FINAL 3

149. A client is scheduled to receive an oral solution of radioactive iodine (131I). In order to reduce hazards, the priority information for the nurse to include during the instructionsto the client is which of these statements?

A)In the initial 48n hours avoid contact with children and pregnant woman and after urination or defecation flush the commode twice.

160. A client who is hospitalized and recently is now confused and lethargic. Which actions should the nurse implement? (Select all that apply) l

A)Measure capillary glucose leve B)Monitor cardiac telemetry pattern E) Initiate fall risk precautions

138. A client who is hospitalized and recently diagnosed with Addison's disease is now confused and lethargic. Which actions should the nurse implement? (Select all that apply)

A)Measure capillary glucose level B)Monitor cardiac telemetry pattern E) Initiate fall risk precautions

148. After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? (Select all that apply)

A)Place a small pillow under the head B)Remove resuscitation equipment from the room E) Gently close the eyes

139. 61-An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, which nursing care interventions should the nurse include in the client's plan of care? (Select all that apply)

A)Teach client to use incentive spirometer q2 hours while aware B)Remove urinary catheter as soon as possible and encourage voiding

159. The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective sign of depression? (Select all that apply)

A. Interacts with a flat affect B. Avoids eye contact C. Has a disheveled appearance

112. The nurse has been teaching a client with Insulin Dependent Diabetes Mellitus. Which statement by the client indicates a need for further teaching?

D) "I always make sure to shake the NPH bottle hard to mix it well."

144. Which of these clients would the nurse recommend to keep in the hospital during an internal disaster at the agency?A) An adolescent diagnosed with sepsis 7 days ago with vital signs maintained withinlow normal

D) A young adult in the second day of treatment for an overdose of acetometaphen

128. Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls?

D) Altered patterns of urinary elimination related to nocturia

114. The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity. Which choice indicates the client understands dietary needs?

D) Baked potato

120. Which bed position is preferred for use with a client in an extended care facility on falls risk prevention protocol?

D) Bed in lowest position, wheels locked, place bed against wall

132. A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client?

D) Contact

146. The nurse is to administer a new medication to a client. Which actions are in the best interest of the client? Verify the order for the medication. Prior to giving the medicationthe nurse should say

What is your name?What allergies do you have?then check the client's name band and allergy band As the room is entered say

142. While assessing a client's chest tube (CT), the nurse discovers bubbling in the water seal chamber of the chest tube collection device. The client's vital signs are: blood pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32 breaths/minutes, oxygen saturation 88%. Which interventions should the nurse implement? (Select all that apply).

A) Provide supplemental oxygen B) Auscultate bilateral lung fields D) Reinforce occlusive CT dressing

117. A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers?

A) A 79 year-old malnourished client on bed rest

118. After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is

A) Abdominal x-ray

134. An older adult resident of a long-term care facility has a 5-year history of hypertension. The client has a headache and rate the pain 5 on a pain scale 0 to 10. The client's blood pressure is currently 142/89. Which interventions should the nurse implement? (Select all that apply)

A) Administer a daily dose of lisinopril as scheduled. D) Provide a PRN dose of acetaminophen for headache

129. A nurse who is reassigned to the emergency department needs to understand that gastric lavage is a priority in which situation?

A) An infant who has been identified to have botulism

119. The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to

A) Exercise doing weight bearing activities

58. A client newly diagnosed with diabetes mellitus suddenly becomes confused and weak. Which interventions should the nurse implement? (Select all that apply)

A) Give the client 4 ounces of orange juice B)Obtain blood pressure and pulse rate E)Check the client's current finger stick blood glucose

140. An older adult client admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CVA). Which intervention should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.)

A) Measure neurological vital signs every 4 hours B)Encourage family to participate in the client's care E) Play classical music in room while client is awake

135. An older adult client is admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CAV). Which interventions should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.)

A) Measure neurological vital signs every 4 hours D)Encourage family participate in the client's care E) Play classical music in room while client is awake

152. When assessing a client, it is important for the nurse to be informed about cultural issues related to the client's background because

A) Normal patterns of behavior may be labeled as deviant, immoral, or insane

136. A client is receiving ophthalmic drops preoperatively for a cataract extraction and asks the nurse why the healthcare provider has prescribed all these medications. Which information should the nurse included when responding to this client? (Select all that apply.)

A) One of the medications is used to anesthetize the corneal surface B) Pupillary dilation is necessary to access the eye chamber for lens removal C)The iris must be paralyzed during surgery to prevent it from reacting to light

113. Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs?

A) Orthostatic hypotension is a common side effect

141. To reduce the risk of symptoms exacerbation for a client with multiple sclerosis (MS), which instructions should the nurse include in the client's discharge plan? (Select all that apply).

A) Practice relaxation exercises C) Space activities to allow for rest periods D) Avoid persons with infections

111. A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin?

A) Protamine

145. The mother of a toddler who is being treated for pesticide poisoning asks: "Why is activated charcoal used? What does it do?" What is the nurse's best response?A) "Activated charcoal decreases the systemic absorption of the poison from thestomach."

B) "The charcoal absorbs the poison and forms a compound that doesn't hurt your child."

147. Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which medical condition?

B) A positive purified protein derivative with an abnormal chest x-ray

131. Which of these clients with associated lab reports is a priority for the nurse to report to the public health department within the next 24 hours?

B) An elderly factory worker with a lab report that is positive for acid-fast bacillus smear

137. The nurse is interacting with a female client who is diagnostic with postpartum depression. Which findings should the nurse document as an objective signs of depression? (Select all that apply)

B) Avoid eyes contact D)Has a disheveled appearance E) Interacts with felt effect

115. An 86 year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with aclear liquid diet, the client begins to cough. What should the nurse do next?

B) Check the client's gag reflex

121. When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula

B) Continuously

124. The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine areelevated. What dietary modifications are most appropriate

B) Decreased sodium and potassium

125. What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction?

B) Oozing liquid stool

153. A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client's teaching plan? (Select all that apply.)

B) Recognize signs and symptoms of hypoglycemia C)Report persist polyuria to the healthcare provider E)Take Glucophage with the morning and evening meal

156. A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states "I don't think I need those medications. They make me too sleepyand drowsy. I insist that you explain their use and side effects." The nurse shouldunderstand that

B) The client has a right to know about the prescribed medications

A) B) C) 157. A nurse is administering diazepam, a benzodiazepine, 10 mg IV push PRN, as prescribed to a client with alcohol withdrawal symptoms. Which actions should the nurse implement when administering the medication? (Select all that apply)

B)Monitor for changes in level of consciousness D) Perform ongoing assessment of respiratory status E) Administer slowly over at least two minutes

154. After working with a very demanding client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that client. I just can't do anything that pleaseshim. I'm not going in there again." The nurse should respond by saying

C) "He is scared and taking it out on you. Let's talk to figure out what to do."

133. The school nurse is teaching the faculty the most effective methods to prevent the spread of lice in the school. The information that would be most important to includewould be which of these statements?

C) Children are not to share hats, scarves and combs.

151. The charge nurse is planning assignments on a medical unit. Which client should be assigned to the PN?

C) Irrigate and redress a leg wound

123. A nurse is providing care to a 63 year-old client with pneumonia. Which intervention promotes the client's comfort?

C) Keep conversations short

122. The nurse is teaching an 87 year-old client methods for maintaining regular bowel movements. The nurse would caution the client to AVOID

C) Laxatives

143. After an explosion at a factory one of the workers approaches the nurse and says "I am an unlicensed assistive personnel (UAP) at the local hospital." Which of these tasksshould the nurse assign to this worker who wants to help during the care of the woundedworkers?

C) Palpate pulses

127. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first?

C) Place in respiratory/secretion precautions

116. The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown?

C) Reposition every two hours

126. A 20 year-old client has an infected leg wound from a motorcycle accident, and the client has returned home from the hospital. The client is to keep the affected leg elevatedand is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that:

C) Visitors should wash their hands before and after touching the client

130. A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy,in addition to hand washing, to be implemented is which of these?

D) Have gloves on while handling bedpans with feces

155. A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client's mental status and adjustment. The appropriate response ofthe nurse should be which of these statements?

D) I need to get the client's written consent before I release any information to you.

150. The nurse is assigned to a client newly diagnosed with active tuberculosis. Which of these protocols would be a priority for the nurse to implement?

D)Place client in a negative pressure private room and have all who enter the room use masks with shields