1. A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of the following statements by the client indicates an understanding
... [Show More] of the teaching?
a. I would avoid food and beverages that contain caffeine
b. I will use ibuprofen as needed to control abdominal pain
c. I will take sucralfate with meals three times per day
d. I will decrease my daily protein to 15 g per day
2. A nurse is performing a gastric lavage for a client who has upper gastrointestinal bleed. Which of the following actions should the nurse take?
a. Instruct the client to lay on the right side
b. Instill 500 ML’s of solution through the NG tube c. Insert a large bore NG tube
d. Use a cold irrigation solution
3. The nurse is caring for a postpartum client who has urinary retention which of the following actions should the nurse take?
a. Place the client hands in warm water b. Perform bladder scan
c. Administer a prescribed diuretic
d. Apply an ice pack on the clients
4. A nurse manager is reviewing medical records to recommend clients for discharge following a local mass casualty event. Which of the following clients should the nurse recommend for discharge?
a. Who was admitted 24 hours ago with chest pain
b. A client who has heart failure and received euros in my IV eight hours ago
c. A client is scheduled to have a colonoscopy in 12 hours
d. A client who had a seizure 48 hours ago and he’s on seizure precaution
5. A nurse is reviewing the medical record of a client who has a prescription for intermittent heat therapy for a foot injury. Which of the following findings should the nurse identify as a contraindication for heat therapy?
a. Peripheral neuropathy
b. Osteoarthritis
c. Abdominal aortic aneurysm
d. Phlebitis
6. A nurse in an antepartum clinic is caring for four clients. Which of the following client should the nurse assess first.
a. A client who is at 8 weeks gestation and reports excessive salivation b. A client who is at 34 weeks gestation and reports double vision
c. A client who is at 38 weeks gestation and reports leg cramp
d. A client who is at 24 weeks gestation and reports periodic finger numbness
7. A nurse is assessing a client who has left-sided heart failure which of the following findings should the nurse identify as a manifestation of pulmonary congestion.
a. Jugular vein distention b. Bradypnea
c. Weight gain
d. Frothy, pink sputum
8. A nurse is caring for a client who has hypertension and a new prescription for chlorthalidone. The nurse should monitor for which of the following adverse effects? a. Hypokalemia
b. Hypoglycemia
c. Increased intraocular pressure
d. Euphoria
9. A nurse in an emergency department is caring for a client following a motor vehicle crash. The client Glasgow coma scale is 15 which of the following findings should the nurse expect?
a. The client is oriented times three
b. The client open the eyes to sound
c. The client is unable to be command
d. The client with drawls from pain
10. A newly licensed nurse is unsure if an assigned task is within their scope of practice. Which of the following resources should the nurse consult?
a. Institutional policies and procedures
b. Verbal direction from the nurse manager c. State nurse practice act
d. Written prescription for the provider
11. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take?
a. Assess the newborns pain level using the FACES pain scale
b. Obtained a newborns body temperature using a tympanic thermometer
c. Measure the newborn head circumference over the eyebrows and below the occipital permanence
d. Auscultate the newborns apical pulse for 60 seconds
12. A nurse is reviewing the medical records of a client who has delayed healing of a leg ulcer. Which of the following findings should the nurse identify as a contributing factor?
a. The client takes prednisone for arthritis
b. The client is receiving IV dextrose 5% in water at 100ml/hr
c. The client has an albumin level of 3.8 g/dl
d. The client has a total cholesterol level of 190 mg/dl
13. A nurse is reviewing the laboratory report of a client who is receiving lithium carbonate for the past 12 weeks. The nurse notes the lithium level is 0.8. which of the following should the nurse follow?
a. Increase the dosage
b. Administer the medication
c. Discontinue the medication
d. With all the next dose
14. A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis which of the following findings should the nurse report to the provider?
a. Erythrocyte sedentation rate 75mm/hr (no more than 30)
b. WBC count 8,000/mm
c. Platelets 150,000/mm
d. Aspartate aminotransferase 10 units/L
15. A nurse is teaching a client who has GERD about appropriate dietary choices. Which of the following choices by the client indicates an understanding of the teaching?
a. Whitefish
b. Decaffeinated coffee
c. Tomato soup
d. Hot cocoa
16. A community health nurse is reviewing laboratory reports for a group of clients. The nurse should identify that which of the following disorders is on the CDC nationally notifiable conditions list?
a. Bacterial vaginosis
b. Pediculosis capitis c. Lyme disease
d. Respiratory syncytial virus
17. A client’s partner tells a staff nurse that he overhears laboratory staff discussing the result of the client’s biopsy report while on the elevator. Which of the following actions should the nurse take?
a. Report the information to the charger nurse
b. Notify the facility legal department
c. Review confidentiality policies with laboratory employees
d. Contact the laboratory manager regarding the situation
18. A nurse is caring for a client who is in a seclusion room following violent behavior. The client continues to display aggressive behavior. Which of the following actions should the nurse take?
a. Express sympathy for the client’s seclusion
b. Confront the client about his behavior
c. Stand within 30 cm (1 foot) of the client when speaking with them d. Speak assertively to the client
19. A nurse is caring for a client who is recovering from an amputation of her right arm below the elbow. Which of the fallowing interprofessional team member should the nurse consult with the Occupational therapies?
a. The client lives in a two-story home
b. The client is allergic to penicillin
c. The client has two small children at home
d. The client’s parent is in a skilled nursing facility
20. A nurse manager is planning to promote client advocacy among staff in a medical unit. Which of the following actions should the nurse take?
a. Develop a system for staff members to report safety in the client care environment
b. Tell staff to explain procedures to clients before obtaining informed consent
c. Inquirer stuff to implement the principle of paternalism want to clan is having difficulty making decisions
d. Instruct unit stuff to share personal experiences to help clients make decisions
21. Nurse is teaching a client who has heart failure about engaging in an exercise program. Which of the following statements by the client indicates an understanding of the teaching?
a. I will make sure I can still talk while exercising
b. I will slow my walking pace if I experience chest pain
c. I will work to achieve 60 minutes of exercise each day
d. I will wait 30 minutes after eating before exercising
22. A nurse is caring for a client who is comatose and has advance directives that indicate the client does not want life-sustaining measures. The client’s family want the client to have life- sustaining measures. Which of the following action should the nurse take?
a. Complete an incident report
b. Arrange for an ethnic committee meeting to address the family concerns
c. Support the family’s decision and initiate life-sustaining measures
d. Encourage the family to contact the attorney
23. A nurse is teaching a new licensed nurse about incident report. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
a. They are mandatory government documentation
b. They are used as a disciplinary tool for nurse evaluations c. They assist with unit equality improvement
d. They assist the facility to achieve benchmark goals
24. A nurse is planning care for four client who are at risk for fluid imbalance. The nurse should identify that which of the following clients is address for fluid volume excess?
a. A client who has an exacerbation of peptic ulcer disease
b. A client who has ulcerative colitis
c. A client who has diabetes insipidus
d. A client who has advanced stage liver cirrhosis
25. A nurse is providing teaching about the administration of gastrostomy tube feedings to the parents of a school-age child. Which of the following instructions should the nurse take?
a. Change the fitting bag and tubing every 3 days b. Administer the feeding over 30 minutes
c. What is the formula in the microwave prior to administration
d. Place the child in a supine position after the feedings
26. A nurse is planning care for a client who has an L4 spinal cord injury. Which of the following interventions to prevent skin breakdown should the nurse include in the plan of care?
a. Maintain the head of the bed at a 45° angle
b. Ask the client to shift his weight every 20 minutes while sitting in a chair.
c. Provide a high fiber diet for the client
d. Massage redness area or a boy prominence
27. A nurse is counseling a group of clients from a town that was affected by the hurricane 6 months ago. For which of the following client should the nurse initiate a referral to assess for the presence of posttraumatic stress disorder? (Select all that apply [Show Less]