1. A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following laboratory findings should the nurse expect?
a. Negative
... [Show More] urine ketones
b. BUN 32 mg/dL
c. pH 7.43
d. HCO3 23 mEq/L
2. A nurse and an assistive personnel (AP) are caring for a client who has bacterial meningitis. The nurse should give the AP which of the following instructions?
a. Wear a mask
b. Wear a gown
c. Keep the client’s room well-lit
d. Maintain the head of the bed at a 45 degree elevation
3. A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new prescription for metformin. Which of the following statements by the client indicates an understanding of the teaching?
a. "I will monitor my blood sugar carefully because the medication increases the secretion of insulin."
b. "I should take this medication with a meal."
c. "I can expect to gain weight while taking this medication."
d. “While taking this medication, I will experience flushing of my skin."
4. A nurse in a provider’s office is assessing a client who has hypertension and takes propranolol. Which of the following findings should indicate to the nurse that the client is experiencing an adverse reaction to this medication?
a. Report of a night cough
b. Report of tinnitus
c. Report of excessive tearing
d. Report of increased salivation
5. A nurse is caring for a client who has a leg cast and is returning demonstration on the proper use of crutches while climbing stairs. Identify the sequence the client should follow when demonstrating crutch use.
6. A nurse in an emergency department is caring for a client who is experiencing a thyroid storm. Which of the following manifestations should the nurse expect? (Select all that apply.)
a. Fever
b. Non-Pitting edema c. Hypertension
d. Tachycardia
e. Hypoglycemia
7. A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a productive cough. Which of the following actions should the nurse take first?
a. Obtain a sputum sample
b. Administer antipyretics
c. Provide hand hygiene education d. Initiate airborne precautions
8. A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which of the following findings indicates that the client is experiencing increased
intracranial pressure (ICP)? (Select all that apply.)
a. Flat jugular veins
b. A Glasgow Coma Scale score of 15
c. Sleepiness exhibited by the client
d. Widening pulse pressure
e. Decerebrate posturing
9. A nurse is caring for a client who is having a seizure. Which of the following interventions is the nurse’s priority?
a. Loosen the clothing around the client's neck.
b. Check the client's pupillary response.
c. Turn the client to the side.
d. Move furniture away from the client.
10.A A nurse is providing discharge instructions to a client who has a partial-thickness burn on the hand. Which of the following instructions should the nurse include?
a. Change the dressing every 72 hr.
b. Immobilize the hand with a pressure dressing.
c. Take pain medication 30 min after changing the dressing.
d. Wrap fingers with individual dressings.
11.A A home health nurse is assigned to a client who was recently discharged from a rehabilitation center after experiencing a right-hemispheric stroke. Which of the following neurologic deficits should the nurse expect to find when assessing the client? (Select all that apply.)
a. Expressive aphasia
b. Visual spatial deficits
c. Left hemianopsia
d. Right hemiplegia
e. One-sided neglect
12. An older adult client is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration?
a. Serum sodium level 145 mEq/L
b. Forearm skin tents when pinched
c. Respiratory rate decreased
d. Urine specific gravity 1.045
13.A A nurse is assessing a client who has had a suspected stroke. The nurse should place the priority on which of the following findings?
a. Dysphagia
b. Aphasia
c. Ataxia
d. Hemianopsia
14.A A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for omeprazole. The nurse should instruct the client that the medication provides relief by which of the following actions?
a. Neutralizing gastric acid
b. Reducing the growth of ulcer-causing bacteria
c. Coating the stomach lining
d. Suppressing gastric acid production
15.A A nurse is providing discharge instructions to a client following an upper gastrointestinal series with barium contrast. Which of the following information should the nurse provide?
a. Increase fluid intake.
b. Take an over-the-counter antidiarrheal medication.
c. Expect black, tarry stools.
d. Follow a low-fiber diet.
16.A A nurse is caring for a client who has type 1 diabetes mellitus and has had acute bronchitis for the past 3 days. Which of the following statements should the nurse include when instructing the client?
a. "Take insulin even if you are unable to eat your regular diet."
b. "It's okay if your ketone levels are temporarily high."
c. "Monitor your blood glucose levels every 12 hours."
d. "Call the provider if your glucose levels reach 170 milligrams per deciliter."
17.A A nurse is caring for a client who has bilateral pneumonia and an SaO2 of 85%. The client has dyspnea with a productive cough and is using accessory muscles to breathe. Which of the following actions should the nurse take first?
a. Obtain a prescription for ABGs.
b. Administer IV antibiotics to the client.
c. Instruct the client to use the incentive spirometer.
d. Place the client in high-Fowler's position.
18.A A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching?
a. "I will monitor my blood pressure while taking this medication."
b. "I should take a vitamin D supplement to increase the effectiveness of the medication."
c. "I should inform the provider if I experience an increased appetite while taking this medication."
d. "I will decrease the amount of protein in my diet while taking this medication."
19.A A nurse in a provider’s office is assessing a client who has migraine headaches and is taking feverfew to prevent headaches. The nurse should identify that which of the following client medications interacts with feverfew.
a. Metoprolol
b. Bupropion c. Naproxen
d. Atorvastatin
20.A A nurse is providing dietary teaching to a client who is postoperative following a thyroidectomy with removal of the parathyroid glands. The nurse should instruct the client to include which of the following foods that has the greatest amount of calcium in her diet?
a. 12 almonds
b. One small banana
c. 1 tbsp peanut butter
d. 1/2 cup tomato juice
21.A A nurse is providing teaching to an older adult female client who has stress incontinence and a BMI of 32. Which of the following statements by the client indicates an understanding of the teaching?
a. "I am taking my progesterone daily."
b. "I am dieting to lose weight."
c. "I am limiting my daily fluid intake."
d. "I have switched my morning cups of coffee to hot tea."
22.A A nurse is caring for a client who has pancreatitis. The nurse should expect which of the following laboratory results to be below the expected reference range?
a. Amylase
b. Alkaline phosphatase
c. Bilirubin d. Calcium
23.A A nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. Which of the following statements should the nurse identify as an indication that the client understands the teaching?
a. "I will wash the ink markings off the radiation area after each treatment."
b. "I will use my hands rather than a washcloth to clean the radiation area."
c. "I will be able to be out in the sun 1 month after my radiation treatments are over."
d. "I will use a heating pad on my neck if it becomes sore during the radiation therapy." The client
24.A A nurse is caring for a client who is undergoing hemodialysis to treat end-stage kidney disease (ESKD). The client reports muscle cramps and a tingling sensation in their hands. Which of the following medications should the nurse plan to administer?
a. Epoetin alfa
b. Furosemide
c. Captopril
d. Calcium carbonate
25.A A nurse is reviewing the laboratory results of a client who has cirrhosis. Which of the following laboratory values should the nurse expect?
a. Decreased prothrombin time b. Elevated bilirubin level
c. Decreased ammonia level
d. Elevated albumin level
26.A A nurse is providing discharge teaching to a client who has heart failure and a new prescription for a potassium-sparing diuretic. Which of the following information should the nurse include in the teaching?
a. Try to walk at least three times per week for exercise.
b. To increase stamina, walk for 5 min after fatigue begins.
c. Take over-the-counter cough medicine for persistent cough.
d. Use a salt substitute to reduce sodium intake.
27.A A nurse has received a change-of-shift report for a group of clients. Which of the following clients should the nurse assess first?
a. A client who is 1 day postoperative following abdominal surgery and reports pain of 4 on a scale of 0 to 10
b. A client who had a myocardial infarction (MI) 4 days ago and is asking for a PRN sublingual nitroglycerin tablet
c. A client who has atopic dermatitis manifesting with scaling and excoriation of the skin and reports severe itching
d. A client who has pneumonia manifesting with bilateral crackles and diminished breath sounds
28.A A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following assessment findings should the nurse expect?
a. Positive Trousseau's sign
b. 4+ deep tendon reflexes
c. Deep respirations
d. Hypoactive bowel sounds
29.A A nurse is caring for a client who has a new diagnosis of hyperthyroidism. Which of the following is the priority assessment finding that the nurse should report to the provider?
a. Restlessness
b. T3 level 215 ng/dL
c. Blood pressure 170/80 mm Hg
d. Decreased weight
30.A A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. Which of the following prescribed medications should the nurse instruct the client to withhold for 48 hr prior to cardioversion?
a. Enoxaparin
b. Metformin
c. Diazepam d. Digoxin
31.A A nurse is caring for a client who has viral pneumonia. The client’s pulse oximeter readings have fluctuated between 79% and 88% for the last 30 minutes. Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen?
a. Non-Rebreather mask
b. Venturi mask
c. Simple face mask
d. Partial rebreather mask
32.A A nurse is planning care for a client who has extensive burn injuries and is
immunocompromised. Which of the following precautions should the nurse include in the plan of care to prevent pseudomonas aeruginosa infection?
a. Encourage the client to eat raw fruits and vegetables.
b. Avoid placing plants or flowers in the client's room.
c. Limit visitors to members of the client's immediate family.
d. Wear an N95 respirator mask when providing care to the client.
33.A A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pneumonia. Which of the following assessment findings is the nurse’s priority?
a. Temperature 38.4º C (101.1º F)
b. Increased respiratory secretions
c. Fluid intake of 200 mL in the prior 8 hr
d. Limited range of motion
34.A A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take first?
a. Check laboratory values for recent hemoglobin and hematocrit levels.
b. Establish a peripheral IV line for possible transfusion.
c. Call the laboratory to obtain a stat platelet count.
d. Obtain vital signs.
35.A A nurse is assessing a client who had extracorporeal shock wave lithotripsy (ESWL) 6 hours ago. Which of the following findings should the nurse expect?
a. Stone fragments in the urine
b. Fever
c. Decreased urine output
d. Bruising on the lower abdomen [Show Less]