5. A client being treated for hypertension returns to the community clinic for follow up.
The client says, "I know these pills are important, but I just
... [Show More] can't take these water pills
anymore. I drive a truck for a living, and I can't be stopping every 20 minutes to go to the
bathroom." Which of these is the best nursing diagnosis?
A) Noncompliance related to medication side effects
B) Knowledge deficit related to misunderstanding of disease state
C) Defensive coping related to chronic illness
D) Altered health maintenance related to occupation
The correct answer is A: Noncompliance related to medication side effects
16. When teaching effective stress management techniques to a client 1 hour before
surgery, which of the following should the nurse recommend?
A) Biofeedback
B) Deep breathing
C) Distraction
D) Imagery
The correct answer is B: Deep breathing
17. When observing 4 year-old children playing in the hospital playroom, what activity
would the nurse expect to see the children participating in?
A) Competitive board games with older children
B) Playing with their own toys along side with other children
C) Playing alone with hand held computer games
D) Playing cooperatively with other preschoolers
The correct answer is D: Playing cooperatively with other preschoolers
18. The nurse is assessing a 4 month-old infant. Which motor skill would the nurse
anticipate finding?
A) Hold a rattle
B) Bang two blocks
C) Drink from a cup
D) Wave "bye-bye"
The correct answer is A: Hold a rattle
19. When teaching a 10 year-old child about their impending heart surgery, which form of
explanation meets the developmental needs of this age child?
A) Provide a verbal explanation just prior to the surgery
B) Provide the child with a booklet to read about the surgery
C) Introduce the child to another child who had heart surgery 3 days ago
D) Explain the surgery using a model of the heart
The correct answer is D: Explain the surgery using a model of the heart
20. The parents of a child who has suddenly been hospitalized for an acute illness state
that they should have taken the child to the pediatrician earlier. Which approach by the
nurse is best when dealing
with the parents' comments?
A) Focus on the child's needs and recovery
B) Explain the cause of the child's illness
C) Acknowledge that early care would have been better
D) Accept their feelings without judgment
The correct answer is D: Accept their feelings without judgment
21. When caring for a client with total parenteral nutrition (TPN), what is the most
important action on the part of the nurse?
A) Record the number of stools per day
B) Maintain strict intake and output records
C) Sterile technique for dressing change at IV site
D) Monitor for cardiac arrhythmias
The correct answer is C: Sterile technique for dressing change at IV site
22. When caring for a client who is receiving a thrombolytic agent to open a clot
occluded coronary artery after a myocardial infarction, which finding would be of
greatest concern to the nurse?
A) Sero sanginous drainage from gums
B) Hematemesis
C) Pink frothy sputum
D) Slight red color at urine
The correct answer is B: Hematemesis
23. A 52 year-old client is being transfused with one unit of packed cells. A half hour after
the transfusion was initiated, the client complains of chills and headache. Which action
should the nurse
implement first?
A) Notify the health care provider
B) Check the client's temperature
C) Stop the transfusion
D) Obtain a urine specimen
The correct answer is C: Stop the transfusion
24. An adolescent client is hospitalized with menarthrosis from a Hemophilia A bleeding
episode. Which order should be questioned by the nurse?
A) Passive range of motion
B) Replacement of factor VIII
C) Aspirin for pain management
D) Immobilization splint
The correct answer is C: Aspirin for pain management
25. The nurse is giving instructions to the mother of a newborn infant with oral
candidiasis. Which statement by the mother would indicate the need for further teaching?
A) "Nystatin should be given 4 times a day after my baby eats."
B) "I will boil the nipples and pacifiers for twenty minutes."
C) "I should be taking the medication prescribed for this infection."
D) "The therapy can be discontinued when the spots disappear."
The correct answer is D: "The therapy can be discontinued when the spots disappear."
26. The nurse is preparing a client for discharge following in-patient treatment for
pulmonary tuberculosis. Which of these instructions should be given to the client?
A) Continue medication until findings are relieved
B) Continue medication use as prescribed
C) Avoid contact with children, pregnant women or immune depressed persons
D) Take medication with Amphogel if epigastric distress occurs
The correct answer is B: Continue medication use as prescribed
27. The nurse is administering an intravenous piggyback infusion of penicillin. Which of
the following client statements would require the nurse's immediate attention?
A) "I have a burning sensation when I urinate."
B) "I have soreness and aching in my muscles."
C) "I am itching all over."
D) "I have cramping in my stomach."
The correct answer is C: "I am itching all over."
28. A woman diagnosed with bipolar disorder is to take lithium (Lithane) as part of the
treatment. What should the nurse discuss with the client as part of the teaching plan?
A) Risks of oral contraceptives
B) Reduction in exercise program
C) Avoidance of alcohol
D) Cessation of smoking
The correct answer is C: Avoidance of alcohol
29. The nurse prepares to administer eye drops to a 6 year-old child. Which of these
demonstrates the correct method for instillation of eye drops?
A) Directly on the anterior surface of the eyeball
B) In the corner where the lids meet
C) Under the upper lid as it is pulled upward
D) In the conjunctival sac as the lower lid is pulled down
The correct answer is D: In the conjunctival sac as the lower lid is pulled down
30. A depressed client is experiencing severe insomnia. The health care provider orders
trazadone (Desyrel). The nurse tells the client to expect
A) Improvement of acne
B) Relief of insomnia
C) Reduced arthritic pain
D) Less nasal stuffiness
The correct answer is B: Relief of insomnia [Show Less]