1. Which of the instructions should a nurse include in the teaching for a pt. who had removal of a cataract in the left
eye?
a. "Forcefully cough and
... [Show More] take deep breaths every two hours to keep your airway clear."
b. "Perform the prescribed eye exercises each day to strengthen your eye muscles."
c. "Rinse your eyes with saline each morning to prevent postoperative infection."
d. "Take the prescribed stool softener to avoid increasing intraocular pressure."
2. A client vomits during a continuous nasogastric tube feeding. A nurse should stop the feeding and take which of these
actions?
a. Suction the nasogastric tube.
b. Flush the tube with 30 mL of sterile water.
c. Remove the nasogastric tube.
d. Check the residual volume.
3. Which of these actions best demonstrates cultural sensitivity by a nurse?
a. The nurse talks in a slow-paced speech.
b. The nurse asks clients about their beliefs and practices toward pregnancy.
c. The nurse uses charts and diagrams when teaching pregnant clients.
d. The nurse can speak several different languages.
4. Which of these manifestations should a nurse expect to observe in a 3-month-old infant who is diagnosed with
dehydration?
a. Hyperreflexia.
b. Tachycardia.
c. Bradypnea.
d. Agitation.
5. When assessing a client's risk of developing nosocomial infection, a nurse plans to determine potential entry portals,
which include:
a. the urinary meatus.
b. vomitus.
c. contaminated water.
d. sexual intercourse.
6. A client who is on the inpatient psychiatric unit has a history of violence. Which of these actions should a nurse take if
the client is agitated?
a. Encourage the client to verbalize feelings.
b. Lock the client in a secluded room.
c. Ask the other clients to give feedback regarding the client's behavior.
d. Ignore the client's inappropriate behavior.
7. Which of these measures should a nurse include when planning care for a school-aged child during a sickle cell crisis
episode?
a. Monitoring for signs of bleeding.
b. Providing pain relief.
c. Administering cool sponge baths to reduce fevers.
d. Offering a high calorie diet.
8. Which of these instructions should a nurse include in the plan of care for a 32-week gestation client who had an
amniocentesis today?
a. "Drink at least six glasses of fluids during the next six hours after the test."
b. "Call the clinic if you experience any abdominal cramps."
c. "Don't be concerned if you have some vaginal spotting in the next 12 hours."
d. "When you get home, stay on bed-rest for the next 48 hours."
9. An adolescent has a nursing diagnosis of fatigue related to inadequate intake of iron-rich foods. Selection of which of
these lunches by the client indicates a correct understanding of foods high in iron content?
a. Peanut butter and jam sandwich.
b. Chicken nuggets with rice.
c. Tuna salad sandwich.
d. Beefburger with cheese.
10. A client has been admitted with acute pancreatitis. Which of these laboratory test results supports this diagnosis?
a. Elevated serum potassium level.
b. Elevated serum amylase level.
c. Elevated serum sodium level.
d. Elevated serum creatinine level.
11. Which of these manifestations, if assessed in a client who is two-hours postoperative after abdominal surgery,
should a nurse report immediately?
a. Vomiting and a pulse rate of 106/minute.
b. Respiratory rate of 12/minute and urine dribbling.
c. Blood pressure of 100/60 mm Hg and wound discomfort.
d. Urine output of 100 mL/hr and flushed skin.
12. Which of these observations of a student nurse's behavior while interacting with a client who is crying indicates a
correct understanding of therapeutic communication?
a. The student maintains continuous eye contact with the client.
b. The student places one arm around the client's shoulder?
c. The student sits quietly next to the client.
d. The student leaves the room to provide privacy for the client.
13. Which of these actions should a nurse take initially if a client who is diagnosed with diabetes mellitus develops
tremors and ataxia?
a. Measure the client's blood sugar level.
b. Administer a concentrated form glucose to the client.
c. Administer a prn dose of insulin.
d. Measure the client's urine for ketones.
14. An elderly client is at increased risk of developing drug toxicity to prescribed medications due to declining hepatic
and renal functioning. Which of these strategies should a nurse plan to decrease this risk?
a. Increasing the time interval between medication doses.
b. Limiting the client's oral fluid intake.
c. Administering the medications with meals.
d. Encouraging the client to void every three to four hours.
15. A client has persistent paranoid delusions that the food on the unit is poisoned. Which of these measures should a
nurse include in the client's care plan?
a. Explaining that staff does not poison clients.
b. Focusing on how the hospital staff helps clients.
c. Allowing the client to eat food from sealed containers.
d. Telling the client that not eating the food that is served will result in privilege restrictions. [Show Less]