1. A nurse on a mental health unit is admitting a client who has posttraumatic stress disorder. Which of the following findings should the nurse
... [Show More] expect?
A. Talks continuously about the event
B. Preoccupied with having a serious illness
C. Has difficulty concentrating on a task
D. Experiences frequent grandiose thoughts
2. A nurse is administering a scheduled medication to a client. The client reports that the medication appears different than what they take home. Which of the following responses should the nurse make?
A. "Did the doctor discuss with you that there was a change in this medication? "
B. "Do you know why this medication is being prescribed for you?"
C. "I will call the pharmacist now to check on this medication "
D. "I recommend that you take this medication as prescribed"
3. A nurse is assessing a client who is in skeletal traction for a fractured left tibia. The nurse should Identify that which the following findings indicates altered tissue perfusion of the affected extremity?
A. Purulent drainage at the site
B. Faint pedal pulse of left leg
C. Pain with movement of the left great toe
D. Warm skin temperature distal to pin site
4. A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching?
A. "I will decrease my daily protein intake to 15 grams per day"
B. "I will use ibuprofen as needed to control abdominal pain"
C. "I will take sucralfate with meals three times per"
D. "I will avoid food and beverages that contain caffeine"
5. A nurse is caring for a client who is in the advanced stage of amyotrophic lateral sclerosis (ALS). Which of the following referrals is the nurse's priority?
A. Occupational therapist
B. Social worker
C. Speech-language pathologist
D. Psychologist
6. A nurse administers digoxin 0.125 mg PO to an adult client. For which of the following findings should the nurse notify the provider?
A. Constipation for 2 days
B. Potassium level 4.2 mEq/L
C. Digoxin level 1 ng/mL ** normal levels 0.5- 2.0
D. Apical pulse 58/ min
7. A nurse is updating the plan of care for a client who has an exacerbation of psoriasis. Which of the following interventions should the nurse include in the plan?
A. Discontinue ultraviolet light therapy if lesions become itchy
B. Cover lesions with an occlusive dressing after applying a corticosteroid.
C. Scrub external lesions with a pumice stone
D. Instruct the client to add rubbing alcohol to bath water
8. A nurse is verifying a record of informed consent for a client who scheduled for surgery. Which of the following actions should the nurse take?
A. Provide Information on the informed consent form about the benefits of the surgery
B. Confirm the client's signature is authentic
C. Inform the client about the condition that requires treatment
D. Explain the procedure to the client before verifying informed consent.???
9. A nurse is caring for a client who requests the creation of a living will. Which of the following actions should the nurse take?
A. Schedule a meeting between the hospital ethics committee and client
B. Determine the client's preferences about postmortem care
C. Evaluate the client's understanding of life sustaining measures
D. Request a conference with the client's family
10. A nurse in an emergency department caring for a toddler who has burns following a house fire. Which of the following actions should the nurse take first?
A. Administer antibiotics prophylactically to prevent sepsis.
B. Determine the location and depth of the burns.
C. Calculate fluid replacement based on vital signs and urinary output.
D. Check the mouth for soot and smoky breath. ABC’S
11. A nurse is caring for an older adult client who has prescriptions for multiple medications. Which of the following factors should the nurse identify as an age-related change that increases the risk for adverse effects from medications?
A. Prolonged medication half-life
B. Increased medication elimination
C. Decreased medication sensitivity
D. Rapid gastric emptying
12. 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 situation.
B. Confront the client about this behavior.
C. Speak assertively to the client.
D. Stand within 30 cm (1 fu of the client when speaking with them.
13. A nurse is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client's history is a contraindication to the use of combination oral contraceptives?
A. Hypocalcemia
B. Diverticulosis
C. Hyperthyroidism
D. Thrombophlebitis
14. A nurse is creating a plan of care for a female client who has recurrent urinary tract infections. Which of the following interventions should the nurse include in the plan?
A. Wear loose-fitting underwear.
B. Take a bubble bath after intercourse
C. Drink four 240 mL (8 oz) glasses of water each day
D. Void every to 6 hr during the day. NO
15. A nurse is consulting a pharmacological reference about medication compatibility prior to administering warfarin to a client. Which of the following medications should the nurse identify as being incompatible with warfarin?
A. Magnesium hydroxide
B. Naproxen NSAID’S
C. Lisinopril
D. Propranolol
16. A nurse in an emergency department is caring for a client following a motor-vehicle crash. The client's Glasgow coma scale rating is 15. Which of the following findings should the nurse expect?
A. The withdraws from pain.
B. The client is oriented times three.
C. The dent is unable to obey commands non.
D. The client opens eyes to sound.
17. A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding. The nurse speaks a different language than the client. The client's partner and 10- year-old child are accompanying her. Which of the following actions should the nurse take to gather the client’s admission data?
A. Request a female interpreter through the facility
B. Ask nursing student who speaks the same language as the client to translate
C. Allow the client’s partner to translate
D. Have the client’s child translate
18. A nurse is planning care for a client who is recovering from an acute myocardial infarction that occurred 3 days ago. Which of the following interventions should the nurse Include?
A. Perform an ECG every 12hr.
B. Place the client in a supine position while resting.
C. Draw a troponin level every 4hr.
D. Obtain a cardiac rehabilitation consultation.
19. A nurse in the infectious disease division of the local health department is caring for a client. Which of the following infections should the nurse identify should be reported to the health department?
A. Clostridium difficile
B. Human papilloma virus
C. Herpes simplex virus
D. Chlamydia trachomatis
20. A nurse is administering an intradermal injection for allergy testing to a client. Into which of the following sites should the nurse inject the medication? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer
21. A nurse is caring for a client who has compartment syndrome following the application of a cast to the leg. Which of the following actions should the nurse take?
A. Apply ice to the extremity
B. Check the client’s pedal pulses.
C. Administer a dose of antiemetic medication
D. Position the client’s leg above the level of the heart
22. A nurse is caring for a client who speaks a language different from the nurse. Which of the following actions should the nurse take?
A. Review the facility policy about the use of an interpreter.
B. Request a family member or friend to interpret information for the client.
C. Direct attention toward the interpreter when speaking to the client.
D. Request an interpreter of a different sex from the client.
23. A nurse is providing discharge instructions about newborn safety to a client who is 2 days postpartum. Which of the following instructions should the nurse include?
A. Change smoke detector batteries every other year.
B. Use a car seat when traveling by airplane.
C. Place a plastic waterproof sheet over the crib bedding.
D. Lay the baby on his stomach to nap during the daytime.
24. A nurse manager is reviewing the steps of the progressive discipline process prior to counseling a staff member who exhibits unprofessional behavior. Identify the sequence of steps the nurse manager should plan to take in response to the staff members conduct (Move the steps into the box on the right placing them order of performance. Use all the steps)
Set up a meeting to speak the staff member about the behavior Verbally remind the staff member of the expected chances Give the staff member a written warning about the behavior Suspend the staff member from work for several days
Dismiss the staff member from employment at the
25. A nurse is assessing a client who has a prescription for hydrocodone PRN. Which of the following adverse effects should the nurse identity as priority for withholding this medication and notifying the provider?
A. Hypotension
B. Nausea
C. Constipation ** normal side effect
D. Urinary retention
26. A nurse is initiating bladder retraining for a client who has urge urinary incontinence. Which the following instructions should the nurse give the client?
A. "Take your diuretic medication with your evening meal"
B. "Decrease your intake of cranberry juice"
C. "Plan to urinate every 3 hours while you are awake"
D. "Limit your fluid intake to 500 per day"
27. A nurse is teaching participants at a community center about advance directives. Which of the following information should the nurse include in the teaching?
A. A client must create a do not resuscitate order when completing advance directives.
B. A health care surrogate makes health care decision when the client is no longer able.
C. Advance directives cannot be changed once implemented.
D. Assigning a health care surrogate requires legal consultation.
28. A nurse is caring for a client who has bipolar disorder. Which of the following behaviors should the nurse identify indicating the client is experiencing mania?
A. The client speaks using word salad.
B. The client speaks using echopraxia.
C. The client is socially withdrawn.
D. The client is easily distracted by external stimuli.
29. A nurse is caring for a client who has colon cancer and is terminally ill. The client states, "I can't believe I'm going to die." Which of the following statements should the nurse make?
A. "It might be comforting to pray for spiritual assistance."
B. "Your doctor will make sure you won't be in much pain "
C. "Tell me what is important to you right now."
D. "I felt the same way you're feeling when my mother died"
30. A home health nurse is teaching a new parent about caring for his 1-week-old infant. Which of the following statements by the client indicates an understanding of the teaching?
A. "I will avoid picking up my baby too often to keep from spoiling him will"
B. "I will place a ticking clock nearby to soothe my baby throughout the day"
C. "I will hang a pastel-colored mobile 24 inches above my baby's crib. "
D. "I can use a firm pillow to prop up the bottle when feeding my baby. "
31. A nurse is assessing a client who is receiving daily aspirin therapy. The nurse should identify that which of the following findings might indicate an allergic reaction to this medication?
A. Weight gain
B. Blurred vision
C. Difficulty swallowing
D. High blood pressure
32. A nurse is creating a plan of care for a newly admitted client who has obsessive- compulsive disorder. Which of the following interventions should the nurse include?
A. Discourage the client from exploring irrational fears.
B. Provide negative reinforcement for ritualistic behaviors.
C. Allow the client enough time to perform rituals.
D. Give the client autonomy in scheduling activities. [Show Less]