Comp. Test (Q. SEVEN) #960-996

The nurse is caring for a client who is at risk for suicide. What is the priority nursing action for this cleint? 1. Provide authority, action and participation 2. Display an attitude of detachment, confrontation and efficiency 3. Demonstrate confidence in the clients ability to deal with stressors 4. Provide hope and reassurance that the problems will resolve themselves.

1. Provide authority, action and participation

The nursing instructor asks a nursing student to identify the priorities of care for an assigned client. Which statement indicates that the student correctly identifies the priority client needs? 1. Actual or life-threatening concerns 2. Completing care in a reasonable time frame 3. Time constraints related to the client needs 4. Obtaining needed supplies to care for the client

1. Actual or life-threatening concerns

A client has refused to eat more than a few spoonfuls of breakfast. The HCP has prescribed that tube feedings be initiated if the client fails to eat at least half of a meal because the client has lost a significant amount of weight during the previous 2 months. The nurse enters the room, looks at the tray, and states, "If you don't eat any more than that, Im going to have to put a tube down your throat and get a feeding in that way." The client begins crying and tries to eat more. Based on the nurse's actions, the nurse may be caused of which violation? 1. Assault 2. Battery 3. Slander 4. Invasion of privacy

1. Assault

A client is diagnosed with glaucoma. Which pierce of nursing assessment data identifies a risk factor associated with this eye disorder? 1. Cardiovascular disease 2. Frequent UTI 3. hx of migraine headaches 4. Frequent URI

1. Cardiovascular disease

The nurse inspects the color of he drainage form a NG tube on a postop client approximately 24 hours after gastric surgery. Which findings indicates that need to notify the HCP? 1. Dark red drainage 2. Dark brown drainage 3. Green- tinged drainage 4. Light yellowish-brown drainage

1. Dark red drainage

The nurse is preparing to care for a client who will be weaned from a cuffed trach tube. The nurse is planning to use a trach plug and plans to insert it into the opening in the outer cannula. Which nursing action is required before plugging the tube? 1. Deflate the cuff on the tube 2. Place the inner cannula into the tube 3. Ensure that the client is able to speak 4. Ensure that the client is able to swallow

1. Deflate the cuff on the tube

To perform CPR the nurse should use the method pictured to open the airway in which situation? 1. IF neck trauma is suspected 2. In all situations requiring CPR 3. If client has a history of seizures 4. If the client has a history of headaches

1. IF neck trauma is suspected

The nurse is caring for client with acute pancreatitis and is monitoring the client for paralytic lilies. Which piece of assessment data should alert the nurse to this occurrence? 1. Inability to pass flatus 2. Loss of anal sphincter control 3. Severe, constant pain with rapid onset 4. Firm, nontender mass palpable at the lower right costal margins.

1. Inability to pass flatus

The nurse is preparing to DC a clients NG tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse should make which statement to the client? 1. Take a deep breath when I tell you and hold it while I remove the tube 2. Take a deep breath when I tell you and bear down while I remove the tube. 3. Take a deep breathe when I tell you, and slowly exhale while I remove the tube 4. Take a deep breath when I tell you and breathe normally while I remove the tube

1. Take a deep breath when I tell you and hold it while I remove the tube

The nurse has reviewed with the preop client the procedure for the administration of an enema. Which statement by the client would indicate the need for further instruction? 1. The enema will be given while I am sitting on the toilet 2. I should try and hold the fluid as long as possible after it is instilled 3. I know that there will be some cramping after the enema administration 4. I should tell the nurse if cramping occurs during the instillation of the fluid

1. The enema will be given while I am sitting on the toilet

After performing an initial abdominal assessment on a client with N/V, the nurse should expect to note which finding? 1. Waves of loud gurgles auscultated in all 4 quadrants 2. Low-pitched swishing auscultated in 1 or 2 quadrants 3. Relatively high-pitched clicks or gurgles auscultated in all 4 quads. 4. Very high pitched, loud rushes auscultated especially in 1 or 2 quadrants.

1. Waves of loud gurgles auscultated in all 4 quadrants

A HCPs prescription reads levothyroxine 150 mag orally daily. The medication label reads levothyroxine 0.1 mg per tablet. The nurse should administer how many tablets to the client?

1.5

A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postopp, what time of drainage should the nurse expect? 1. Serous 2. Bloody 3. Serosanguineous 4. Bloody, with frequent small clots

2. Bloody

A sexually active young adult client has developed viral hepatitis. Which client statement indicates the need for further teaching? 1. I should avoid drinking alcohol 2. I can go back to work right away 3.My partner should get the vaccine 4. A condom should be used for sexual intercourse

2. I can go back to work right away

Th nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which lab result should the nurse expect to note if the client doesn't have appendicitis? 1. Leukopenia with a shift to the left 2. Leukocytosis with a shift to the left 3. Leukopenia with a shift to the right 4. Leukocytosis with a shift to the right

2. Leukocytosis with a shift to the left

A client with TB whose status is being monitored in an ambulatory care clinic asks the nurse when it is permissible to return to work. What factor should the nurse include when responding to the client? 1. Five blood cultures are negative 2. Three sputum cultures are negative 3. A blood culture and chest x ray are negative 4. A sputum culture and TB skin test negative

2. Three sputum cultures are negative

What action should the nurse consider when counseling a client of the amish tradition? 1. Speak only to the husband 2. Use complex medical technology 3. Avoid using scientific or medical jargon 4. Stand close to the client and speak loudly

3. Avoid using scientific or medical jargon

The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals r/t the prevention of DVT and pulmonary emboli. Which nursing action is most helpful in preventing those disorders from developing? 1. Restricting fluids 2. Placing a pillow under the knees 3. Encouraging active ROM exercises 4. Applying a heating pad to the lower extremities

3. Encouraging active ROM exercises

A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder? 1. Bradycardia and hyperactivity 2. Decreased RR and depth 3. Headache restlessness and confusion 4. Bradypnea, dizziness and paresthesias

3. Headache restlessness and confusion

The nurse is creating a POC for a client who is experiencing anxiety after the loss of a job. The client is now verbalizing concerns regarding the ability to meet role expectations and financial obligations. What is the priority nursing problem for the client? 1. Anxiety 2. Unrealistic outlook 3. Lack of ability to cope effectively 4. Change the chest tube drainage system

3. Lack of ability to cope effectively

A client comes to the ED after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client? 1. Begin to teach relaxation techniques 2. Encourages the client to discuss the assault. 3. Remain with the client until the anxiety decreases 4. Place the client in the quest room alone to decrease simulation

3. Remain with the client until the anxiety decreases

When creating an assignment for a team consisting of an RN, 1 LPN and 2 UAPs, which if she best client for the LPN? 1. A client requiring frequent temp checks 2. A client requiring assistance with ambulation every 4 hours 3. A client on a mechanical vent requiring assessment and suctioning 4. A client with a SCI requiring urinary catheterization every 6 hours.

4. A client with a SCI requiring urinary catheterization every 6 hours.

A client arrives at the clinic c/o fatigue, lack of energy, constipation and depression. Hypothyroidism is diagnosed, and levothyroxine is prescribed. What is an expected outcome of the medication? 1. Alleviate depression 2.Increase energy level 3. Increase blood glucose levels 4. Achieve normal thyroid hormone levels

4. Achieve normal thyroid hormone levels

The nurse is caring for a client with a resolved intestinal obstruction who has a NG tube in place. The HCP has now prescribed tat the NG tube be removed. What is the priority nursing assessment prior to removing the tube. 1. Checking of normal serum electrolyte levels 2. Checking for normal pH of the gastric aspirate 3. Checking for proper NG tube placement 4. Checking for the presence of bowel sounds in all 4 quadrants.

4. Checking for the presence of bowel sounds in all 4 quadrants.

Metformin is prescribed for a client with type 2 diabetes mellitus. What is the most common side effect that the nurse should include int he clients teaching plan? 1. Weight gain 2. Hypoglycemia 3. Flushing and palpitations 4. GI disturbances

4. GI disturbances

The nurse teaches skin care to a client receiving eternal radiation therapy. Which client statement indicates the need for further instruction? 1. I will handle the area gently 2. I will wear loose-fitting clothing 3. I will avoid the use of deodorants 4. I will limit sun exposed to 1 hour daily

4. I will limit sun exposed to 1 hour daily

A client with a retinal detatchment is admitted to the nursing unit in preparation for a repair procedure. Which prescription should the nurse anticipate? 1. Allowing bathroom privileges only 2. Elevating HOB to 45 3. Wearing dark glasses to read or watch TV 4. Placing an eye patch over the clients affected eye

4. Placing an eye patch over the clients affected eye

A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy? 1. This form of therapy can be applied to new situations 2. An advantage of this technique is that change is likely to last 3. Talking to oneself is a basic component of this form of therapy 4. This form of therapy provides a negative reinforcement when the stimulus is produced

4. This form of therapy provides a negative reinforcement when the stimulus is produced