1. A nurse is caring for a client who had a total hip arthroplasty. Which of the
following actionsshould the nurse take to prevent dislocation?
a.
... [Show More] Encourage the client to lean forward when attempting to stand.
b. Elevate the knees higher than the hips when sitting
c. Place to bed pillows between the legs when in bed
d. Remove the wedge device when turning
2. A nurse suspects that a client who has diabetes mellitus is experiencing
hypoglycemia.Which of the following assessment findings suspicion?
a. Increased urine output
b. Kussmaul respiration
c. Acetone breath
d. Cool, clammy skin
3. A nurse is providing discharge teaching for a client who has asthma and a
new prescriptionfor a metered dose inhaler which of the following client
statements indicates an understanding of the teaching?
a. “I should clean the cap of the inhaler once per week”
b. “I should wait 15 seconds between puffs”
c. “I should shake the inhaler before I use it”
d. “I should inhale the medication quickly”
4. A nurse is planning care for an older adult client who has Meniere’s disease.
Which of thefollowing intervention should the nurse include in the plan?
a. Limit the clients fluid intake to 1500 mL/day
b. Encourage the client to change position slowly
c. Perform range of motion exercises to the clients neck every 4 hr
d. Administer aspirin if the client reports a headache
5. Nurse is caring for a client who is experiencing a hypertensive crisis. Which of
the followingactions should the nurse take?
a. Initiate an IV dopamine infusion
b. Place the client supine
c. Begin an IV bolus of lactated ringer’s
d. Perform neurological assessment
6. The nurse is caring for a client who has a lower extremity fracture and a
prescription forcrutches. Which of the following client statements indicate
that the client is adapting totheir rule change?
a. “These crutches will make it impossible to care for my child”
b. “I will need to have my partner take over shopping for groceries and
cooking themeals for us”
c. “I feel bad that I have to ask my partner to keep the house clean”
d. “It’s going to be difficult to tell my parents I can’t take
them to theirappointments anymore.”
7. Nurse is caring for an older adult client who has dementia. Which of the
following questionshould the nurse ask to assess thinking?
a. “Can you count backwards from 100 and intervals of 7?”
b. “Can you tell me the state where you were born?”
c. “What is meant by the saying don’t be around a brush?”
d. “What do you understand about your condition?”
a. Apply an ice pack to the clients knee.
b. Perform range of motion exercises to the clients knee
c. Please pillows under the clients knee
d. Gently massage the area around the clients incision
9. A nurse is caring for a client who has just returned from surgery with an
external fixator to the left tibia which of the following assessment findings
require immediate intervention bythe nurse?
a. The client reports a pain level of seven on a scale from 0 to 10 at
the operativesite
8. A nurse is caring for a client following a total knee arthroplasty. The client reports a pain
level of six on a pain scale of 0 to 10. Which of the intervention should the nurse take?
b. The client has an oral temperature of 38.3°C (100.9°F)
c. The client has 100 mL blood in the closed section drain
d. Client capillary refill in the left toe is 6 seconds
10.Nurse is caring for a client who has hypertension, cool and clammy skin,
tachycardia, andtachypnea. In which position should the nurse place the
client?
a. Reversed Trendelenburg
b. High-Fowler’s
c. Side-lying
d. Feet elevated
11.A nurse is caring for a client in the emergency department who experience a
full thickness burn injury to the lower torso one hour ago which of the
following findings should the nurseexpect?
a. Decreased respiratory rate
b. Hypotension
c. Bradycardia
d. Urinary diuresis
12.A nurse is caring for a client who is postoperative and develops respiratory
depression afterreceiving morphine for pain which the following medication
should the nurse expect the provider to prescribe?
a. Calcium gluconate
b. Naloxone
c. Flumazenil
d. Diphenhydramine
13.A nurse is caring for a client who has infective endocarditis. For which of
the followingcomplications should the nurse monitor?
a. Bradycardia
b. Cardiac tamponade
c. Heart failure
d. Pericardial friction rub
14.A nurse is planning care for a plant to have for thickness burns on the lower
extremities.
Which of the following intervention should the nurse include?
a. Limit visitation time for the clients children to 40 minutes per day
b. Provide a diet of fresh fruits and vegetables for the client
c. Clean the equipment in the clients room once per week
d. Apply new gloves when alternating between wound care sites
15.A nurse is assessing a client admitted with peripheral vascular disease which of
the followingfindings indicates a venous vascular disorder?
a. An ulcer on the tip of a toe
b. Hair loss just go to the clients calves
c. Edema of the ankle
d. Leg pain at rest
16.The nurse is caring for a client who has a sealed radiation implant. Which of
the followingactions should the nurse take?
a. Limit family member visits to 30 minutes per day
b. Removed soiled linens from the room after each change apply a
second pair ofgloves before touching the client’s implant if it
dislodges
c. Apply a second pair of gloves before touching the clients implant if it
dislodges
Give the dosimeter badge to the oncoming nurse at the end of the
shift
17.A nurse is assessing a client following the insertion of a central venous
catheter. Which ofthe following findings
a. Distended neck veins
b. Diminished breath sounds
c. Irregular heart rate
d. Itching over the incision
18.A nurse is administering potassium chloride via IV infusion to a client
who has severehypokalemia. Which of the following actions should the
nurse take?
a. Check the infusion site at least every 4 hr
b. Start the infusion at 30 mEq/hr
c. Monitor the client for adequate urine output
d. Assess the client for a positive Chvostek’s sign
19.The nurse is planning care for a client who has left-sided Hemiplegia following a
stroke.
Which of the following actions should the nurse include in the plan of care?
a. Provide the client with a short handled reacher
b. Position the bedside table on the clients left side
c. Place a plate guard on the clients meal tray
d. Remind the client to use a cane on his left side while ambulating
20.A nurse is preparing to administer two units of packed RBCs to a client.
Which of thefollowing actions should the nurse take?
a. Transfuse each unit of blood over 5 hr
b. Administer the blood through a 22-gauge intravenous catheter
c. Change the IV tubing after each unit of blood transfused
d. Prime to being with 0.9% sodium chloride
21.A nurse is caring for a client who is postoperative following an endoscopy
with moderate(conscious)sedation. Which of the following findings is the
nurses priority.
a. Temperature
b. Level of pain
c. Warmth of extremities
d. Gag reflex
22.A nurse is caring for a client who has just undergone a total laryngectomy.
Which of thefollowing findings is the nurse’s priority for this intervention?
a. IV infiltration
b. Tachypnea
c. Blood tinged secretions
d. Fever
23.A nurse is admitting a client to the emergency department after a gunshot
wound to the abdomen. Which of the following actions should the nurse take
to help prevent the onset ofacute kidney failure?
a. Insert a urinary catheter
b. Prepare the client for an intravenous pyelogram
c. Initiate beta blocker therapy
d. Administer IV fluids to a client
24.Charge nurse received a call from the house supervisor requesting room
assignments for four new clients. Based on the admission which of the
following clients requires a privateroom?
25.A nurse is caring for a client who has bounding pulses, crackles on
auscultation, and pink frothy secretions when receiving s. The nurse should
recognize these assessment findings asindicating which of the following?
a. Fluid volume excess
b. Aspiration
c. Increase cardiac output
d. Plural effusion
26.A nurse in an emergency department is preparing a client for emergency
surgery. The clientsblood alcohol level is 180mg/dL. Which of the following
actions is the nurses priority?
a. Apply antiembolic stockings
b. Insert an indwelling urinary catheter
c. Insert an NG tube
d. Obtain consent for surgery
27.A nurse is completing an assessment of an older adult client and notes
reddened areas ofover the bony prominences, but the client skin is intact.
Which of the following interventions should the nurse include in the plan of
care?
a. Support bony prominences with pillows
b. Apply an occlusive dressing
c. Massage the reddened areas three times daily
d. Turn and reposition the client every 4 hr
28.A nurse is caring for a client who is receiving continuous bladder
irrigation following atransurethral resection of the prostate. The bladder
spasms and the nurse observes decreased urinary output. Which of the
following actions should the nurse take?
a. Administer ibuprofen 400 mg for pain relief
b. Decrease traction on the catheter
c. Flush the catheter manually with 0.9% sodium chloride
d. Remove the indwelling urinary catheter
29.A nurse is providing teaching to a client and his partner about performing
peritoneal dialysisat home. When discussing peritoneal dialysis which of the
following manifestations should the nurse identify as the earliest indication of
this complication?
a. Cloudy effluent
b. Generalized abdominal pain
c. Increased heart rate
d. Fever
30.Nurse is caring for a client admitted with a skull fracture. Which of the
following assessmentfindings should be of g nurse?
a. WBC count changes from 9000 to 16,000/mm3
b. Pulse pressure changes from 30 to 20 mm Hg
c. Glasgow coma scale score changes from 14 to 9
d. Bilateral people diameter changes from 4 to 2 mm
31.A nurse finds a client in bed, unresponsive and breathing. Which of the
following actionsshould the nurse take first?
a. Apply a blood pressure cuff
b. Establish an IV access
c. Palpate for the clients carotid pulse
d. Initiate cardiac monitoring for the client
32.Nurse is caring for a client who is receiving a blood transfusion. The nurse
observes that theclient has bouncing peripheral pulses and distended of
jugular veins. The nurse should anticipate administering which of the
following prescribes medication?
a. Pantoprazole
b. Diphenhydramine
c. Furosemide
d. Acetaminophen
33.Nurse is caring for a client who is receiving total parenteral nutrition TPN.
The current infusion is almost complete and the new solution is not
available. Which of the followingactions should the nurse take?
a. Infuse dextrose 10% in water
b. Disconnect and flush the IV access line
c. Decrease the TPN infusion rate
d. Administer lactated ringer’s through a peripheral IV site
34.A nurse is planning care for a client who has a central venous access device for
intermittentinfusion. Which of the following actions should the nurse include
in the plan of care?
a. Use clean technique when changing the dressing
b. Flush the catheter using 10-mL syringe
c. Change the dressing every 24 hr
d. Cleanse the site with providone iodine
35.A nurse is reviewing the medical record of a client who is scheduled for a CT
scan with contrast media. Which of the following would the nurse instruct the
client to withhold for 48hours following the procedure?
a. Clopidogrel
b. Metformin
c. Carvedilol
d. Furosemide
36.A nurse is assessing a client who has right sided heart failure. Which of
the followingassessment findings should the nurse expect?
a. S3/S4 galloping heart sounds
b. Pitting edema
c. Poor skin turgor
d. Oliguria
37.A nurse on an oncology unit is caring for a client who is receiving internal
radiation therapy.Which of the following actions should the nurse instruct the
patient?
a. Leave the door to the clients room open
b. Allow visitors to hold the clients hand
c. Wear a lead apron when providing client care
d. Place the dosimeter film badge on the clients floor
38.A community health nurse is reviewing home care instructions with an
older adult client who has a new diagnosis of heart failure which of the
following is a priority topic for the nurse to review with the client?
a. Changes in weight
b. Fluid intake record
c. Daily exercise routine
d. Daily sodium restrictions
39.The nurse is preparing to administer furosemide to a client who has acute
heart failure.Which of the following laboratory results identify as a contra
indication for receiving themedication?
a. BUN 18 mg/dL
b. Sodium 136 mEq/L
c. Potassium 3.2 mEq/L
d. Creatinine 0.8 mg/dL
40.A nurse in the clinic is providing preventative teaching to an older adult client
during a wellvisit. The nurse should instruct the client that which of the
following immunizations are recommended for healthy adults after the age
of 60? (select all that apply)
a. Herpes zoster
b. Meningococcal
c. Pneumococcal
polysaccharided. Influenza
e. Human papilloma virus
41.A nurse in an emergency department is reviewing a clients ECG reading. [Show Less]