• A client has returned from a cardiac catheterization. Which one of the
... [Show More] followingassessmentswouldindicatetheclientisexperiencingacomplicationfromtheprocedure?
A) Increasedbloodpressure
B) Increasedheartrate
C) Lossofpulseintheextremity
D) Decreasedurineoutput
ThecorrectanswerisC: Lossofpulsein theextremity
• Anursechecksaclientwhoisonavolume-cycledventilator.Whichfindingindicatesthattheclientmayneedsuctioning?
A) drowsiness
B) complaintofnausea
C) pulserateof92D)restlessness
ThecorrectanswerisD:restlessness
• WhichinformationisapriorityfortheRNtoreinforcetoanolderclientafterintravenouspylegraphy?
A) Eatalightdietfortherestoftheday
B) Restforthenext24hourssincethepreparationandthetestistiring.
C) Duringwakinghoursdrinkatleast18-ounceglassoffluideveryhourforthenext2days
D) Measuretheurineoutputforthenextdayandimmediatelynotifythehealthcareproviderifitshoulddecrease.
ThecorrectanswerisD:Measuretheurineoutputforthenextdayandimmediatelynotifythehealthcareproviderifitshoulddecrease.
• Aclienthasalteredrenalfunctionandisbeingtreatedathome.Thenurserecognizesthatthemostaccurateindicatoroffluidbalanceduringtheweeklyvisitsis
A) differenceintheintakeandoutput
B) changesinthemucousmembranes
C) skinturgor
D) weeklyweight
ThecorrectanswerisD:weeklyweight
• Thenurseisabouttoassessa6month-oldchildwithnonorganicfailure-tothrive(NOFTT).Uponenteringtheroom,thenursewouldexpectthebabytobe
A) Irritableand"colicky"withnoattemptstopulltostanding
B) Alert,laughingandplayingwitharattle,sittingwithsupport
C) SkincolorduskywithpoorskinturgoroverabdomenD)Pale,thinarmsandlegs,uninterestedinsurroundings
ThecorrectanswerisD:Pale,thinarmsandlegs,uninterestedinsurroundings
• As the nurse is speaking with a group of teens which of these side effects ofchemotherapyforcancerwouldthenurseexpectthisgrouptobemoreinterestedinduringthediscussion?
A) Mouthsores
B) Fatigue
C) DiarrheaD)Hairloss
ThecorrectanswerisD:Hairloss
•
• A14 year-old with ahistoryofsicklecelldiseaseis admittedto the hospitalwithadiagnosis of vaso-occlusive crisis. Which statements by the client would be mostindicativeoftheetiologyofthiscrisis?
A) ”Iknewthiswouldhappen.I'vebeeneatingtoomuchredmeatlately."
B) ”Ireally enjoyedmyfishingtripyesterday.Icaught 2fish."
C) ”Ihavereallybeenworkinghardpracticingwiththedebateteamatschool."D)”IwenttothehealthcareproviderlastweekforacoldandIhavegottenworse."ThecorrectanswerisD:"IwenttothedoctorlastweekforacoldandIhavegottenworse."
• Whichthesefindingswouldthenursemorecloselyassociatewithanemiaina10month-oldinfant?
A) Hemoglobinlevelof12 g/dI
B) Palemucosaoftheeyelidsandlips
C) Hypoactivity
D) Aheartratebetween140to160
ThecorrectanswerisB:Palemucosaoftheeyelidsandlips
• Thenurseiscaringforaclientinhypertensivecrisisinanintensivecareunit.The
priorityassessmentinthefirsthourofcareis
A) Heartrate
B) Pedalpulses
C) Lung soundsD)Pupilresponses
ThecorrectanswerisD:Pupilresponses
• Whichoftheseclientswho areallin theterminalstageofcancer is leastappropriatetosuggesttheuseofpatientcontrolledanalgesia(PCA)with apump?
A) AyoungadultwithahistoryofDown'ssyndrome
B) Ateenagerwhoreadsata4thgradelevel
C) AnelderlyclientwithnumerousarthriticnodulesonthehandsD)Apreschoolerwithintermittent episodesofalertness
ThecorrectanswerisD:Apreschoolerwithintermittentepisodesofalertness
• While caring for a client who was admitted with myocardial infarction (MI) 2 daysago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degreesCelsius).Theappropriate
nursinginterventionisto
A) Callthehealthcareprovider immediately
B) Administeracetaminophenasorderedasthisisnormalatthistime
C) Sendblood,urineandsputumforculture
D) Increasetheclient's fluid intake
ThecorrectanswerisB:Administeracetaminophenasorderedasthisisnormalatthistime
• A clientis admitted for first and second degreeburns ontheface,neck,anteriorchestandhands.Thenurse'spriorityshouldbe
A)CovertheareaswithdrysteriledressingsB)Assessfordyspneaorstridor
C) Initiateintravenoustherapy
D) Administerpainmedication
ThecorrectanswerisB:Assessfordyspneaorstridor
• Whichoftheseclientswhocallthecommunityhealthclinicwouldthenurseasktocomeinthatdaytobeseenbythehealthcareprovider?
A) Istartedmyperiodandnowmyurinehasturnedbrightred.
B) IamandiabeticandtodayIhavebeengoingtothebathroomeveryhour.
C) Iwasstartedonmedicineyesterdayforaurineinfection.NowmylowerbellyhurtswhenIgotothebathroom.
D) I went to the bathroom and my urine looked very red and it didn’t hurt when I went.ThecorrectanswerisD:Iwenttothebathroomandmyurinelookedveryredanditdidn’thurtwhenI
went.
• Amiddleagedwomantalkstothenurseinthehealthcareprovider’sofficeaboututerine fibroids also called leiomyomas or myomas. What statement by the womanindicatesmoreeducationisneeded?
A) Iamoneoutofevery4womenthatgetfibroids,andofwomenmyage–betweenthe30sor40s,fibroidsoccursmorefrequently.
B) Myfibroidsarenoncanceroustumorsthatgrowslowly.
C) MyassociatedproblemsIhavehadarepelvicpressureandpain,urinaryincontinence,frequenturinationorurineretentionandconstipation.
D) Fibroidsthatcausenoproblemsstill needtobetakenout.
Thecorrectansweris D:Fibroidsthatcauseno problemsstillneedto be takenout.
• Anelderlyclientadmittedafterafallbeginstoseizeandlosesconsciousness.Whatactionbythenurseisappropriatetodonext?
A) Staywithclientandobserveforairwayobstruction
B) Collect pillows andpadthe side railsofthe bed
C) Placeanoralairwayinthemouthandsuction
D) Announceacardiacarrest,andassistwithintubation
ThecorrectanswerisA:Staywithclientandobserveforairwayobstruction
• Thenurseisteachingan87year-oldclientmethodsformaintainingregularbowelmovements.ThenursewouldcautiontheclienttoAVOID
A) Glycerinesuppositories
B) FibersupplementsC)Laxatives
D)Stoolsofteners
ThecorrectanswerisC:Laxatives
• A clientwithdiarrheashouldavoidwhich [Show Less]