1. A nurse is caring for a client who is taking alprazolam. Which of the following prescriptions should the nurse clarify with the provider?
A. Digoxin
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B. Lorazepam
C. Atomoxetine
D. Ceftriaxone
2. A nurse is assessing a client who is postoperative following abdominal surgery. The client states "I feel like my incision ripped open" the nurse notes dehiscence of the incision. which of the following actions should the nurse take?
A. Extend the client’s legs above heart level
B. Place the client in low fowlers position.
C. Instruct the client to perform the Valsalva maneuver
D. Apply a dry gauze dressing to the incision.
3. A nurse is caring for a client who is receiving radiation therapy through a sealed implant. Which of the following actions should the nurse take?
Wear a lead apron when providing care for the client.
4. A nurse is inserting an IV catheter for a client who requires fluid replacement. Which of the following actions should the nurse take?
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A. Apply the tourniquet 15cm (6 in) above the insertion site
B. Check for pulsation at sited proximal to the tourniquet
C. Anchor the vein by stretching the skin 2.5 cm (1 in) proximal to the insertion site
D. Wipe the skin dry before inserting the catheter
5. A nurse is administering medications to a client who has dysphagia and a new prescription for divalproex sodium extended-release tablets. Which of the following actions should the nurse take?
Administer the medication with applesauce
6. A nurse is completing a dietary assessment for a client who is Jewish and observes kosher dietary practices. Which of the following behaviors would the nurse expect to fine? A.
Leavened bread maybe eaten during Passover.
B. Shellfish is commonly consumed in the diet.
C. Meat and dairy products are eaten separately.
D. Fasting from meat occurs during Hanukkah.
7. A nurse is assessing a client who has minor injuries following a motor-vehicle crash and appears agitated and apprehensive. The nurse identifies that the client is in the arm stage of general adaptation syndrome and should expect which of the following findings.
Tachycardia
8. A nurse is caring for a client who has a femur fracture and is on bedrest with Buck’s extension traction. which of the following actions should the nurse take?
A. Inspect the client’s skin under the device every 8 hours
9. A charge nurse is creating assignments for the next shift for several nurses and one of them is pregnant. Which of the following clients should the charge nurse assign to a nurse who is not pregnant?
A. A 60-year-old client who is recovering from shingles
B. A 20-year-old client who is HIV positive
C. A 40-year-old client who is suspected of having tuberculosis
D. An 80-year-old client who has alcoholic pancreatitis and is being treated for impetigo
10. A nurse is caring for a client who has a partial laryngectomy and is receiving continuous internal feeding at 65 ml/hr through a gastrostomy tube. which of the following findings requires immediate intervention by the nurse?
A. The gastric residual volume is 250 mL following two hours of infusion.
B. The client is lying in a supine position.
C. The infusion pump for administering continuous feeding is turned off.
D. Interior feeding bag and tubing are not dated.
11. A nurse is teaching a client about smoking cessation. Which of the following client statements should the nurse identify as an understanding of the teaching?
A. If I stop abruptly I cannot use a nicotine replacement.
B. After 6 months, my risk of heart disease is the same as that of a nonsmoker
C. I will set a specific date to stop smoking
D. I will use high carbohydrate snacks as a substitute for cigarette.
12. A nurse has been caring for a female client who has bruises on her arms that are a result of physical abuse by her partner. The client states, "I don't know how much longer I can take this, but I'm afraid he'll really hurt me if I leave" Which of the following is an appropriate nursing intervention?
A. Assist the client to identity personal behaviors that trigger abusive behavior
B. Insist that the client report the abusive behavior to the proper authority
C. Offer to speak to the client’s partner regarding his abusive behavior
D. Help the client to recognize the signs of escalation of abusive behavior
13. A client who is 8 hr postpartum asks the nurse if she will need to receive Rh immune globulin. The client is gravid 2, para 2, and her blood type is AB negative. The newborn's blood type is B Positive. Which of the following statements is appropriate?
A. "You only need to receive Rh immune globulin if you have a positive blood type. "
B. "You should receive Rh immune globulin within 72 hours of delivery."
C. "Both you and your baby should receive Rh immune globulin at your week appointment."
D. "immune globulin is not necessary since this is your second pregnancy."
14. A client hospitalized for a bone marrow transplant is in protective isolation while undergoing total body radiation and intense chemotherapy. The client’s sibling comes to visit but has obvious manifestations of an upper respiratory infection. which of the following nursing actions is appropriate at this time?
A. Allow the sibling to wave at the client through the window or door.
B. Allow the sibling to visit after donning a sterile gown, mask and gloves, but prohibit physical contact. C. D.
15. A nurse is planning care for a client who takes haloperidol for the treatment of schizophrenia. which of the following should the nurse include in the plan of care?
A. Monitor the client for hypothermia
B. Screen the client for tardive dyskinesia
C. Check the client’s weekly potassium level
D. Schedule the client for a 24hr urine collection
16. A nurse is performing a vision screening for a client. which of the following findings should the nurse identify as an indication that the client has cataracts?
A. Report of a chronic dull ache in the eyes
B. Bilateral redness of the sclerae
C. Increased opacity of the lens of the eye
D. Report of seeing halos around lights
17. A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions should the nurse take?
A. Encourage the client to ambulate in the hallway 1 hr before bedtime
B. Tell the client to avoid drinking fluids 1 hr before bedtime
C. Schedule routine care tasks during hours when the client is awake
D. Advise the client to leave the television in the room on when trying to fall asleep
18. A nurse is providing discharge teaching to a client who is postpartum and plans to breastfeed. which of the following should the nurse recommend the client increases in their diet during lactation?
A. Vitamin D
B. Iron
C. Vitamin A D. Calcium
19. A nurse is providing nutritional counseling to the parents of a toddler. Which of the following instructions should the nurse include in the teaching?
A. Offer snacks throughout the day
20. A nurse is assessing a client’s cardiovascular system. Identify where the nurse should place the diaphragm of the stethoscope to best hear the closing of the aortic heart valve. (Selectable areas or Hot Spots" can be found by moving your cursor over the artwork until the cursor changes appearance, usually into a hand. Click only on the Hot Spot that corresponds to your answer.)
A. option A
21. A nurse is planning to perform wound irrigation for a client who has an open secondary wound. When creating a sterile field. which of the following actions should the nurse take?
A. Set up the sterile field 7.6 cm below waist level
B. Hold the bottle of sterile solution with the palm over the label while pouring
C. Place the sterile items within 1 cm of the edge of the sterile border
D. Place the lid of a bottle of sterile solution within the sterile field
22. A nurse is planning an education session for a client who has type 1 diabetes mellitus. which of the following should the nurse plan to include when teaching the client to monitor for hypoglycemia?
A. diaphoresis
B. polyuria
C. abdominal pain D. thirst
21. A nurse is instructing a group of newly hired nurses about medication to promote fetal lung maturation. which of the following medications should the nurse include in the instructions?
A. Betamethasone
22. A nurse is caring for a client who has atypical depression and is taking phenelzine. Which of the following is appropriate for the nurses to offer as an evening snack?
A. Low fat yogurt
23. A nurse is planning care for a newborn who is receiving phototherapy. Which of the following actions should the nurse include the plan of care?
A. Assess the infant’s eyes for corneal irritation every 4 hrs
24. A nurse is caring for a client who is receiving a blood transfusion at 125 ml/hr and develops a hemolytic reaction. Which of the following actions should the nurse perform?
A. infuse 0.9% sodium chloride IV.
B. Administer an antipyretic.
C. Decrease the infusion rate to 75 mL/hr.
D. Place the client in a left lateral position.
25. A nurse is planning care for a client who has schizophrenia and is having difficulty expressing their feelings. which of the following referrals should the nurse make?
A. art therapist
B. speech -language pathologist
C. social worker
D. recreational therapist
26. A nurse from the state health department is instructing a group of nurses regarding reportable infections. Which of the following infections should the nurse report to the centers for disease control and prevention?
A. Lyme disease
B. Herpes simplex virus 2
C. Staphylococcus aureus
D. Candida albicans
27. A nurse is preparing to provide education about electroconvulsive for a client who has major depressive disorder. Which of the following should the nurse include in the teaching?
A. A general anesthetic is administered prior to ECT treatment
B. ECT treatment are administered once every 6 months
C. Oral antidepressants are discontinued after ECT treatment
D. Implied consent is required prior to ECT treatment
28. A nurse is teaching a client and their family about home hospice care. Which of the following information should the nurse include in the teaching?
A. Hospice care improves quality of life through palliative care.
B. Hospice care provides 24-hour in-home care.
C. Hospice care is intended to postpone death.
D. Hospice care encourages the family to coordinate health care services.
29. A nurse is preparing to administer an enteral feeding via NG tube for a client the day after verifying placement of the tube using a chest x-ray. Which of the following methods should the nurse use to confirm placement prior to initiating the feeding?
A. Test the pH level of the client’s gastric aspirate
30. A nurse is assessing a client who has non-Hodgkin’s lymphoma. Which of the following findings should indicate to the nurse that the clients might be experiencing syndrome of inappropriate antidiuretic hormone?
A. Diminished deep tendon reflexes
31. A nurse received change of shift report on four clients. Based on the shift report information which of the following clients would the nurse plan to assess first?
A client who had a hip arthroplasty reports pain and erythema in their calf
32. A nurse is caring for a client who is postpartum and has a new prescription for methylergonovine for vaginal bleeding refractory to fundal massage and oxytocin. When reviewing the client’s medical history, the nurse should recognize which of the following diagnosis as a contraindication to the administration of methylergonovine?
A. Hypertension
B. Diabetes mellitus
C. Migraine headaches
D. Hepatitis B
33. A nurse is caring for a client who is undergoing peritoneal dialysis and notes that the dialysate outflow has become cloudy. Which of the following complications of this procedure should the nurse suspect?
Peritonitis
34. A home health nurse is teaching a guardian about administering tube feedings to their 3- month-old infant. Which of the following information should the nurse include in the teaching?
Allow the infant to suck on the pacifier during feedings?
35. A nurse in an inpatient psychiatric unit is setting short-term goals for an adolescent client who was admitted for treatment of anorexia nervosa. which of the following is an appropriate short-term goal the nurse should set?
A. The client will reach an appropriate body weight
B. The client will gain 2 to 3 lb weekly
C. The client will verbalize a realistic body image
D. The client will develop a personalize meal plan
36. A nurse is preparing to witness a client’s signature on an informed consent for a total knee arthroplasty. Which of the following client statements indicates the nurse should contact the surgeon?
A. "I am thankful there are no serious complications from this type of surgery"
B. "I wonder if the metal in my knee will show up in airport screenings"
C. "The physical therapy has not been working, so I will need to have the surgery"
D. "I look forward to being able to bend my knee again when I sit in a chair"
37. A nurse is caring for a client who reports chest pain. Which of the following laboratory findings indicates myocardial damage?
A. aPTT 80 secs
B. Troponin I 1.8ng/ml
C. ESR 17MM/HR
D. Human B type
38. A nurse is caring for a school-age child who has a blood pressure of 88/50 mmhm and develops septic shock. Which for the following medications should the nurse expect the provider to prescribe?
Dopamine
39. A nurse is caring for a client who is receiving a controlled epidural analgesia infusion. Which of the following nursing actions is appropriate?
Covering the insertion site with a transparent dressing
40. A nurse discovers that the wrong dosage was given to a client. When determining what action to take, the nurse should recognize that which of the following ethical principles should be applied?
A. Veracity
B. Paternalism
C. Fidelity D. Utility
41. A nurse notices smoke coming from a client’s room and discovers a fire in the wastebasket. after moving the client to safety. which of the following is the priority action?
A. Notify the facility operator.
B. Close the fire doors on the unit.
C. Turn off oxygen sources.
D. Put out the fire with the appropriate extinguisher.
42. A home health nurse is teaching the parents of a school-age child who has Legg-Calvé- Perthes disease. Which of the following information should the nurse include?
A. “Your child will be contagious until the first round of antibiotics is complete.”
B. “Your child should perform weight-bearing exercises daily”
C. “Your child should continue to attend school”
D. “Your child will need to increase their daily caloric intake until they gain 5 pounds.” [Show Less]