Hurst (Readiness Exam #4)
The nurse is caring for an adolescent client diagnosed with depression. The client is prescribed fluoxetine. What is the best response by the nurse when the client says, "What will this medicine do to me?" 1. It will increase the level of serotonin in the brain. 2. It will decrease the production of noradrenaline. 3. It will lower your level of the brain hormone norepinephrine. 4. It will balance blood glucose and dopamine levels in your head.
1
Which assignment would be most appropriate for the charge nurse to assign to the LPN/VN in the Labor, Delivery, Recovery and Postpartum Unit (LDRP)? 1. Primipara needing assistance with breastfeeding. 2. Multipara reporting a headache and epigastric discomfort. 3. Primipara who is two days post op cesarean section. 4. Primipara who is preeclamptic in active labor. 5. Multipara post op cesarean section with a PCA pump.
1,3
A nurse has just inserted an indwelling urinary catheter in a client scheduled for surgery. What should the nurse document? 1. Perineal skin assessment 2. Client teaching 3. Color of urine 4. Date and time of insertion 5. Type catheter inserted 6. Infusing rate of IV fluid
1,2,3,4,5
A case manager is assessing an unresponsive client diagnosed with terminal hepatic encephalopathy to determine equipment needs upon discharge to home for hospice care. Which equipment should the case manager obtain for this client? 1. Alternating pressure mattress 2. Hospital bed 3. Walker 4. Suction equipment 5. Oxygen
1,2,4,5
An elderly client arrives in the emergency department (ED) after a fall. What assessment findings would lead the nurse to suspect that the client has a fractured right hip? 1. Severe pain in the right hip and groin. 2. Inability to bear weight on the right leg. 3. Right leg slightly longer in length than the left leg. 4. External rotation of right lower leg. 5. Bruising and swelling around the right hip.
1,2,4,5
The nurse is administering the prescribed Mantoux tuberculin skin test to a client. The nurse does not observe the tense blister-like formation at the injection site. Which action should the nurse take? 1. Chart the injection site response as the only action. 2. Administer another Mantoux tuberculin skin test at a different site. 3. Circle the area, wait 48 to 72 hours, and assess for a reaction. 4. Call the primary healthcare provider.
2
The nurse observes a client at a follow-up appointment using correct cane walking technique but losing balance each time the quad cane is lifted off of the floor. The client reports a history of recent falls. What is the best action for the nurse to take? 1. Inform the primary healthcare provider of the observations made regarding quad cane use, and imbalance assessment. 2. Inform client that there are only a few assistive devices available to help with ambulation. 3. Instruct the client on proper quad cane use. 4. Notify the primary healthcare provider after consulting with the neighbor.
1
A client arrives at the emergency department after sustaining partial and full-thickness burns over the anterior neck, chest, and right arm. Which interventions will the nurse initiate? 1. Administer oxygen 2. Start two intravenous lines 3. Remove necklace 4. Elevate right arm 5. Debride wounds
1,2,3,4
The public health nurse is planning to participate in local forums regarding the placement of a factory that is known to produce pollution through discharge of chemical by-products into the air. What actions demonstrate ethical nursing practice in the public health arena? 1. Speaking up for the underrepresented, such as the poor and uneducated persons. 2. Encouraging community leaders to accept placement of the factory. 3. Requesting that forums be held throughout the community at various times of the day or evening. 4. Asking for information regarding the health status of people in other factory locations. 5. Requesting information from individuals in areas where the factories are currently located.
1,3,4,5
The home care nurse visits a client who has moderate cognitive impairment and whose family provides care for the client. Which suggestions would be helpful for this family to reduce the risk of injury? 1. Suggest that the family lock up medications and poisons and keep the keys. 2. Encourage the family to place locks high on the door frame to make it difficult for the client to leave. 3. Suggest that the family talk with the client weekly about safety issues around the house. 4. Suggest that the family remove knobs from stove when not in use. 5. Keep fire extinguishers present and in working order.
1,2,4,5
What should a nurse teach a client who has been diagnosed with hepatitis A? 1. Hepatitis A is spread through blood and body fluid. 2. Chronic liver disease is a common complication of hepatitis A. 3. Symptoms of hepatitis A include malaise, dark colored urine, and jaundice. 4. Treatment includes alpha-interferon and ribavirin.
3
When assessing a client's testes, which finding would indicate to the nurse the need for further investigation? 1. Rope like area located at the top of the back of a testicle. 2. Right testicle is slightly larger than the left testicle. 3. Lump the size of a piece of rice. 4. Nonpalpable lymph nodes in groin.
3
A client tells the nurse, "I am dying from cancer. I have told my primary healthcare provider that I do not want to be revived if my heart stops beating or I stop breathing." What action should the nurse take first to assure that the client's request is respected? 1. Ensure a do-not-resuscitate prescription has been provided. 2. Report client wishes during the end-of-shift report. 3. Have the client sign an advanced directive. 4. Ask the client who holds the durable power of attorney for health care decisions.
1
While performing a vaginal examination on a client in labor, the nurse feels soft, squishy tissue instead of a head. What conclusion should the nurse make based on this assessment finding? 1. Breech presentation 2. Edema of cervix 3. Closed cervix 4. Bulging membranes
1
The primary healthcare provider is preparing to drain a large abdominal abscess. The client has dementia and moves about on the bed frequently. Which personal protective equipment (PPE) should the nurse wear while holding the client for the procedure? 1. Face shield 2. Sterile Gloves 3. Gown 4. Mask 5. Regular exam gloves
1,3,4,5
A client has been admitted with a diagnosis of septic shock and has been successfully intubated. The nurse performs and documents a rapid assessment. Which information from the assessment requires the most immediate action by the nurse? Exhibit 1. Lung assessment finding. 2. Blood pressure reading. 3. Elevated temperature 4. Urine description and output.
2
A nurse has received the following arterial blood gas results on a client with a post bowel resection: pH 7.48; PCO2 30; HCO3 24. Which acid/base imbalance is the client experiencing? 1. Metabolic alkalosis 2. Metabolic acidosis 3. Respiratory alkalosis 4. Respiratory acidosis
3
The nurse is caring for a newly diagnosed diabetic in diabetic hyperosmolar hyperglycemic nonketotic (HHNK) state. What does the nurse anticipate the immediate treatment plan for this client will include? 1. NPH insulin. 2. Potassium 40 mEq (40 mmol/L) slow intravenous push. 3. Intravenous administration of isotonic saline. 4. Intravenous sodium bicarbonate.
3
The nurse is preparing to provide oral care to an unconscious client. What is the most important step for the nurse to provide? 1. Performing hand hygiene. 2. Explaining the procedure to the family. 3. Positioning the client in side-lying position. 4. Raising the head of bed 30 degrees.
3
What statements by a client diagnosed with a hiatal hernia would indicate to the nurse that the discharge teaching was effective? 1. "I should eat six small meals a day." 2. "Sitting up for an hour after I eat will decrease symptoms." 3. "Eating a grapefruit for breakfast will help digest the rest of my food." 4. "Ten inch blocks need to be placed under the head of my bed." 5. "I will get assistance for lifting heavy objects." 6. "I will avoid using laxatives."
1,2,4,5
A nurse is instructing a client who had a cesarean birth 2 days ago about adverse signs that should be reported to the primary health care provider. Which signs should the nurse include? 1. Fever greater than 100.4° F (38° C) for 2 or more days. 2. Change in lochia from rubra to serosa. 3. Calves with localized pain, redness, and swelling. 4. Burning with urination. 5. Feeling of apathy toward newborn. 6. Able to provide self care.
1,3,4,5
Which finding should a nurse expect when assessing a healthy 65 year old client? 1. Anomia 2. Presbyopia 3. BP 156/88 4. Apraxia
2
A client with a history of increasing dyspnea over the past week comes to the emergency department. After arterial blood gases (ABGs) are drawn, which information would be important for the nurse to document? 1. The client had not been NPO prior to the test. 2. The client was on 2 L of oxygen by nasal canula. 3. Lung sounds are wet. 4. Client is sitting in upright position.
2
Which nursing tasks can the RN delegate to an unlicensed assistive personnel (UAP)? 1. Tell a female client who has recurrent urinary tract infections how to wipe after urinating. 2. Obtain blood pressure of client diagnosed with nephrotic syndrome. 3. Collects a urine specimen from an indwelling catheter tubing. 4. Document the intake and output of a client in acute renal failure. 5. Irrigate the foley catheter of a client who has had transurethral resection of the prostate (TURP). 6. Perform perineal care of a client who has urinary incontinence.
2,4,6
A nurse is planning to provide an education class on preconception health care to a group of young women wishing to become pregnant. What points should the nurse include in this class? 1. Attain a healthy weight. 2. Make sure immunizations are up to date. 3. Avoid drinking alcohol. 4. Learn family health history. 5. Maintain folic acid intake at 200 micrograms/day.
1,2,3,4
Which interventions should the nurse initiate to lessen acid reflux in a client diagnosed with gastroesophagel reflux disease (GERD)? 1. Provide small, frequent meals. 2. Avoid carbonated beverages. 3. Administer omeprazole as prescribed. 4. Assist with smoking cessation. 5. Place in left lateral position for 2 hours after eating.
1,2,3,4
What should the nurse teach a pregnant client who comes to the clinic reporting hemorrhoids and constipation? 1. Increased rectal pressure from the gravid uterus may result in hemorrhoids. 2. Hormones decrease maternal GI motility, resulting in constipation. 3. The client needs more fiber in the diet. 4. A mild laxative is recommended to alleviate constipation. 5. The client needs to increase fluid intake. Rationale
1,2,3,5
A quality assurance (QA) manager plans to evaluate performance improvement regarding the implementation of fall precautions for at risk clients. What steps should the QA manager include in this evaluation? 1. Chart review for fall precaution documentation. 2. Direct observation of unit staff. 3. Poll staff to identify what fall precautions are implemented for at risk clients. 4. Identify at risk clients on unit. 5. Make unannounced visits to the unit for evaluating staff performance.
1,2,4,5
A nurse is attempting to develop trust with a psychiatric client exhibiting concrete thinking. Which nursing intervention would promote trust in this individual? 1. Attend an activity with the client who is reluctant to go alone. 2. Allow the client to break an insignificant rule. 3. Consider client preferences when possible in decisions concerning care. 4. Provide a blanket when the client is cold. 5. Provide food when the client is hungry.
1,3,4,5
The nurse is teaching the client about benzodiazepines. Which comments by the client indicate adequate understanding of the drug effects/side effects? 1. I should not drive my car until I see how the medication affects me. 2. I can expect my reaction time to be slowed in the beginning. 3. I may need to double the dose if I continue to be anxious. 4. I must be careful to take the medication for a limited time. 5. There is a risk for dependence on this medication.
1,2,4,5
Which interventions should the nurse include when planning care for a client diagnosed with paranoid personality? 1. Develop a trusting relationship. 2. Be honest when communicating with the client. 3. Encourage the client to participate in group therapy. 4. Encourage the client to clean the day room daily. 5. Give clear explanations of procedures before hand.
1,2,5
A new mother brings her infant to the clinic for a well-baby checkup. While at the clinic, the mother asks the nurse if there are any reasons why her infant should not have the measles, mumps, rubella (MMR) vaccine. The nurse's response is based on evidence that the MMR vaccine is contraindicated under which condition? 1. A known allergy to gelatin. 2. A family history of autism. 3. In infants with diarrhea. 4. A known allergy to sulfonamides.
1
The nurse is caring for a client in an outpatient clinic. The client is being treated with warfarin for prevention of a stroke due to atrial fibrillation. The international normalized ratio (INR) was noted to be 4.6. What should the nurse do? 1. Inform the primary healthcare provider immediately. 2. Instruct the client to continue medication as ordered. 3. Inform the client to watch for signs of bleeding. 4. Inform the client to return to the clinic per routine monitoring schedule. 5. Take no action as this value is within target range.
1,3
A nurse from the neonatal unit is transferred to the adult medical-surgical unit. Which client should the charge nurse assign to the neonatal nurse? 1. Undergoing surgery for placement of a central venous catheter. 2. Diagnosed with leukemia, hospitalized for induction of high-dose chemotherapy. 3. Receiving IV heparin for left leg thrombosis. 4. Admitted with a cerebrovascular accident.
1
The unit charge nurse is responsible for reporting all healthcare associated infections. Which client condition needs to be reported? 1. A client diagnosed with Clostridium Difficile while receiving intravenous (IV) antibiotics. 2. A client admitted with Methicillin-Resistant Staphylococcus aureus (MRSA) in a wound. 3. A client with ulcerative colitis exhibiting diarrhea. 4. A client with a fever of 99.1º F (37.2° C) two days post gastrectomy.
1
What is the best instruction the nurse should provide when administering acetylsalicylic acid 81 mg to a client experiencing severe, crushing chest pain radiating up the left jaw? 1. Chew the acetylsalicylic acid prior to swallowing. 2. Place the acetylsalicylic acid under the tongue so that it can dissolve. 3. Swallow the acetylsalicylic acid tablet. 4. Insert the acetylsalicylic acid between the cheek and gum for greater absorption.
1
A homebound client lives alone, has a history of poorly controlled diabetes, and has an open wound on the left heel. The home health nurse is concerned about the client's condition and the possible need for a referral. Which intervention should the nurse initiate for this client? 1. Ask the primary healthcare provider to prescribe a diabetes educator consult. 2. Increase home health visits to monitor the healing process of the open wound. 3. Suggest nursing home placement to the family until wound has healed. 4. Suggest that the client's family hire sitters to assist with hygiene care.
1
What statements by a new nurse would indicate to the charge nurse an understanding of how to maintain skin integrity for a client on bedrest? 1. "Clients on bedrest should be placed on therapeutic mattresses." 2. "I will assess for the skin every 4 hours." 3. "I will assess the skin using the Braden scale." 4. "A pillow will be placed between the knees when client is side lying." 5. "The incontinent client will be kept clean and dry."
1,3,4,5
What should the nurse include in the post-op care of a client following the removal of the posterior pituitary gland? 1. Monitor intake and output. 2. Restrict fluids to no more than 1500 ml/day. 3. Weigh daily. 4. Monitor urine specific gravity. 5. Assess the level of consciousness (LOC). 6. Instruct client to avoid blowing the nose forcefully.
1,3,4,5,6
A nurse is planning to teach a group of men about their sildenafil prescription. What information should the nurse include? 1. Notify primary healthcare provider if prescribed an alpha-adrenergic blocker. 2. This medication protects against sexually transmitted diseases. 3. Sildenafil should be taken only once per day if needed. 4. This medication is most effective if taken with grapefruit juice. 5. The most common side effects are flushing, headache, and dyspepsia.
1,3,5
The nurse in the outpatient clinic performs an assessment on a client who takes propranolol for management of palpitations associated with mitral valve prolapse. Which statement by the client should be reported immediately to the primary healthcare provider? 1. "My resting pulse was 60 this morning." 2. "I feel a little short of breath when walking." 3. "I have lost 5 pounds in the last 2 weeks." 4. "My blood pressure (BP) was lower this visit than last time."
2
The nurse is obtaining a health assessment from the preoperative client scheduled for hip replacement surgery. Which statement by the client would be most important for the nurse to report to the primary healthcare provider? 1. "When I was 8 years old I had chickenpox." 2. "I had rheumatic fever when I was 10 years old." 3. "There is a strong history of gastric cancer in my family." 4. "I have pain in my hip with any movement."
2
The nurse is working at the triage station. Which client should the nurse triage first? 1. A client with hepatitis A who states, "My arms and legs are itching." 2. A client with a cast on the right leg who states, "My right leg is killing me and nothing I do makes it stop hurting. " 3. A client with nausea and vomiting for two days states, "I am very weak and can't eat." 4. A client with hematuria and reports left flank pain.
2
The nurse is teaching parents of a school aged child about interventions to keep the child safe. Which interventions would be appropriate to include in the health promotion plan? 1. Encourage bicycle helmet use when riding bikes. 2. Teach children to swim at an early age. 3. Use booster seats until the child is at least 6 years old. 4. Keep firearms in the home locked and unloaded. 5. Teach "stop, drop, and roll" in case clothing catches on fire.
1,2,4,5
Which observations by the nurse indicate that a mother is protecting her two day old female newborn from infection? 1. Cleans perineum from front to back after newborn soils diaper. 2. Makes certain the umbilical cord remains dry with each diaper change. 3. Places the top of the diaper just above the umbilicus. 4. Wraps sterile petroleum gauze around umbilical cord. 5. Submerges newborn in warm water up to the chest for first bath.
1,2
The nurse is planning health promotion strategies for a single parent of young children who is trying to increase personal physical activity level but expresses a lack of time. Which interventions would help the client get more regular physical activity into the day? 1. Suggest walking up and down steps at home several times each morning and evening. 2. Suggest parking further away from the grocery store and work. 3. Walk with the children in the evening instead of watching TV with them. 4. Suggest waking one hour earlier in the morning to go to the gym. 5. Suggest walking for 30 minutes with a buddy each afternoon before leaving work.
1,2,3
Which tasks would be appropriate for the nurse to assign to an LPN/VN? 1. Changing a colostomy bag. 2. Administer antibiotic via intravenous piggyback (IVPB). 3. Teach insulin self administration to a diabetic client. 4. Administer IV pain medication to a two day post op client. 5. Check for urinary retention. 6. Remove wound sutures.
1,2,5,6
A client at 36 weeks gestation is receiving magnesium sulfate for treatment of pre-eclampsia. Which finding by the nurse requires immediate action? 1. Respiratory rate of 12 2. Deep tendon reflexes (DTR) of 3+ 3. Urinary output (UOP) of 100cc/4hours 4. Fetal heart rate (FHR) of 120
3
A client has been prescribed chlorpromazine for the treatment of schizophrenia. The nurse makes afternoon rounds and finds the client's temperature to be 104.7º F/40.4º C. The client has extreme muscle rigidity, and the vital signs have been fluctuating for the last four hours. What should the nurse do first? 1. Provide a tepid sponge bath. 2. Notify the primary healthcare provider immediately. 3. Administer an antipyretic immediately. 4. Administer the chlorpromazine as prescribed.
2
A client is in the surgical suite to have a left total knee replacement. Prior to the surgeon initiating the first incision, what should the circulating nurse remind the surgical team to perform? 1. Surgical scrub 2. Time-out 3. Sponge and instrument count 4. Inspection of the surgical site
2
A client received a leg cast that was applied following fracturing the left femur. What assessment finding would be a priority for the nurse to report to the primary healthcare provider? 1. Reports of a feeling of warmness under the cast after application. 2. Pain not relieved by elevation, cold packs, and pain medication. 3. Reports of itching under the cast not relieved by cool air. 4. Slight swelling of the toes of the affected extremity.
2
A client who has developed hypovolemic shock is receiving albumin. What assessment finding by the nurse indicates that the albumin has been effective? 1. Swelling in the legs 2. Increase in uninary output 3. Proteinuria 4. Increase in waist measurement
2
A client with Crohn's disease develops a fever and symptoms of an infection. The nurse recognizes this complication may occur as a result of which finding? 1. Perianal irritation from frequent diarrhea 2. Fistula formation with an abscess 3. Stricture formation 4. Impaired immunologic response to infectious microorganisms
2
A client with chronic alcoholism has been admitted to the intensive care unit after overdosing on alcohol. Which medication should the nurse prepare to administer? 1. Disulfiram 250 mg po daily 2. Thiamine 100 mg IV twice a day 3. Naloxone 0.4 mg IV prn 4. Clonidine TTS patch 2.5 mg per week
2
A nurse has responded to the scene of a natural disaster to triage clients. Which client should the nurse triage with a black disaster tag? 1. Traumatic amputation to the left lower leg. 2. 2nd and 3rd degree burns over 75 % of the body. 3. Fracture of the humerus. 4. Blood pressure of 90/40 and lethargic.
2
An elderly Asian woman has been in the hospital for three weeks, and it seems that her condition is such that nursing home placement is in the client's best interest. The family is against placing their relative in the nursing home. How should the nurse respond to this? 1. Encourage the family to accept nursing home placement as the best option for their loved one. 2. Listen to the family's concerns and report those to the primary healthcare provider. 3. Ask the client what she wants and tell the family to abide by the client's wishes. 4. Realize that the nurse does not need to be involved in this decision.
2
An elderly client is admitted to the floor with vomiting and diarrhea for three days. She is receiving IV fluids at 200 mL/hr via pump. What is the priority nursing action? 1. Intake and output every shift. 2. Lung assessments every 2-4 hours. 3. Vital signs every shift. 4. IV site assessment every 2-4 hours.
2
The charge nurse is evaluating knowledge of tracheostomy suctioning of a new nurse prior to that procedure being performed. Which statement by the new nurse would indicate to the charge nurse that additional education is needed? 1. "Prior to suctioning, I will hyper-oxygenate the client." 2. "I will instill normal saline bullets to liquefy secretions." 3. "I will allow at least 20 seconds between suctioning passes." 4. "Suctioning will be limited to a maximum of three catheter passes."
2
A nurse is planning a health education seminar for a group of females who are age 45-54. What should the nurse recommend be done annually? 1. Chest xray 2. Mammography 3. Influenza vaccine 4. Tuberculous (TB) skin test 5. Colonoscopy
2,3
Post thyroidectomy, the nurse assesses the client for complications by performing which assessment? 1. Perform blood glucose monitoring every 6 hours 2. Check for a positive Chvostek's 3. Assess swallowing reflex 4. Monitor neck dressings for change in fit and comfort 5. Administer desmopressin per nasal spray for urinary output (UOP) greater than 200 mL/hr
2,3,4
The nurse is teaching a client regarding buspirone. The nurse recognizes that teaching has been effective when the client makes which statements? 1. "I should start feeling better in two or three days." 2. "I should not drink alcohol while taking this medication." 3. "I will rise slowly from lying to sitting or standing." 4. "I will notify my primary healthcare provider of any unusal facial movements." 5. "I need to keep the medication in a closed container in the refrigerator."
2,3,4
A client has been admitted to the medical unit and placed on airborne precautions for suspected pulmonary tuberculosis (TB). The nurse will assess for which signs and symptoms? 1. Weight gain 2. Fatigue 3. Hemoptysis 4. Diaphoresis during sleep 5. Anorexia
2,3,4,5
A nurse is calling the primary healthcare provider about a client who is experiencing dyspnea and chest pain two days post total knee replacement. Which statements by the nurse are appropriate according to the communication tool SBAR (Situation, Background, Assessment and Recommendation)? 1. "Hello Dr, I am calling about one of your clients." 2. "Jane Doe is having increasing dyspnea and is reporting chest pain." 3. "Jane Doe had a total knee replacement two days ago. Pulse is 120, BP 128/54, Resp 32. She is restless." 4. "From my assessment, I think she may be having a cardiac event or a pulmonary embolism." 5. "I recommend that you see the client immediately and that we start oxygen stat. Do you agree?"
2,3,4,5
A client who has been on a psychiatric unit because of several attempted suicides states, "I am happy to be going home today." What is the nurse's best analysis of this statement? 1. No longer has depression. 2. Has developed appropriate coping mechanisms. 3. May have decided on another suicide plan. 4. Is happy to go home and see family.
3
The nurse is providing care to a client who has a large abdominal dressing. Which intervention is most likely to reduce the risk of skin irritation due to frequent dressing changes? 1. Use a paper tape for adhering the dressing. 2. Use tape sparingly. 3. Secure the dressing with Montgomery straps. 4. Change the dressing only if it becomes saturated with drainage.
3
The nurse is teaching a class to primiparas on breastfeeding. How many extra kilocalories per day would the nurse instruct the class participants to consume post-delivery to compensate for the increased energy requirements of lactation? 1. 1000 2. 300 3. 500 4. 800
3
A client arrives in the emergency department with fever, nuchal rigidity, and seizures. What action should the nurse take first? 1. Administer Penicillin IVPB. 2. Obtain blood cultures from two sites. 3. Place on droplet precautions. 4. Set up for lumbar puncture.
3
A child is being admitted to the hospital with a diagnosis of acute glomerulonephritis. In performing the history and physical, what would be a priority assessment that the nurse should include when questioning the child and caregivers? 1. Types of contact sports played 2. Amount of acetaminophen intake 3. Recent sore throat 4. Recent exposure to salmonella
3
A child was diagnosed with attention-deficit/hyperactivity disorder (ADHD) in the clinic one week ago. Today the child's mother calls the clinic to tell the nurse, "My child has not been able to sleep since being put on methyphenidate." What is the best response for the nurse to make? 1. "I will discuss this with the primary healthcare provider. A different medication may be prescribed." 2. "The insomnia will get better over time. Just wait it out." 3. "To prevent insomnia, give your child the last daily dose at least 6 hours before bedtime." 4. "Your child may have overdosed on the medication. Go to the emergency department now."
3
The primary healthcare provider prescribes a combination of pyrazinamide and isoniazid to treat a client with tuberculosis. The client asks the nurse, "Why am I taking two drugs?" Which explanation should the nurse give the client? 1. One diminishes the side effects of the other. 2. Hepatoxicity is reduced. 3. Bacterial resistance is decreased. 4. One kills the live bacteria, and the other the spores.
3
What is priority for the nurse to determine about a client who is scheduled for a tubal ligation in the outpatient surgical center? 1. Client's prior experiences with outpatient surgery. 2. Medical plan and the extent of insurance coverage for outpatient surgery. 3. Client's plan for transportation and care at home. 4. Client's plan to spend the night at the surgical center.
3
Which findings would indicate to the nurse that a client with Addison's disease has received too much glucocorticoid replacement? 1. Dry skin and hair 2. Hypotension 3. Rapid weight gain 4. Decreased blood glucose level 5. Increased cholesterol
3,4
The nurse is teaching a newly diagnosed diabetic about proper foot care. Which statements by the nurse are correct? 1. Cut the toenails in a rounded fashion. 2. Wash the feet with warm water and betadine. 3. Wear appropriate fitting shoes at all times. 4. View the bottom of the feet daily. 5. Protect feet from hot and cold.
3,4,5
The nurse is caring for a client with pneumococcal pneumonia. Which nursing observations would indicate a therapeutic response to the treatment regime for the infection? 1. Dyspnea on exersion with nonproductive cough 2. Tachypnea with use of accessory muscles 3. Expectorating moderate amounts of thin, white sputum 4. White blood cell count of 18,000 cells per mcL 5. Crackles clearing with cough
3,5
The primary healthcare provider suspects the client has tuberculosis (TB) and prescribes a Mantoux test. What precautions should the nurse take when administering the Mantoux test? 1. Don sterile gloves. 2. Place the client on reverse isolation. 3. Wear a particulate respirator 4. Obtain a consent form. 5. Initiate airborne precautions.
3,5
The nurse is caring for a client with myasthenia gravis. What is essential for the nurse to teach this client regarding treatment? 1. Frequent low-calorie snacks. 2. Strict monitoring of intake and output. 3. Use of sweeping gaze when walking. 4. Setting the alarm clock for medication times.
4
A client has returned to the burn unit after an escharotomy of the forearm. What is the priority nursing intervention? 1. Roll sterile q-tip over the wound 2. Elevate the affected arm 3. Ask the client to rate pain level 4. Assess bilateral radial pulses
4
A nurse is caring for a client who has developed ventricular fibrillation. Where should the nurse place the conductive electrodes for maximum defibrillation effectiveness? 1. The left lower sternum and the right side of the thorax in the midclavicular line. 2. On the right shoulder and the left side of the sternum just below the rib cage. 3. The left upper chest to the left of the sternum and the lower right half of the sternum. 4. Below the right clavicle to the right of the sternum and just below the left nipple.
4
A nurse is teaching a client about the prescription aripiprazole discmelt. The nurse documents that teaching has been effective when the client makes which statement? 1. "If I start to have shakiness and sweating I need to call my primary healthcare provider at once." 2. "I must be certain to take this medication with food to eliminate vomiting." 3. "If I miss a dose of medication, I need to take an extra dose to make up for the missed dose." 4. "I will allow the tablet to dissolve in my mouth."
4
A parent tells the clinic nurse, "My child has just been diagnosed with attention-deficit/hyperactivity disorder (ADHD). What will be done to help my child?" How should the nurse best respond to the parent? 1. The primary healthcare provider will want to start your child on a central nervous system (CNS) depressant in order to decrease hyperactivity and improve attention. 2. You will need to admit your child to the psychiatric behavioral unit so that group therapy can be initiated. 3. Children are often placed on central nervous system stimulants that improve behavior associated with ADHD. 4. The standard of care for children with ADHD includes central nervous system stimulants along with behavior and family therapy.
4
In what position should the nurse place a client post liver biopsy? 1. Left Sims' 2. Reverse Trendelenburg 3. Semi-Fowler's 4. Right Lateral Decubitus
4
The nurse is caring for a client while fluorouracil is being infused. The client reports burning at the intravenous (IV) site. What should the nurse do first? 1. Apply warm compresses. 2. Slow the infusion. 3. Inspect the IV site. 4. Stop the infusion.
4
The nurse is caring for a client with hypothyroidism. Which dietary consideration is most important for the nurse to teach this client? 1. Increase carbohydrate intake. 2. Decrease fluid intake. 3. Avoid shellfish. 4. Increase fiber.
4
The nurse will be admitting a client from the operating room following a left total pneumonectomy for adenocarcinoma. Which type of chest drainage should the nurse anticipate that the client will have? 1. Bilateral chest tubes. 2. One chest tube on the operative side 3. Two chest tubes on the operative side 4. No chest drainage will be necessary.
4
What is most important for the nurse to do prior to initiating peritoneal dialysis? 1. Aspirate for placement. 2. Have the client void. 3. Irrigate the catheter for patency. 4. Warm the dialysate fluid.
4
What is most important for the nurse to have at the client's bedside when inserting a large orogastric tube for rapid gastric lavage? 1. Emesis basin 2. Portable x-ray machine 3. Oxygen 4. Suction equipment
4
Which client must the nurse assign to a private room? 1. Primiparous client who delivered twins at 28 weeks gestation two days ago 2. Postpartum client on IV Ampicillin and Gentamicin for chorioamnionitis 3. Postpartum client whose 2 hour old infant is being worked up for sepsis 4. Postpartum client 32 hours after delivery with a temperature of 101º F (38.05 ° C)
4
Which actions by the nurse, working in the recovery room, should be performed to prevent injury from a needle stick? 1. Recap the needle after use to prevent injury. 2. Reinsert the sylet if it becomes loose in the vascular assess device. 3. After drawing up saline to flush an intravenous (IV) line, place the syringe in a pocket to prevent possible injury. 4. Replace the puncture resistant biohazard container when three-quarters full. 5. Use "needleless" devices whenever possible.
4,5
Which home routines help reduce the risk of skin damage in a client with impaired sensation? 1. Using a hot water bottle to help warm up when first going to bed. 2. Hot water heater set at a temperature of 140 °F (60 °C) 3. Open flame heaters in the living areas of the home. 4. Testing the water with the back of the wrist and forearm before getting in the shower. 5. Check condition of all equipment used in the home.
4,5
Based on the Parkland formula, the primary healthcare provider has determined that a burn victim needs 9,250 mL of LR intravenously over the first 24 hours. How many milliliters of LR should the nurse administer over the first eight hours? Round answer to the nearest whole number.
4625
The nurse is providing discharge education to a client after a concussion. What should the nurse emphasize to report to the primary healthcare provider? 1. Difficulty waking up 2. Headache (3/10 on the pain scale) 3. Blurry vision 4. Achy feeling all over 5. Vomiting
1,3,5
A nurse is preparing to conduct a presentation on barriers to therapeutic communication with clients from a culture other than the nurse's culture. Which points should the nurse include in the presentation? 1. Lack of knowledge about a client's culture is a major barrier to therapeutic communication. 2. Follow cultural beliefs when caring for all clients of that particular culture. 3. Ethnocentrism facilitates therapeutic communication. 4. Do not touch the client until you know what the cultural belief is about touching. 5. Adapt care to client's cultural needs and preferences.
1,4,5
The nurse is caring for a client with hyperparathyroidism. The nurse will monitor the client for which complications? 1. Kidney stones 2. Diarrhea 3. Osteoporosis 4. Tetany 5. Fluid volume deficit
1,3
The nurse is caring for a client with renal failure. The client has a 24 hour intake of 2500 mL and a 24 hour urinary output of 200 mL. What is the priority nursing assessment? 1. Assess for dependent edema. 2. Monitor for cardiac arrhythmias. 3. Auscultate breath sounds. 4. Monitor sodium and potassium levels
3
The nurse is instructing a client on achieving relaxation using deep breathing exercises. Which statement by the client indicates to the nurse that further teaching is necessary? 1. "I can perform deep breathing exercises anywhere and at any time that I feel tension and anxiety." 2. "I should sit or lie in a comfortable position, making sure my back is straight." 3. "I will inhale slowly and deeply through my mouth focusing on my chest expansion." 4. "When I have inhaled in as much as possible, I will hold my breath for a few seconds before exhaling."
3
A charge nurse is planning care for several clients on the unit. Which activities can the nurse safely delegate to an unlicensed assistive personnel (UAP)? 1. Administer a nebulizer treatment to a client diagnosed with pneumonia. 2. Obtain vital signs on a postoperative client who required naloxone 5 minutes ago. 3. Report a urinary output (UOP) less than 50 ml/hr on a post-op client. 4. Assist a client with obtaining a clean catch urine sample. 5. Remove an indwelling urinary catheter from a client.
3,4
A client was prescribed thioridazine hcl five days ago and presents to the emergency department with a shuffling gait, tremors of the fingers, drooling, and muscle rigidity. Which adverse reaction to this medication does the nurse suspect? 1. Akinesia 2. Neuroleptic malignant syndrome 3. Pseudoparkinsonism 4. Oculogyric crisis
3
A teenage client is placed on life-support as a result of a motor vehicle accident (MVA). Following an electroencephalogram (EEG), the client has been declared brain dead. Which action by the nurse would take priority? 1. Call the respiratory department to have the ventilator removed. 2. Notify the facility's pastoral personnel. 3. Contact the regional organ procurement team. 4. Ask the family to select a funeral home.
3
Blood and urine samples are sent to the laboratory for a client who has had a spinal cord injury. After reviewing these results, the nurse would expect which finding? Exhibit 1. Gross hematuria 2. Septicemia 3. Urinary tract infection 4. Anemia
3
The nurse is performing the admission assessment on a client who is having a breast augmentation. Which client information would be most important for the nurse to report to the surgeon before surgery? 1. Client is concerned about who will care for her two children while she recovers. 2. There is a history of postoperative dehiscence after a previous C-section. 3. Client's last menstrual period was 8 weeks ago. 4. Client is concerned over pain control postoperatively.
3
Which client requires immediate intervention by the nurse? 1. Client diagnosed with Crohn's disease reporting frequent bloody diarrhea and abdominal cramping. 2. Client with renal calculi who reports no pain relief from ketorolac administered 30 minutes ago. 3. Client with a fractured femur reporting sharp chest pain of 4/10. 4. Client admitted with cholelithiasis reporting right-sided abdominal pain of 8/10.
3
Which factor would most likely predispose a client to developing shock following a fracture of the femur? 1. Pooling of the blood in the lower leg 2. Generalized vasoconstriction in the lower extremities 3. Loss of blood into soft tissues surrounding the fracture 4. Depression of the adrenal gland by toxins released at the injury
3
Which intervention can the nurse safely delegate to an unlicensed assistive personnel (UAP)? 1. Irrigate a colostomy in a client who is 2 days postoperative. 2. Remove a fecal impaction in a client. 3. Apply a condom catheter to an incontinent client. 4. Insert a urinary catheter to obtain a urine sample.
3
Which pediatric client should the nurse see first? 1. Six year old with a femur fracture. 2. Two year old with a fever of 102 ° F (38.8 ° C) 3. Three year old with wheezes in right lower lobe. 4. Two year old whose gastrostomy tube came out.
3
The nurse is caring for a client suffering from major depression. The client spends all day in bed. Which nursing action is appropriate? 1. Frequently initiate contact with client. 2. Frequently round at regular intervals. 3. Patiently wait for the client to come out of the room. 4. Question the client about reason for not getting out of the bed.
1
The occupational health nurse is leading a group discussion about addiction. What should the nurse include as the primary barrier to the client with alcohol addiction seeking treatment? 1. Co-dependency 2. Denial 3. Depression 4. Stigma
2
A client recently diagnosed with diabetes is sent home with a prescription for subcutaneous insulin. What statement made by the client indicates that teaching has been effective regarding safe needle disposal? 1. "I should wrap the needle in a paper towel and place in the trash." 2. "I should use a hospital issued biohazard container for all needles." 3. "I may use any hard plastic container with a screw-on cap." 4. "I should take my needles to the nearest hospital for disposal. "
3
A hospice nurse is assessing a client reporting chronic pain (5/10 on the pain scale). In addition to the primary healthcare provider and the nurse, what member of the care team will assist in providing comfort therapies for this client? 1. Physical therapist 2. Nutritionist 3. Massage therapist 4. Occupational therapist
3
The charge nurse observes a staff nurse caring for a new mother with oral herpes simplex type I. Which action by the nurse indicates that further instruction on transmission of this disease is needed? 1. Instructs the new mother that she should not kiss the newborn. 2. Wears gloves during the perineal and lochia assessment. 3. Washes hands before and after each client contact. 4. States that the newborn may contract herpes from the birth canal.
4
A client is seen in the clinic for recurrent unexplained, vague stomach pain over the past 5 years. EGD, colonoscopy, gallbladder ultrasound, and lab results have revealed no physical reason for the symptoms. The client tells the nurse, "The doctor thinks the pain in my stomach is psychosomatic. But the pain is so bad some times that I can't function!" What is the nurse's most appropriate response? 1. "The pain you feel is real." 2. "The primary healthcare provider is right. Your pain is not real." 3. "Let me get you an appointment with the psychiatrist." 4. "Don't worry. Everything will be ok."
1
A newborn in a neonatal unit is to receive penicillin G benzathine 50,000 units/kg intramuscularly (IM). The newborn weighs 6 lbs (2.7 kg). The dispensed dose is 25,000 units per 1 mL. What should the nurse do? 1. Administer the drug intravenously (IV) since a large volume is required. 2. Choose three injection sites and give the medication as prescribed. 3. Consult with the pharmacy for a different medication concentration. 4. Read the available drug information to determine how to administer the medication.
3
A woman, diagnosed with an ectopic pregnancy, asks the nurse the purpose of receiving methotrexate. What is the best reply for the nurse to make? 1. "Methotrexate will stop your bleeding." 2. "It will destroy fetal cells that got into your blood so that antibodies will not be formed." 3. "This medication will stop the growth of the embryo to save your fallopian tube." 4. "Cervical dilation is expected after receiving this medication."
3
During evening rounds, the nurse discovers that a violent client with a history of threats against a former girlfriend cannot be located. The client's window is open and personal belongings missing. Based on recent threats of violence against the girlfriend, what is the nurse's initial action? 1. Look for the client quietly to maintain confidentiality. 2. Notify the local police to organize a search party. 3. Initiate the missing client protocol. 4. Complete an "Against Medical Advice" (AMA) form on the client's elopement.
3
The charge nurse has received report from the emergency department about a client diagnosed with Cushing's disease being admitted to the unit. Which client in a semi-private room would be appropriate for the charge nurse to have this client share? 1. Client who has leukemia. 2. Client diagnosed with gastroenteritis. 3. Client who has a fractured hip. 4. Client diagnosed with bronchitis.
3
The nurse is planning daily activities for a client who has a diagnosis of schizophrenia. The client tends to spend most of the time in bed and is very uncomfortable when other clients are in the day area of the unit. What activity would be most therapeutic for this client? 1. Watching TV with two other clients in the day room. 2. Watching TV alone in a conference room. 3. Spending time in brief one on one interactions with the nurse. 4. Sitting in the day-room away from other clients.
3
A client with dementia has been admitted to the medical floor. The family informs the nurse that the client tends to wander at night. When planning client safety goals, which action by the nurse would take priority? 1. Place client with a roommate who is able to notify staff when client wanders. 2. Discuss safety goals with family, encouraging them to spend time with client. 3. Designate an unlicensed assistive personnel (UAP) to sit with the client through the night. 4. Reorient the client every shift regarding floor policies and safety procedures.
3
A 13 year old, found unresponsive in the park, is brought into the emergency department. The nurse sees a medical alert bracelet stating "Diabetic", and notes a fruity smell to the breath. There are no family members available to obtain consent for treatment and an attempt to call them has been unsuccessful. What action should the nurse take? 1. Obtain consent from the social worker on duty in the emergency department. 2. Begin treatment by inserting two large bore IVs of Normal Saline. 3. Give glucogon IM and wait for the arrival of a parent to consent to further treatment. 4. Withhold treatment until a parent arrives to the emergency department.
2
A home care nurse is preparing to perform venipuncture to draw blood. As the nurse gathers supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of losing control. What should be the nurse's first action? 1. Hug the client to provide support. 2. Take the client to the emergency department for sedation. 3. Decrease stimuli in the room. 4. Teach the client deep breathing exercises.
3
A client calls the clinic to ask the nurse if it would be okay to take the herbal medication kava-kava to help reduce anxiety. What is the nurse's best response? 1. "Why do you want to take kava-kava?" 2. "I really doubt your primary healthcare provider will approve you taking kava-kava." 3. "Kava-kava can cause liver damage, so we need to consult your healthcare provider." 4. "Do not take Kava-kava for more than a year without a primary healthcare provider's supervision."
3
A client develops pernicious anemia after a Billroth II procedure and is to receive vitamin B12 intramuscularly. What should the nurse include in discharge instructions? 1. B12 can be stored in a lighted area. 2. The B12 injections will be stopped when symptoms disappear. 3. The B12 injections will be continued for the client's life. 4. Vitamin B12 will be taken by mouth once the maintenance dose is determined.
3
A client admitted with a myocardial infarction has developed crackles in bilateral lung bases. Which prescription written by the primary healthcare provider should the nurse complete first? 1. Draw blood for arterial blood gases. 2. Place compression hose on legs. 3. Insert indwelling catheter for hourly urinary output. 4. Administer furosemide 20 mg intravenous push (IVP).
4
A client has an order for two units of packed red blood cells (PRBCs) to be administered. The current IV prescribed is D5LR with 20 mEq KCL at 125 mL/hr infusing through a 22 gauge needle to the left hand. What action should the nurse take? 1. Piggyback the PRBCs to the current IV fluid at the lowest port on the tubing. 2. Change the current IV fluid to NS so the blood can infuse through the IV tubing. 3. Disconnect the current IV fluid and connect NS with a y-tubing blood administration set. 4. Start another IV with an 18 gauge needle to the right arm.
4
A client diagnosed with pancreatitis becomes increasingly restless, confused and has pulled out the NG tube and IV catheter. HR-128/min, BP 96/62. Oxygen saturation = 90%. Skin is cool and clammy to touch. Prioritize the actions that the nurse should take. Initiate oxygen. Insert another IV line. Obtain blood sugar level. Insert NG tube. Repeat vital sign checks
This is the correct order
A primary healthcare provider has prescribed the insertion of a nasogastric (NG) tube. In what order should the nurse perform this procedure? Place actions in the correct order. Elevate head of bed to fowler's position. Measure distal NG tube from nose tip to earlobe to xiphoid process. Lubricate 2-3 inches of distal NG tube. Insert NG tube into unobstructed naris. Advance NG tube upward and backward until resistance is met. Rotate catheter and advance into nasopharynx. Have client swallow ice as NG tube advances into stomach. Secure NG tube.
This is the correct order
The nurse is caring for a client in the emergency department. The primary healthcare provider prescribed 1000 mL of D5 ½ NS. The IV is infusing at 25 gtts/min. (Drop factor is 60 gtts/mL). What is the infusion time in hours? Round your answer to the nearest whole number.
x = 2400 min. divide by 60 = 40 hours
