PN COMPREHENSIVE A
PN COMPREHESIVE GUIDE(ONLINE PROCT 2014)
1. A client begins treatment with phenytoin (Dilantin). Which following should the
... [Show More] nurse reinforce as a measure to help minimize possible adverse effects of this medication?
A. Performing daily gum massage
2. A nurse who is facilitating a support group notices that one client in the group is extremely talkative, to the point where others in the group have difficulty sharing their own ideas. Which of the ff. strategies should the nurse use to facilitate the group process with this client?
A. Speak privately to the client about this behavior.
3. The partner of a client who died from leukemia tells a nurse, “It’s so unfair that God took him from me. I just can’t live without him.”. Which of the following ac- tions by the nurse is the priority?
A. Ask the client she has had suicidal thoughts.
4. A nurse is preparing to remove a client’s peripheral IV catheter. Which of the fol- lowing actions should the nurse plan to take?
A. Maintain the catheter parallel to the vein when withdrawing the catheter.
5. A nurse is reinforcing teaching to the parents of a newborn who has a new pre- scription for nystatin (Mycostatin) for oral candidiasis. Which of the following should the nurse include in the teaching?
A. Instill the medication 1 hr. after feeding.
6. A nurse is reinforcing teaching about an IV urography (IVP) with the parent of a 3yr. old child. Which of the ff. statements indicates the parent understands the teaching?
A. My child will need to have a soapsuds enema before this procedure.
7. A nurse is reinforcing teaching with the parent of a school-age child who has nephrotic syndrome with peripheral edema. Which of the ff. statements by the par- ent indicates understanding of the teaching?
A. I will provide a low-sodium diet for my child.
8. A nurse is caring for a client who is on complete bed rest and is unable to change positon in bed without assistance. The nurse delegates the task of repositioning the client every 2 hr. to an assistive personnel(AP). Which of the ff. is an appropri- ate method to ensure that the AP has performed the task correctly?
A. Check that the client is in a new position every 2hr.
9. A newly hired nurse discovers that some medication doses provided on a client’s medication record have not been updated since yesterday. Coworkers admit that new changes in the medication orders have not been processed yet, but they ad- vise the nurse to administer the new prescriptions anyway. The nurse should notify which of the ff.?
A. The nurse manager.
10. A registered nurse and a licensed practice nurse (LPN) on a medical–surgical unit are collaborating to provide care for a group of clients. The LPN should recog- nize that which of the ff. tasks are not within the LPN scope of practice?
A. Develop a plan of care for a client who requires bladder training.
11. Which of the ff. should a nurse recognize as indicative of a positive client re- sponse to systematic desensitization for treatment of a phobia?
A. The client remains relaxed when thinking of the phobia.
12. A nurse in a long-term care facility is reviewing standard precaution guide- lines with an assistive personnel(AP). The nurse should instruct the AP that which of the ff. should be used to clean up a blood spill?
A. Chlorine bleach solution.
13. A nurse is caring for a client who is 3 days postoperative ff. a transurethral resection of the prostate and has an indwelling urinary catheter. Which of the ff. findings should the nurse expect?
A. Yellow urine with red sediment.
14. A nurse is preparing to administer cephalexin (Keflex) to a client when he states, “ I just remembered that I have an allergy to penicillin. “Which of the ff. ac- tions should the nurse take?
A. Call the provider who prescribed the medication.
15. A nurse is observing a newly licensed nurse who is providing tracheostomy care for a client. The nurse identifies proper performance of the procedure when the newly licensed nurse selects which of the ff. solutions to clean the inner can- nula?
A. Hydrogen peroxide.
16. A nurse is working with an interpreter to explain a diagnostic procedure to a client who does not speak English. Which of the ff. actions should the nurse take?
A. Ensure the interpreter is culturally compatible with the client.
17. A client 12 hr. postoperative cholecystectomy was given morphine 10mg in- travenously at 0700. The nurse marking rounds at 0720 should recognize which of the ff. as an adverse effect of the medication?
A. Respiratory rate 10/min
18. A nurse is inserting an indwelling catheter into a female client who has uri- nary retention. After urine is seen in the tubing, which of the ff. actions should the nurse take next?
A. Advance the catheter 2.5 to 5 cm.
19. A nurse is administering morning medication to clients on the unit. A client questions the nurse regarding a medication that she does not recognize. Which of the ff. nursing interventions should the nurse take first?
A. Verify the prescription in the client’s medical record.
20. A nurse is reinforcing teaching regarding prenatal discomfort to a client who is at 20 weeks of gestation. Which of the ff. statements made by the client indi- cates an understanding of the teaching?
A. I will wear a supportive bra overnight.
21. A nurse is caring for a client who has leukemia and is experiencing stomati- tis ff. treatment. Which of the ff. is an appropriate diet selection by the nurse?
A. Oatmeal and apple sauce
22. A nurse is reinforcing teaching for a client who has coronary artery disease and is taking low-dose aspirin daily. The nurse should reinforce that this medica- tion regimen has which of the ff. therapeutic effects?
A. Antiplatelet
23. A nurse is discussing STIs with a group of adolescents at a health fair. Which of the ff. is an appropriate statement?
A. An infection with Neisseria gonorrhoeae may result in infertility.
24. A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) to treat major depressive disorder. After the procedure, which of the ff. ac- tions should the nurse take?
A. Orient the client frequently.
25. A nurse is contributing to the plan of care for a client who is newly diag- nosed with iron deficiency anemia. Which of the ff. should the nurse include in the client’s diet plan?
A. Dried beans
26. A nurse working in a long-term care facility discovers a client has fallen and appears to have injured his neck. After calling for help, which of the ff. actions should the nurse take?
A. Place a rolled blanket on each side of the client’s head.
27. A nurse is reinforcing client teaching on relaxation techniques during labor. Which of the ff. indicates a need for further client teaching?
A. I will wait until I go into labor to decide if I will use hypnosis as a relaxation tech- nique.
28. A nurse is caring for a client experiencing hypovolemic shock. Which of the ff. actions should the nurse take?
A. Elevate the clients leg.
29. A nurse in a provider’s office is auscultating the lung sounds of an older adult client and notices small, circular burn marks on her back and trunk. Which of the ff. actions is appropriate for the nurse to take?
A. Interview the client privately about the burn marks.
30. A nurse is reinforcing discharge teaching with a client who has undergone vein ligation and stripping. Which of the ff. instructions should the nurse include?
A. Preform range of motion exercises
31. A nurse is contributing to the plan for care for a client who has a nasogastric tube and is receiving continuous enteral feedings. Which of the ff. should the nurse include in the plan?
A. Measure the pH of gastric tube aspirate prior to administering nutrition.
32. When preparing a client for an enteral feeding, a nurse notices that the pump at the client’s bedside is very hot to the touch. Which of the ff. actions should the nurse take?
A. Unplug the equipment and remove it from the room.
33. A nurse is reinforcing teaching for a client who is taking spironolactone (Al- dactone). Which of the ff. dietary choices should the client limit?
A. Cantaloupe
34. A nurse is caring for a client who has been prescribed amitriptyline. After 1 week, the client calls the provider’s office and states, “I’m not taking these pills anymore. They are not doing anything”. Which of the ff. response by the nurse is appropriate?
A. It may take up to 4 weeks before you feel a difference when taking this medica- tion.
35. A nurse is caring for an older adult client who had surgery for a ruptured ap- pendix 3 days ago the client has a tube in place. Which of the ff. should the nurse do to determine whether or not peristalsis is restored?
A. Auscultate for bowel sounds.
36. A nurse is working in a long-term care facility. Which of the ff. actions should the nurse take when using computer-based client records?
A. Shred printouts of client care information when they are no longer needed.
37. A nurse working in a community clinic is caring for an adolescent who has infectious mononucleosis. The client the nurse to explain how the disease was ac- quired. The nurse explains that an individual acquires this disease which of the ff.
A. Sharing eating utensils with an infected person.
38. A nurse is reinforcing discharge teaching for a client who has a new colostomy. Which of the ff. statements made by the client indicates an understand- ing of the teaching?
A. “I will open the bottom of the pouch to empty the contents before I remove it.”
39. A nurse is preparing the administer NPH (Novolin N) insulin to a client who has diabetes mellitus before breakfast at 0700. At which of the ff. times should the nurse plan to check the client for hypoglycemia?
A. 1100
40. A nurse in a clinic is obtaining a health history from a client scheduled to un- dergo a cardiac catheterization in 2 days. Which of the ff. questions is the most im- portant for the nurse to ask?
A. “Do you know if you’re allergic to iodine?”
41. A nurse in an urgent-care facility is collecting data from a client who is scheduled for a procedure. Which of the ff. clinical manifestations indicates a possi- ble latex allergy?
A. Rhinorrhea
42. A nurse in a provider’s office is reinforcing teaching with a client who has a new prescription for ferrous sulfate elixir. Which of the ff. statements by the client demonstrates understanding of the teaching?
A. “I will rinse my mouth after taking this medication.”
43. A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client who is at risk for a deep thrombosis. Which of the following actions the AP is applying the stockings correctly?
A. The AP applies the stockings before getting the client out of bed.
44. A nurse working in a provider’s office receives a phone call from the parent of a school-age child who has varicella (chickenpox). The parent asks the nurse when the child can return to school. Which of the ff. responses by the nurse is cor- rect?
A. “When all the blisters are scabbed over.”
45. A nurse is caring for a client who just had blood drawn for an arterial blood gas analysis. Which of the ff. values should the nurse expect if the client is in respi- ratory acidosis?
A. PaCO2 51 mm Hg
46. A nurse is reinforcing teaching with a client who has a new prosthesis for an above the knee amputation of the right leg. Which of the ff. instructions should the nurse reinforce to the client?
A. Apply the prosthesis immediately upon waking each day.
47. A nurse is preparing a client for the insertion of an NG tube. Which of the ff. actions should the nurse take?
A. Determine if the client has a deviated septum.
48. A nurse is caring for a client who has a fractured radius and has a short arm cast applied yesterday. Which of the ff. findings should the nurse report to the provider?
A. Client report of decreased sensation in the finger.
49. A nurse is contributing to the plan of care for a client who is on suicide pre- cautions. Which of the ff. interventions is appropriate for the nurse to recommend?
A. Encourage the client to sign a no-harm contract.
50. A nurse is preparing to administer haloperidol (Haldol) 4 mg IM start to a client. Available is haloperidol for injection mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if applica- ble. Do not use a trailing zero.)
A. 0.8 mL
51. A nurse is caring for a client who reports an excruciating headache, nuchal rigidity, nausea and vomiting, and fever with chills. Which of the following diagnostics tests should the nurse expect to be prescribed?
A. Cerebrospinal fluid analysis
52. A nurse is discussing alopecia with a client who is scheduled to begin chemotherapy. Which of the following statements is appropriate for the nurse to make?
A. If you’d like to wear a wig, you should select it before hair loss occurs
53. A change nurse in a long-term care facility observes an assistive personnel (AP) who appears to be under the influence of alcohol. Which of the following actions should the nurse take first?
A. Confront the AP about suspected impairment
54. A nurse is caring a client who has asthma and has a prescription for theophylline (theochron) 200mg PO BID. Which of the following should the nurse include in the teach- ing?
A. Discontinue drinking caffeinated beverages
55. While a nurse is assisting a client to ambulate, the client reports lightheadedness and begins to fall. Which of the following nursing actions demonstrates a correct under- standing by the nurse about ergonomic principles?
A. Spread feet apart and extend one leg for the client to slide down while lowering the client to the floor
56. A nurse is caring for an older adult client who appears lethargic and somnolent. The nurse reviews the client’s medications prior to contacting the provider. Which of the fol- lowing medication is the likely cause of the increased sedation?
A. Lorazepam (Ativan)
57. A nurse is caring for a client who had a bronchoscopy and just arrived to the medical surgical unit. Which of the following actions should the nurse perform first?
A. Check for a gag reflex
58. A client is requesting information form a nurse regarding the appointment of a health care proxy. Which of the following responses by the nurse is appropriate?
A. The person you appoint will make health care decision for you if you cannot do so yourself.
59. A nurse enters client’s room and sees smoke coming from a wastebasket next to the bed. Which of the following actions should the nurse first?
A. Assist the client to a nearby waiting area
60. A nurse is interviewing clients as part of a skin cancer screening program. Which of the following statement made by a client indicates that he may have a premalignant le- sion?
A. I have this flat, scaly area with red edge on neck
61. A nurse is caring for a client who reports 12 liquid stools in the past 8hr. Which of the following findings indicates that the client is experience dehydration?
A. Potassium level 2.5 mg/L
62. A nurse is talking with a client whose son died in a motor vehicle crash 2 weeks. The client states, “I really thought I’d be back to my usual routines by now, but I can’t think of anything else except that my son is gone.” Which of the following is an appropriate re- sponse?
A. Grieving for your son is hard work, It will take as much time as you need to come to terms with your loss.
63. A nurse in a long-term care facility is providing postmortem care for a client. Which of the following actions should the nurse take first?
A. Check with the family about religious practices
64. A nurse is delegating the administration of an enema to an assistive personnel (AP). Which of the following actions should the nurse take?
A. Explain the expected outcome to the AP
65. A nurse is reinforcing teach with the parent of a toddler who has acute otitis media. Which of the following instructions should the nurse give the parent?
A. Give acetaminophen (Tylenol) for discomfort
66. A nurse is reinforcing teaching with a client who is reeving radiation therapy for can- cer of the larynx. Which of the following statements made by the client indicates under- stand of the instructions?
A. I will wear a soft scarf around my neck when I am outside
67. A nurse is reviving a client’s medication record. He recognizes that a double does of oral digoxin (lanoxin) was administered 1 hr. ago. Which of the following actions should the nurse take first?
A. Obtain a set of vital signs
68. A nurse enters a client’s room with a prescribed IM medication. The client refuses the injection, but the nurse administers it anyway. This action by the nurse is an example of which of the following?
A. Battery
69. A nurse is caring for a client who is postpartum and has deep-vein thrombosis. The client has be receiving heparin via IV infusion. Which of the following medications should the nurse ensure is readily available?
A. Protamine sulfate
70. A nurse is preparing to administer a client’s morning medications. Which of the fol- lowing actions should the nurse take to verify the client’s identity?
A. Scan the facility identification band
71. A newborn passes her first stool within 24 hr. after deliver. The nurse recognize that the newborn’s stool is normal because it is
A. dark green and viscous
72. A nurse is caring for a client who has hepatitis A. The nurse should recognize that this type of hepatitis can be transmitted through
A. contaminated food
73. A nurse is collecting data from a client who has Tourette syndrome. The client re- ports taking haloperidol (Haldol) 0.5 mL orally three times a day at home. Which of the following components of the prescription should the nurse question?
A. Dosage
74. A nurse is collecting data from a client who has a head injury and has a Glasgow Coma Scale score of 15. Which of the following finding should the nurse expect?
A. Oriented and obeys commands
75. A nurse is collecting data from a client in the diagnostic center who is scheduled to undergo a colonoscopy. Based on the information provided in the clients’ chart, which of the following places this client at risk for colorectal cancer
A. IBM
76. A nurse is having a discussion with a group of parents regarding prevention of sud- den infant death syndrome (SIDS). Which of the following informant should the nurse in- clude in the discussion?
A. Use a firm mattress to the crib
77. A client in a mental health facility unjustly accuses a nurse of the stealing money from his hospital room. Which of the following is an appropriate therapeutic response by the nurse?
A. Tell me how you decide who took your money
78. A nurse receives a telephone call from a client who has type 2 diabetes mellitus and reports having influence for the past 24 hr. Which of the following instructions should the nurse include?
A. Drink 240 mL (8oz) of sugar-free liquid every hour
79. A client is In the end stage of AIDS. She tells the nurse “I knew this day would come, but I’m still so scared.” Which of the following is the appropriate response by the nurse?
A. Share your thoughts with me
80. A nurse in a long-term care facility is serving on the ethics committee, which is ad- dressing a client care dilemma. Which of the following strategies will facilitate resolving the dilemma? (Select all that apply.)
A. Determine the facts related to the dilemma Identify possible solutions
Consider the client’s wishes
81. A nurse is receiving change-of shift report on four clients. The nurse should plan to collect data on which of the following clients first?
A. A client who has asthma who had frequent exacerbations on the previous shift
82. A long-term care nurse notices notices a client who has Alzheimer’s disease standing at the exit doors at the end of the hallway. The client appears to be anxious and agi- tated. Which of the following actions would the nurse take?
A. Escort the client to a quiet area on the nursing unit.
83. A nurse is collecting date from a client who has left sided heart failure. Which of the following findings should the nurse expect?
A. Due to decrease peripheral perfusion, dizziness is an expected finding in left- sided heart failure.
84. A nurse is assisting a provider who is performing an amniotomy to augment a client’s labor. Following the procedure, which is the priority action by the nurse?
A. obtain fetal heart tones
85. A charge nurse is observing a newly hired nurse apply sterile gloves to perform a sterile dressing change. Which the following actions by the newly hired nurse maintains stile technique?
A. Puts a glove on her dominate hand first
86. A nurse is reinforcing teaching regarding puberty to a group of prepubescent female clients. Which for the following should the nurse include the teaching?
A. You will likely gain weight before you start to get taller
87. A nurse is preparing to administer prednisone 1mg/kg PO to a preschooler who weights 44lb. Available is prednisone oral solution 5mg/1mL. How many mL should the nurse administer? ( round the answer to the nearest whole number. Use a leading zero if applicable. Do not use a trailing zero).
A. 4
88. A nurse is making assignments at the start of a shift. Which of the following task may be delegated to assistive personnel (AP)?
A. Assisting a client who is 2 days postoperative with bathing
89. A nurse is reinforcing teaching with a client who is newly diagnosed with gastroe- sophageal reflux. Which of the following instructions should the nurse include in the teaching?
A. Elevate the head of the bed 15 cm (6in) when sleeping
90. A nurse is caring for a client who is in an impatient mental health unit and has a di- agnosis of depend personality disorder. Which of the following is an expected behavior for this client?
The client calls her partner to ask what she should wear each day
91. An adolescent client is in the emergency department after a motor vehicle crash. The nurse notes that he is experiencing sever anxiety. Which of the following actions should the nurse take a decrease the clients anxiety?
A. Speak to the client using simple sentences
92. A nurse is caring for a client who has COPD and is receiving oxygen at 2 L/min via a nasal cannula. The client is experience respiratory difficulties. Which of the following ac- tions should the nurse take first?
A. Place the client in an orthopnea position
93. A nurse is reinforcing teaching to a client who has tuberculosis (TB). The nurse recog- nizes that the teaching has been effective when the client makes which of the following statements?
A. my family members will need to be tested for TB
94. A nurse in a provider’s office is collecting data from a client who has type 2 diabetes mellitus. Which of the following findings is an expected finding?
Infection
95. A nurse is caring for a group of clients. The nurse should fill out an incident report for which of the following situations?
A visitor who develops a bruise on her head following a syncopal episode
96. A nurse is preparing to administer timolol (Timoptic) eye drops to a client who has glaucoma. The nurse should monitor the client for which of the following adverse effects?
Decreased blood pressure
97. A nurse instructs an assistive personnel (AP) to thicken all liquid offered to a client who has impaired swallowing. Which of the following indicates that the AP needs further instruction?
A. The AP feeds the client ice chips with a spoon.
98. A nurse is collecting data from a client who sustained spinal cord damage from frac- tures to T1 and T2 vertebrae. Which of the following client outcomes should the nurse expect?
Flexes and extends the shoulders
99. A nurse is caring for a client who is at 34 weeks of gestation and has mild preeclamp- sia. Which of the following indicates a progression from mild to severe preeclampsia?
A. Client repots of blurred vision
100. A nurse in a telemetry unit is caring for a client who is recovering from a myocardial infarction. The nurse is monitoring for potential dysrhythmias. Which of the following in- dicates ventricular fibrillation?
Irregular rate without P waves, bizarre and variable QRS
101. A nurse is contributing to the plan of care for a client who sites in a wheelchair most of the day. Which of the following instructions should the nurse include?
A. Use a gel-filled seat cushion
102. A nurse is planning care for a client who has COPD. Which of the following images indicates the appropriate oxygen delivery method the nurse should prepare to use if the client develops an exacerbation?
A. A venture mask delivers a low to moderate controlled concentration of oxygen. Client who have COPD benefit from this delivery system because it provides a consistent level of oxygen regardless of the clients breathing pattern
103. A nurse is caring for child who is in sickle cell crisis. Which of the following is the nurse priority action?
Promote oxygenation
104. A nurse is preparing to administer a dose of digoxin (Lanoxin) to client receiving continuous tube feedings. Which of the following actions should the nurse take?
A. Flush the feeding tube with 30 mL of watering before and after administering the medication
105. A nurse is reinforcing activity limitations with a client who is postoperative following a mastectomy. Which of the following should the nurse include in the teaching?
A. Avoid raising the elbow above the shoulder until drains are removed
106. Due to client reports of inadequate pain management, the staff has selected pain management as an area for improvement. Which of the following strategies should the nurse use to collect data regarding the quality of pain control?
A. Check each client’s level of pain within 1 hr. of the client reeving an oral anal-
gesic
107. A nurse is reinforcing teaching abuse initial management of acute diverticulitis with a newly admitted client. Which of the following statement by the client indicates an un- derstanding of the teaching?
A. I will relive the nutrients I need through my IV fluid
108. A nurse is reinforcing teaching with the parent of a school-age child who has juve- nile idiopathic arthritis. Which of the following instructions should the nurse include?
A. Use heat therapy prior to the physical activities
109. A nurse is reinforcing teaching for a client who has a new diagnosis of type 2 dia- betes mellitus. The client will use an insulin pen for self-administration of insulin. The nurse reinforces psychomotor learning by having the client
A. Perform self-injection of the insulin
110. A nurse in provider’s office is caring for four clients. Which of the following client should the nurse see first?
A. A client who is at 36 weeks of gestation who reports painless vaginal bleeding
111. A nurse is witnessing a client’s signature on a consent form. Which of the following is included among the nurse’s legal responsibilities?
A. Verifying that the client understands the procedure before signing
112. A nurse is collecting data from a client who is taking digoxin (lanoxin) for heart fail- ure. Which of the following findings should the nurse report to the provider as a indica- tion of digoxin toxicity?
A. Anorexia
113. A nurse working in a clinic should recognize that which of the following client condi- tions must be reported to a regulatory agency?
A. A client in respiratory distress is diagnosed with tuberculosis.
114. A nurse is preparing to administer an injection of tetanus toxoid to an adolescent client who stepped on a rusty nail. Which of the following statements by the nurse is ap- propriate?
A. another booster will be needed in 10 years
115. A nurse is reviewing discharge instructions with a new mother regarding car seat safety instructions. Which of the following statements by the mother indicates an under- standing of the teaching?
A. I will secure the car seat in the car by using the seatbelt
116. A nurse on a medical surgical unit is providing care for four clients. The nurse should ensure that informed consent is obtained from the client who is scheduled for which of the following diagnostic procedures?
A. Lumbar puncture
117. A nurse is reviewing a client’s chart and finds that an assistive personnel (AP) recorded the client’s temperature as 35.3C (95.5F) 2 hr. earlier. Which of the following actions should the nurse take first?
A. Check the clients’ temperature
118. A nurse is assisting a client who is to undergo a nonstress test (NST). Which of the following actions should the nurse take?
A. Administer 120 mL (4oz) of orange juice prior to the test.
119. A nurse is reinforcing teaching with a client who has left-sided weakness and is learning how to ambulate with a cane. The nurse knows that the client understands the teaching when she places the cane in which of the following positions when advancing forward?
The cane is held in the hand of the stronger side of the body; in this scenario, it would be the right hand. When ambulating forward, the can is moved forward first (in front of right foot) and the weaker leg is oved forward next, so that the clients body weight is evenly distributed between the cane and the stronger leg.
120. A nurse working at an inpatient mental health facility is contributing to the plan of care for a client who has anorexia nervosa. Which of the following actions should the nurse include in the plan of care?
A. Record the amount of food the client consumes
121. A nurse is discussing home safety with a group of clients who have type 1 diabetes mellitus. Which of the following statements indicates an understand of the teaching?
A. I will dispose of my needles in a plastic laundry detergent container
122. A nurse is visiting the home of a client who recently had a total hip arthroplasty. During Observation of the clients’ home, which of the following findings places the client at risk for falls? (select all that apply.)
A. Medication stored on the top shelf of the cupboard Client walks barefoot in the house
123. A nurse is reinforcing teaching with a client who has a new prescription for nitro- glycerin (nitrostat) sublingual tablets for treatment of angina. Which of the following in- structions should the nurse include?
A. Take up to three tablets during a single angina episode
124. A nurse is caring for a client who has right-sided heart failure. The client’s partner expresses concern that the client will die. Which of the following is an appropriate re- sponse by the nurse?
A. “It is difficult to see someone so sick. What have you have been told about your partner’s prognosis”
125. A nurse in a long-term care facility is auscultating the lung sounds of a client who reports shortness of breath and increase fatigue. Listen to the audio clip. Which of the following lung sounds should the nurse report to the provider?
A. Fine crackles
126. A nurse is reinforcing teaching with a client who is to self-administer epoetin alfa (Epogen). Which of the following instructions should the nurse include.
A. Administer the medication subcutaneously
127. A nurse is caring for a client who has a Salem Sump tube connected to intermittent wall suction. Which of the following nursing interventions should the nurse perform?
Reposition the client every 2 hrs.
128. A nurse is provider’s office is reviewing pediculosis capitis management and pre- vention strategies with the parent of a school-age child. Which of the following strategies should the nurse include? (select all that apply)
A. Store the child’s clothing in a separate cubicle when at school Boil brushes and combs in water for 10 min
Dry bed linens and clothing in a hot dryer for at least 20mins
129. A nurse is contributing to the plan of care for an adolescent who has cystic fibrosis. Which of the following diets should the nurse recommend?
A. High-calorie
130. A nurse is assisting with the transfer of a client to a long-term care facility. The nurse should review which of the following sections of the medical record to the locate information about the clients personal health insurance?
A. Admission sheet
131. A nurse is reinforcing teaching with a client who has a new prescription for pred- nisone for the treatment of Addison’s disease. Which of the ff. instructions should the nurse include?
A. “You will need to schedule a bone density test.”
132. A nurse is assisting in the admission of a client who has diabetic ketoacidosis to a medical unit. Which of the ff. IV solutions the nurse anticipates administering first upon admission?
A. 0.9% sodium chloride
133. A nurse is caring for a client who is postoperative following a thyroidectomy. Which of the following findings is the priority?
A. Tingling around the mouth
134. A client who has asthma and is started on montelukast (Singular) returns to the clinic 1 month later. Which of the ff. indicates that the client is complying with this medi- cation regimen?
A. The client takes the medication once daily at bedtime.
135. A nurse is collecting data from an older adult client who is receiving a unit of packed RBCs. Which of the ff. findings should the nurse report to the provider as an indi- cation of circulatory overload?
A. Crackles heard on auscultation
136. A nurse is preparing a client for surgery. The client states, “I’m sure this surgery will not help me get better.” Which of the ff. responses by the nurse is appropriate?
A. “You’re saying that you are doubtful that this procedure will benefit you.”
137. A nurse is preparing to provide suctioning for a toddler who has a tracheostomy. Which of ff. actions should be included in the plan of care?
A. Allow the child to rest for 45 seconds between aspirations.
138. A nurse is assisting with the plan of care for a client who has chest tube con- nected to a disposable chest tube drainage system. Which of the ff. should the nurse in- clude in the plan of care?
A. Maintain the drainage system below the level of this client’s chest.
139. A nurse in a long-term care facility is assisting with the admission of a client who requires oropharyngeal suction. Which of the ff. supplies does the nurse need to perform this task?
A. Yankauer catheter
140. A nurse is maintaining droplet precautions for a client who has meningitis. Which of the following actions by the nurse is appropriate?
A. Wear a surgical mask within 3 feet of the client.
141. A nurse is collecting data from a client who has cholecystitis. In which of the ff. lo- cations should the nurse expect the client to report pain?
A. Right upper quadrant
142. The parents of a 12-month-old voice their concern that their child is crawling but not pulling herself up to stand like the other children at the day care center. The nurse should recommend to the parents that them.
A. have the child evaluated by a pediatrician.
143. A nurse recognizes that nurse-client communication is effective when the client.
A. asks the nurses to listen to potential solutions.
144. A nurse is caring for a client who is receiving IV fluids. As the nurse enters the room, the IV pump’s alarm begins beeping. The client tells the nurse, “That happens all the time. Just turn off the alarm.” Which of the ff. actions should the nurse take first?
A. Observe the IV site.
145. A nurse is caring for a client who is scheduled for colonoscopy with polyp removal. Which of the following client statements should alert the nurse that the client may be at risk for complications from the procedure?
A. “I needed three ibuprofens for my arthritis pain last night.”
146. A nurse is reinforcing teaching with the parents of a newborn about physical as- sessments. Which of the ff. statements by the parent demonstrates understanding of the newborn hearing screening test?
A. “If my baby fails the hearing test, he will need to be rested in 3 months.”
147. A nurse is reviewing instructions with a male client who is uncircumcised about ob- taining a clean-catch midstream urine specimen. Identify the sequence of actions the client should take after washing his hands. (Move the steps into the box on the right, placing them in the selected order of performance. All steps must used.)
a) Expose the glans of the penis
b) Cleanse the penis using antiseptic swab
c) Begin urination
d) Pass the cup into the urine stream
e) Move the cup out of the urine stream
f) Move the cup out of the urine stream
g) Replace the foreskin
148. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. Which of the ff. actions should the nurse take?
A. Provide step-by-step instructions for performing ADLs.
149. A nurse is reinforcing teaching about breastfeeding with a pregnant client. Which of the ff. statements by the nurse is appropriate?
A.” Breastfeeding reduces the infant’s risk of infection.”
150. A nurse is reviewing client positioning for a thoracentesis with a newly licensed nurse. The nurse validates that newly licensed nurse’s understanding when he indicates that the client should be placed in which of the ff. positions for the procedure?
A. Leaning forward over pillows. [Show Less]