours before the procedure."
The nurse provides care for clients at the local eye care center. Several clients who are 24 hours postop after intracellular cataract extraction have left phone messages. Which message should the nurse return first?
1. A client asks if it is appropriate to take acetaminophen for discomfort in the operative eye.
2. A client reports feeling light-headed when assuming a standing position.
3. A client reports mild itching in the operative eye.
4. A client states that the eyelid is swollen and the client is having difficulty seeing with the affected eye.
A client states that the eyelid is swollen and the client is having difficulty seeing with the affected eye.
The nurse reviews the developmental milestones for a 20-month-old client. Which statements made by the parent indicate to the nurse that the family is ready for toilet training? (select all that apply)
1. "Diapers are usually dry when waking up from a nap."
2. "Wearing wet or dirty diapers does not bother my child."
3. "I am looking forward to taking the next 2 weeks off."
4. "Sitting still 2 to 3 minutes is not a problem."
5. "Bowel movements occur at anytime during the day."
6. "Dressing and undressing are a favorite activity." 1, 3, 6
The nurse instructs a client diagnosed with diverticulosis. Which menu selection by the client validates that the nurse's teaching is effective?
1. Fried chicken breast with french fries
2. Biscuits and gravy with scrambled eggs
3. Roast beef with gravy and corn on the cob
4. Tuna sandwich on whole wheat toast with carrot sticks Tuna sandwich on whole wheat toast with carrot sticks
During the initial period following a spinal cord injury, which action is MOST important for the nurse to take?
1. Prevent contractures and atrophy
2. Prevent UTIs
3. Promote rehabilitation
4. Prevent flexion or hyperextension of the spine Prevent flexion or hyperextension of the spine
The nurse provides discharge planning for a group of clients. For which client does the nurse request a healthcare provider's referral for home health care services?
1. A client who reports incisional pain 48 hours following an appendectomy
2. A client diagnosed with diabetes mellitus who had a cardiac catheterization 8 hours earlier
3. A client who reports left knee pain 72 hours following a left total knee arthroplasty
4. A client diagnosed with heart failure who underwent diuresis 4 days earlier A client diagnosed with heart failure who underwent diuresis 4 days earlier
The school nurse accompanies a group of school-age clients on a field trip. While exiting the bus, one of the clients falls and sustains a leg injury. The nurse suspects the client's leg is fractured. Which action does the nurse implement first?
1. Contact the client's parent
2. Help the client get back on the bus
3. Transport the client to a nearby hospital
4. Bandage the client's legs together Bandage the client's legs together
The nurse provides care for a client admitted for abdominal surgery. During the admission interview the client admits to drinking about 1 pint (473 mL) of vodka per day. Which is the best initial response by the nurse?
1. "Why do you drink a whole pint of vodka per day?"
2. "How long have you been drinking that quantity of alcohol?"
3. "Do you drink with someone or at a particular space?"
4. "When did you have your last drink of alcohol?" "When did you have your last drink of alcohol?"
The nurse prepares to give a newborn the first bath after birth. Which action does the nurse take next?
1. Wash the newborn's eyes from the outer canthus to the inner canthus
2. Remove the vernix from the newborn's body
3. Use a pH neutral soap for cleansing the newborn
4. Expose the newborn's body while washing the hair Use a pH neutral soap for cleansing the newborn
A nursing team discusses the new nurse manager's leadership style. A nursing assistive personnel (NAP) states, "The new nurse manager does not give us any direction or supervision." What is an appropriate response by the nurse?
1. "The nurse manager has an autocratic leadership style. It is best to not challenge the nursing chain of command."
2. "The nurse manager has a democratic leadership style. We will vote on all decisions in staff meetings."
3. "The nurse manager has a situational leadership style. Direction will be provided during a crisis."
4. "The nurse manager has a laissez-faire leadership style. Are there specific issues that you have questions about?"
"The nurse manager has a laissez-faire leadership style. Are there specific issues that you have questions about?"
The nurse reviews the laboratory results for a client diagnosed with type 2 diabetes mellitus reporting syncope and weakness. Lab values include: potassium 1.7 mEq/L (1.7 mmol/L), 2-hour postprandial serum glucose 155 mg/dL (8.6 mmol/L), and blood urea nitrogen (BUN) 18 mg/dL (6.4 mmol/L). Which action does the nurse take first?
1. Assess for bleeding
2. Repeat the glucose test
3. Contact the healthcare provider
4. Document the results in the chart Contact the healthcare provider
The nurse provides discharge teaching to a client with myasthenia gravid. Which client statement indicates further teaching is needed?
1. "I should take a shower and was my hair in the morning."
2. "I should use paper and pencil to communicate with my husband."
3. "I should avoid places that I know will be crowded."
4. "I should plan my day around an afternoon rest period."
"I should use paper and pencil to communicate with my husband."
A client is prescribed albuterol two puffs and beclomethasone two puffs. Which information will the nurse provide when instructing the client on the use of these inhalers?
1. Use the albuterol inhaler and then use the beclomethasone inhaler
2. Use the beclomethasone inhaler and then the albuterol inhaler
3. Take one puff of each inhaler, wait a minute, and then repeat the process
4. Use either inhaler first as long as the medications are separated by 2 minutes
Use the albuterol inhaler and then use the beclomethasone inhaler
The nurse plans care for a client with Graves disease. The nurse intervene when the client drinks which fluid?
1. Whole milk
2. Beef broth
3. Orange juice
4. Iced tea Iced tea
A client with preeclampsia at 37 weeks' gestation receives a continuous intravenous infusion of magnesium sulfate. Which assessment finding causes the nurse the most concern?
1. Urine output 40 mL/hr
2. Respiratory rate 14 breaths/min
3. Deep tendon reflexes 4+
4. Serum magnesium level 7 mg/dL Deep tendon reflexes 4+ [Show Less]