3.A 24-year-old female client is scheduled for surgery in the morning. Which of the following is the primary responsibility of the nurse?A.Taking the
... [Show More] vital signsB.Obtaining the permitC.Explaining the procedureD.Checking the lab work
Answer A: The primary responsibility of the nurse is to take the vital signs before any surgery. The actions in answers B, C, and D are the responsibility of the doctor and, therefore, are incorrect for this question.
4.The nurse is working in the emergency room when a client arrives with severe burns of the left arm, hands, face, and neck. Which action should receive priority?A.Starting an IVB.Applying oxygenC.Obtaining blood gasesD.Medicating the client for painAnswer B: The client with burns to the neck needs airway assessment and supplemental oxygen, so applying oxygen is the priority. The next action should be to start an IV and medicate for pain,making answers A and C incorrect. Answer D, obtaining blood gases, is ordered by the doctor.
5.The nurse is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instruction should be given to the client?A.Rest in bed after taking the medication for at least 30 minutesB.Avoid rapid movements after taking the medicationC.Take the medication with water only
D.Allow at least 1 hour between taking the medicine and taking other medicationsAnswer B: The client with burns to the neck needs airway assessment and supplemental oxygen, so applying oxygen is the priority. The next action should be to start an IV and medicate for pain,making answers A and C incorrect. Answer D, obtaining blood gases, is ordered by the doctor.
6.The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs. Which equipment should be kept at the bedside?A.A pair of forcepsB.A torque wrenchC.A pair of wire cuttersD.A screwdriverAnswer B: A torque wrench is kept at the bedside to tighten and loosen the screws of crutchfield tongs. This wrench controls the amount of pressure that is placed on the screws. A pair of forceps, wire cutters, and a screwdriver, in answers A, C, and D, would not be used and, thus, areincorrect.
7.An infant weighs 7 pounds at birth. The expected weight by 1 year shouldbe:A.10 poundsB.12 poundsC.18 poundsD.21 pounds
Answer D: A birth weight of 7 pounds would indicate 21 pounds in 1 year, or triple his birth weight. Answers A, B, and C therefore are incorrect.
8.A client is admitted with a Ewing's sarcoma. Which symptoms would be expected due to this tumor's location?A.HemiplegiaB.AphasiaC.NauseaD.Bone painAnswer D: Sarcoma is a type of bone cancer; therefore, bone pain would be expected. Answers A, B, and C are not specific to this type of cancer and are incorrect.
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9.The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value might indicate a serious side effect of this drug?A.Uric acid of 5mg/dLB.Hematocrit of 33%C.WBC 2,000 per cubic millimeterD.Platelets 150,000 per cubic millimeterAnswer C: Tegretol can suppress the bone marrow and decrease the white blood cell count; thus, a lab value of WBC 2,000 per cubic millimeter indicates side effects of the drug. Answers A and D are within normal limits, and answer B is a lower limit of normal; therefore, answers A, B, andD are incorrect.
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10.A 6-month-old client is admitted with possible intussuception. Which question during thenursing history is least helpful in obtaining information regarding this diagnosis?A."Tell me about his pain."B."What does his vomit look like?"C."Describe his usual diet."D."Have you noticed changes in his abdominal size?"Answer C: The least-helpful questions are those describing his usual diet. A, B, and D are useful in determining the extent of disease process and, thus, are incorrect.11.The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be avoided?A.BranB.Fresh peachesC.Cucumber saladD.Yeast rollsAnswer C: The client with diverticulitis should avoid foods with seeds. The foods in answers A, B, and D are allowed; in fact, bran cereal and fruit will help prevent constipation.12.A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period?A.Teaching how to irrigate the illeostomyB.Stopping electrolyte loss in the incisional areaC.Encouraging a high-fiber diet
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