First Complex Quiz

A client has a tumor of the posterior pituitary gland. The nurse planning his care should include which interventions? Select all that apply. A. Assess urine specific gravity. B. Encourage intake of coffee or tea. C. Monitor intake and output. D. Take daily weight. E. Restrict fluids.

A. Assess urine specific gravity. C. Monitor intake and output. D. Take daily weight.

A client with early acute renal failure has anemia, tachycardia, hypotension, and shortness of breath. The physician has ordered 2 units of packed red blood cells (RBCs). Prior to initiating the blood transfusion the nurse should determine if? Select all that apply. A. Blood typing and cross-matching is documented in the medical record B. The vital signs have been taken and documented in accordance with facility policy and procedure C. There is the second unit of blood in the medication room D. There is a signed informed consent for transfusion therapy E. The client has an identification bracelet and red blood band F. There is an I.V. access with the appropriate tubing and normal saline as the priming solution

A. Blood typing and cross-matching is documented in the medical record B. The vital signs have been taken and documented in accordance with facility policy and procedure D. There is a signed informed consent for transfusion therapy E. The client has an identification bracelet and red blood band F. There is an I.V. access with the appropriate tubing and normal saline as the priming solution

A female client with which condition would be at increased risk for vulvovaginal candidiasis? Select all that apply. A. Human immunodeficiency virus (HIV) infection. B. Uncontrolled diabetes. C. Asthma. D. Hypertension. E. Immunosuppression due to cancer.

A. Human immunodeficiency virus (HIV) infection. B. Uncontrolled diabetes. E. Immunosuppression due to cancer.

The nurse is developing a care plan for a client with leukemia. The plan should include which of the following? Select all that apply. A. Maintain integrity of skin and mucous membranes. B. Avoid crowds. C. Take a baby aspirin each day. D. Recognize signs and symptoms of infection. E. Monitor temperature and report elevation.

A. Maintain integrity of skin and mucous membranes. B. Avoid crowds. D. Recognize signs and symptoms of infection. E. Monitor temperature and report elevation.

When communicating with a client who has aphasia, which of the following are helpful? Select all that apply. A. Make use of gestures. B. Encourage pointing to the needed object. C. Speak with normal volume. D. Present one thought at a time. E. Avoid writing messages.

A. Make use of gestures. B. Encourage pointing to the needed object. C. Speak with normal volume. D. Present one thought at a time.

The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a client who had a craniotomy 12 hours ago. What should the nurse do? Select all that apply. A. Monitor neurologic status using the Glasgow Coma Scale. B. Encourage the client to cough and take deep breaths. C. Stimulate the client with active range-of-motion exercises. D. Elevate the head of the bed 15 to 30 degrees. E. Contact the health care provider if ICP is greater than 20 mm Hg.

A. Monitor neurologic status using the Glasgow Coma Scale D. Elevate the head of the bed 15 to 30 E. Contact the health care provider if ICP is greater than 20 mm Hg

To prevent catheter-associated urinary tract infection, the nurse should do which of the following? Select all that apply. A. Provide perineal care several times a day. B. Change the catheter daily. C. Assess the client for signs of infection. D. Encourage the client to drink 3,000 ml of fluids a day. E. Recommend the health care provider order antibiotics.

A. Provide perineal care several times a day. C. Assess the client for signs of infection. D. Encourage the client to drink 3,000 ml of fluids a day.

The client is admitted to the hospital for alcohol detoxification. Which of the following interventions should the nurse use? Select all that apply. A. Reinforcing reality if the client is disoriented or hallucinating. B. Explaining to the client that the symptoms of withdrawal are temporary. C. Taking vital signs. D. Placing the client in restraints as a safety measure. E. Monitoring intake and output.

A. Reinforcing reality if the client is disoriented or hallucinating. B. Explaining to the client that the symptoms of withdrawal are temporary. C. Taking vital signs. E. Monitoring intake and output.

The client is to receive antibiotic intravenous (IV) therapy in the home. The nurse should develop a teaching plan to ensure that the client and family can manage the IV fluid and infusion correctly and avoid complications. The plan should include which of the following? Select all that apply. A. Report signs of redness or inflammation at the site B. Place the IV bag on a table level with the client's arm C. Wear sterile gloves to change the fluids. D. Cleanse the port with alcohol. E. Call the health care provider for a temperature above 100 degrees F (37.8 degrees C).

A. Report signs of redness or inflammation at the site D. Cleanse the port with alcohol. E. Call the health care provider for a temperature above 100 degrees F (37.8 degrees C).

Which of the following activities should the nurse encourage the unlicensed assistive personnel to assist with in the care of postoperative clients? Select all that apply. A. Reposition clients for pain relief. B. Empty and measure indwelling urinary catheter collection bags. C. Assess I.V. insertion site for redness. D. Tell the nurse if clients report they are having pain. E. Teach clients the proper use of the incentive spirometer.

A. Reposition clients for pain relief. B. Empty and measure indwelling urinary catheter collection bags. D. Tell the nurse if clients report they are having pain

A client has developed a hospital-acquired pneumonia. When preparing to administer cephalexin 500 mg, the nurse notices that the pharmacy sent cefazolin. What should the nurse do? Select all that apply. A. Request that cephalexin be sent promptly. B. Verify the medication order as written by the physician. C. Administer the cefazolin. D. Contact the pharmacy and speak to a pharmacist. E. Return the cefazolin to the pharmacy.

A. Request that cephalexin be sent promptly. B. Verify the medication order as written by the physician. D. Contact the pharmacy and speak to a pharmacist. E. Return the cefazolin to the pharmacy.

A nurse should expect to find which defining characteristics in a client with a nursing diagnosis of Ineffective tissue perfusion (peripheral)? Select all that apply. A. Skin discoloration B. Edema C. Strong, bounding pulses D. Normal sensation E. Skin pink in color F. Skin temperature changes

A. Skin discoloration B. Edema F. Skin temperature changes

Which task should a nurse choose to delegate to a nursing assistant? Select all that apply. A. Taking a client's vital signs B. Assessing a client's pain C. Performing a blood glucose check D. Documenting a client's oral intake E. Evaluating a client's response to a blood pressure medication

A. Taking a client's vital signs C. Performing a blood glucose check D. Documenting a client's oral intake

When witnessing an adult client's signature on a consent for a procedure, the nurse verifies that the consent was obtained in an appropriate manner. The nurse should verify which of the following? Select all that apply. A. That the client has full awareness of the potential complications. B. That there was adequate disclosure of information. C. That the client understood the information. D. The client's relative, spouse or legal guardian was present. E. That there was voluntary consent on the client's part.

A. That the client has full awareness of the potential complications. B. That there was adequate disclosure of information. C. That the client understood the information. E. That there was voluntary consent on the client's part.

A 77-year-old client is brought to the emergency department by her son. The client is reporting a severe headache and lack of sleep because, "I'm so worried about everything." Her son says that she has heart failure and chronic schizophrenia. "In addition to all of her heart medicines, she is on aripiprazole, which was increased to 30 mg by her family doctor 3 days ago." In addition to documenting all of the client's medications and exact dosages, the nurse should particularly investigate which of the following? Select all that apply. A. The client's symptoms of schizophrenia. B. The client's symptoms of heart failure. C. The client's relationship with her son. D. The qualifications of the client's family doctor. E. The dose of aripiprazole.

A. The client's symptoms of schizophrenia. B. The client's symptoms of heart failure. E. The dose of aripiprazole.

A client is taking diazepam for generalized anxiety disorder. Which instruction should the nurse give to this client? Select all that apply. A. To consult with his health care provider before he stops taking the drug. B. To take the medication on an empty stomach. C. To stop taking the drug if he experiences swelling of the lips and face and difficulty breathing. D. Not to use alcohol while taking the drug. E. To avoid eating cheese and other tyramine-rich foods.

A. To consult with his health care provider before he stops taking the drug. C. To stop taking the drug if he experiences swelling of the lips and face and difficulty breathing. D. Not to use alcohol while taking the drug.

The nurse is taking care of a client who had a laryngectomy yesterday. To assure client safety, the nurse should give "hand-off reports" at which of the following times? Select all that apply. A. When nurse goes to lunch. B. When unit clerk goes to a staff meeting. C. Change of nurses. D. Change of shift. E. When new medication orders are written.

A. When nurse goes to lunch. C. Change of nurses. D. Change of shift.

A 14-year-old with rheumatic fever who is on bed rest is receiving an I.V. infusion of dextrose 5% in water administered by an infusion pump. The nurse should verify the alarm settings on the infusion pump at which of the following times? Select all that apply. A. When the child moves in the bed. B. At the beginning of each shift. C. When the infusion is started. D. When the child is sleeping. E. When the child returns from X-ray.

B. At the beginning of each shift. C. When the infusion is started. E. When the child returns from X-ray.

A client with lung cancer is being cared for by his wife at home. His pain is increasing in severity. The nurse recognizes that teaching has been effective when the wife does which of the following? Select all that apply. A. Substitutes acetaminophen to avoid tolerance to the medications. B. Has her husband use a pain rating scale to measure the effectiveness at reaching his individual pain goal. C. Uses music for distraction as well as heat or cold in combination with medications. D. Administers immediate-release medication such as oxycodone for breakthrough pain. E. Administers long-acting or sustained-release oral pain formula regularly around-the-clock. F. Avoids long-acting opioids due to her concern about addiction.

B. Has her husband use a pain rating scale to measure the effectiveness at reaching his individual pain goal. C. Uses music for distraction as well as heat or cold in combination with medications. D. Administers immediate-release medication such as oxycodone for breakthrough pain. E. Administers long-acting or sustained-release oral pain formula regularly around-the-clock.

The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which of the following strategies should the nurse include in the teaching plan? Check all that apply. A. Restrict the diet to liquids until swallowing improves. B. Introducing foods on the unaffected side of the mouth. C. Keeping distractions to a minimum. D. Cutting food into large pieces. E. Maintaining an upright position while eating.

B. Introducing foods on the unaffected side of the mouth. C. Keeping distractions to a minimum. E. Maintaining an upright position while eating.

A client with peripheral vascular disease has poor circulation. The nurse should assess the client for which of the following? Select all that apply. A. Nausea. B. Skin temperature. C. Pain in extremity. D. Nail bed color. E. Fluid intake.

B. Skin temperature. C. Pain in extremity. D. Nail bed color.

A nurse is assessing a client who has a rash on his chest and upper arms. Which questions should the nurse ask in order to gain more information about the client's rash? Select all that apply. A. "How old are you?" B. "Do you smoke cigarettes or drink alcohol?" C. "Are you allergic to any medications, foods, or pollen?" D. "What have you been using to treat the rash?" E. "Have you recently traveled outside the country?" F. "When did the rash start?"

C. "Are you allergic to any medications, foods, or pollen?" D. "What have you been using to treat the rash?" E. "Have you recently traveled outside the country?" F. "When did the rash start?"

A client who is positive for human immunodeficiency virus (HIV) tells the nurse that her significant other is the only family member who knows her health status. What should the nurse do to keep the client's health status confidential? Select all that apply. A. Keep a unit log of all clients infected with HIV for research purposes. B. Discuss the case at lunch to educate other staff members. C. Ask all family members, except the client's significant other, to wait outside when she's educating the client. D. Use the hospital code for HIV when documenting care. E. Discuss the case with the client's mother, who is an immediate family member.

C. Ask all family members, except the client's significant other, to wait outside when she's educating the client. D. Use the hospital code for HIV when documenting care.

A charge nurse completing a deceased client's chart audit notes that the chart contains a copy of the client's advance directive and the do-not-resuscitate (DNR) order. While reviewing the nurses' notes, the charge nurse finds documentation of a code blue and cardiopulmonary resuscitation with a physician entry to "Discontinue code blue due to existing advanced directives and DNR from client." What does the charge nurse conclude? Select all that apply. A. The code should have continued. B. She must have read the chart incorrectly. C. By calling a code blue, the nurse disregarded the client's advance directives and DNR order. D. The physician was correct to stop resuscitation efforts. E. The nurse was correct to call a code blue.

C. By calling a code blue, the nurse disregarded the client's advance directives and DNR order. D. The physician was correct to stop resuscitation efforts.

A nurse is teaching a client about taking antihistamines. Which of the following instructions should the nurse include in the teaching plan? Select all that apply. A. Continue taking antihistamines even if nasal infection develops. B. The effect of antihistamines is not felt until a day later. C. Increase fluid intake to 2,000 ml/day. D. Operating machinery and driving may be dangerous while taking antihistamines. E. Do not use alcohol with antihistamines.

C. Increase fluid intake to 2,000 ml/day. D. Operating machinery and driving may be dangerous while taking antihistamines. E. Do not use alcohol with antihistamines.

A nurse is caring for a client whose cultural background is different from her own. Which actions are appropriate? A. Understand that all cultures experience pain in the same way B. Consider the nonverbal cues, such as eye contact, may have different meanings in different cultures C. Respect the client's cultural beliefs D. Ask the client if he has cultural or religious requirements that should be considered in his care E. Explain the nurse's beliefs so that the client will understand the differences

C. Respect the client's cultural beliefs B. Consider the nonverbal cues, such as eye contact, may have different meanings in different cultures D. Ask the client if he has cultural or religious requirements that should be considered in his care

The nurse is caring for a client who recently experienced a myocardial infarction and has been started on clopidogrel. The nurse should develop a teaching plan that includes which of the following points? Select all that apply. A. The client should always take clopidogrel with food. B. The client should drink a glass of water after taking clopidogrel. C. The client should report unexpected or prolonged bleeding. D. The client may bruise more easily and experience bleeding gums. E. Clopidogrel works by preventing platelets from sticking together and forming a clot.

C. The client should report unexpected or prolonged bleeding. D. The client may bruise more easily and experience bleeding gums. E. Clopidogrel works by preventing platelets from sticking together and forming a clot.

An elderly client hospitalized 4 days for treatment of acute respiratory distress has become confused and disoriented. The client has been picking invisible items from blankets and yelling at a daughter who is not in the room. The family tells the nurse that the client has been treated for anxiety with alprazolam for years, but alprazolam is not part of the client's current medication list. Which of the following safety measures should be implemented? Select all that apply. A. The client will be placed in soft restraints. B. The daughter should not visit until the client is better. C. The client will be placed on withdrawal precautions and treatment immediately. D. Medications will be made available to help with the hallucinations. E. The client's medical and mental status will be evaluated frequently and treated as needed.

C. The client will be placed on withdrawal precautions and treatment immediately. D. Medications will be made available to help with the hallucinations. E. The client's medical and mental status will be evaluated frequently and treated as needed.