practice test
b
The nurse administers a prescribed continuous tube feeding to a client. Which action should the nurse implement as routine care for this client? a. Change the feeding bag and tubing every 48 hours. b. Check the residual in the stomach every 4 hours. c. Leave at least 25mL of formula in the feeding bag when adding additional formula to the bag. d. Withhold the feeding if residual is greater than 200mL.
a
The nurse is creating a plan of care for a client who is experiencing homonymous hemianopsia after a stroke. The nurse documents interventions that will promote a safe environment, knowing that in this disorder the client experiences which symptom? a. Has a visual loss in the same half of the visual field of each eye b. Has lost the ability to recognize familiar objects through the senses c. Is unable to carry out a skilled act, such as dressing, in the absence of paralysis
b
The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? a. Positive reflexes b. Flaccid paralysis c. Hyperreflexia d. Reflex emptying of the bladder
a
The nurse is monitoring a client diagnosed with hypercalcemia. Which assessment finding indicates a need for follow-up? a. Decreased capillary refill b. Increased deep tendon reflexes c. Decreased abdominal circumference d. Increased peristalsis
c
The nurse is performing hourly neurologic checks for a client with a head injury. Which new assessment finding warrants immediate action by the nurse? a. Client cries out when awakened by a verbal stimulus b. Onset of nausea, headache, and vertigo c. A unilateral pupil that is dilated and nonreactive to light d. Client demonstrates a loss of memory of the events leading up to the injury.
d
The nurse is caring for a hospitalized client with a diagnosis of acute pancreatitis. The nurse should assist the client to which position that will decrease the abdominal pain? a. Prone b. Supine with the legs straight c. Side-lying with the head of the bed flat d. Upright in a sitting position with the trunk flexed
a
A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and ineffective cough and is using accessory neck muscles in breathing. The nurse carefully monitors the client and suspects the presence of which problem? a. Altered breathing pattern b. Increased likelihood of injury c. Ineffective oxygen consumption d. Increased susceptibility to aspiration
d
A 25-year-old client was admitted yesterday after a motor vehicle collision. Neurodiagnostic studies have shown a basal skull fracture in the middle fossa. Assessment on admission revealed both halo and Battle signs. Which new symptom indicates that the client is likely to be experiencing a common life-threatening complication associated with a basal skull fracture? a. Intermittent focal motor seizures b. Intractable pain in the cervical region c. Bilateral jugular venous distention d. Oral temperature of 102 F
c
A client has an arteriovenous (AV) fistula in place in the right upper extremity for hemodialysis treatments. When planning care for this client, which measure should the nurse implement to promote client safety? a. Use the right arm blood pressure measurement b. Use the fistula for all venipunctures and intravenous infusions c. Assess the fistula for the presence of a bruit and thrill every 4 hours d. Ensure the small clamps are attached to the AV fistula dressing
d
A client has had an arteriovenous (AV) graft created for hemodialysis. The client asks the nurse when the graft will be ready for use. The most appropriate response by the nurse is which time frame? a. 5 days b. 3 days c. 1 week d. 3 weeks
a
A client is admitted for complications of end-stage liver disease and management of ascites. A family member asks the nurse why the client is on sodium restriction. Which response by the nurse is most appropriate? a. "The extra sodium will cause him to retain fluid that may cause further swelling." b. "The sodium and fluid he drinks will dilute the potassium in the blood." c. "The sodium intake will cause nausea because the liver is enlarged and pressing on the stomach." d. "The extra sodium will cause him to make too much urine and cause dehydration."
a
A client is diagnosed with myasthenia gravis. The nurse reviews the client's physical examination report in the medical record and expects to note documentation of which clinical manifestation of this disorder? a. Muscle weakness b. Skin irritation c. Pruritus d. Tachycardia
c
A client is scheduled for a liver biopsy, and the nurse reviews the results of the laboratory tests prescribed for the client. The nurse should contact the primary health care provider if which laboratory result is noted? a. Hematocrit 40% b. Platelets 210,000 mm3 (210 × 109/L) c. Thrombin time 20 seconds d. Hemoglobin 14 g/dL (140 mmol/L)
b
A client undergoing long-term peritoneal dialysis at home is currently experiencing a problem with reduced outflow from the dialysis catheter. Which recent problem should the home care nurse inquire whether the client has had? a. Vomiting b. Constipation c. Diarrhea d. Flatulence
d
A client who is recovering from a stroke has residual dysphagia. To assist in assessing the client's swallowing ability, the nurse should ask the client to perform which action? a. Swallow a teaspoon of applesauce b. Suck on a piece of hard candy c. Swallow some water d. Produce an audible cough
d
A client who received an implanted port for intermittent chemotherapy says, "I'm not sure if I can handle having a tube coming out of me. What will my friends think?" Which action should the nurse implement first? a. Show the client various central line catheters b.Assure the client that his friends will understand c. Notify the primary health care provider of the client's concerns d. Explain the implanted ports are subcutaneous and not visible
b
Which client is the best candidate for peritoneal dialysis as a treatment option for renal failure? a. A client with a history of 3 previous abdominal surgeries b. A client with severe heart failure c. A client with a history of ruptured diverticula d. A client with a history of herniated lumbar disk
bce
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. a. Limiting bladder catheterization to once every 12 hours b. Turning and repositioning the client at least every 2 hours c. Keeping the linens wrinkle-free under the client d. Ensuring that the client has a bowel movement at least once a week e. Preventing unnecessary pressure on the lower limbs
bd
A client with chronic kidney disease prescribed a protein restrictive diet should be instructed by the nurse to select which incomplete protein option for inclusion in her or his diet? Select all that apply. a. Fish b. Nuts c. Milk d. Grains e. Eggs
b
Which important parameter should the nurse assess on a daily basis for a client diagnosed with nephrotic syndrome? a. Blood urea nitrogen (BUN) levels b. Weight c. Albumin levels d. Activity intolerance
c
Which is a priority component of the management of myasthenia gravis? a. Wearing an eye patch at night b. Consuming a low-residue diet c. Administering myasthenia medication before meals d. Performing muscle-strengthening exercises
d
The client is diagnosed with a right hemisphere stroke. What intervention should the nurse include in the plan of care? a. Increase the lighting in the client's room b. Teach the client to turn the head toward the affected side c. Reinforce the client's ability to provide self-care d. Emphasize safety needs
c
The client has had a history of cirrhosis for 25 years. What aspect of the plan of care is the priority for the nurse to be aware of in the care of this client? a. Obtain a daily weight. b. Position in semi-Fowler's. c. Avoid insertion of a nasogastric tube. d. Encourage foods high in iron.
b
The client has hepatic encephalopathy and is prescribed lactulose. What assessment finding indicates that the medication is achieving the desired therapeutic effect? a. Fetor hepaticus b. Decreased confusion c. Increased serum potassium d. 3 soft stools a day
d
The client is prescribed neurological checks hourly after a craniotomy. At 0100, the client reports a headache. The nurse obtains a Glasgow Coma Scale (GCS) score of 14 and administers acetaminophen as needed. At 0200, the client appears to be sleeping. What action should the nurse take? a. Let the client sleep but verify respiratory rate. b. Document "relief obtained" and recheck at 0300. c. Wake the client and check for the presence of ecchymosis. d. Wake the client ans ask what day it is.
b
The client presents with abdominal pain with coffee-ground emesis. What assessment would be most important for the nurse to inquire about to determine etiology? a. History of hemorrhoids b. Administration of nonsteroidal anti-inflammatory drugs (NSAIDs) c. History of taking oral iron supplements for more than 10 years d. Recent intake of spicy food
c
The client with acute pancreatitis has an elevated amylase and lipase that is 5 times the normal value. What assessment finding is most important for the nurse to address? a. Gray-blue discoloration around the umbilicus b. Client is lying in a fetal-like position c. Cheek has a muscle spasm when the mastoid is tapped d. Pain rated 7 in the left upper quadrant
a
The client with acute pancreatitis presents to the emergency department. What is the priority assessment? a. Orthostatic vital signs b. Pain rating c. Presence of cola-colored urine d. Recent alcohol intake
d
The nurse caring for a client with a diagnosis of chronic pancreatitis collects data on the client, knowing that which sign/symptom indicates poor absorption of dietary fats? a.Electrolyte disturbances b. Gastrointestinal reflux disease c. Bloody diarrhea d. Steatorrhea
b
The nurse has completed instructions regarding diet and fluid restriction for the client diagnosed with chronic kidney disease. The nurse determines that the client understands the information presented if the client selected which dessert from the dietary menu? a. Jello b. Angel food cake c. Sherbert d. Ice cream
a
The nurse has given instructions about site care to a hemodialysis client who had an implantation of an arteriovenous (AV) fistula in the right arm. Which statement by the client indicates a need for further teaching? a. " I will need to sleep on my right side." b. " I will perform range of motion exercises routinely on my right arm." c. "It's important that I report any right arm redness or drainage at the site/" d. "It's important that I don;t carry heavy objects with the right arm"
abd
The nurse in the emergency room assesses a client with a head trauma and notes a Glasgow Coma Scale (GCS) score of 5. What actions will the nurse take to ensure the client's safety? (Select all that apply.) a. Change the client's position every 2 hours b. Monitor for drainage from the ears c. Avoid mouth care, to avoid stimulation a seizure d. Assess the airway and suction secretions as needed e. Place the client in the supine position
a
The nurse initiates neurologic checks for a client who is at risk for neurologic compromise. Which manifestation typically provides the first indication of altered neurologic function? a. Change in level of consciousness b. Changes in pupil size bilaterally c. Progressive nuchal rigidity d. Increasing muscular weakness
b
The nurse is admitting a client scheduled for gastrointestinal (GI) surgery. When asking about the use of over-the-counter medications (OTC), the nurse is concerned when the client makes which statement? a."I don't take any over -the- counter medications." b. "Yes, I take a full-strength aspirin every day." c. "I have stopped the medications my doctor told me to stop taking." d. " I have stopped all medications that can cause bleeding."
b
The nurse is analyzing the laboratory results of a client diagnosed with chronic kidney disease who is receiving epoetin alfa. The nurse interprets that the medication is having the expected effect if the results indicate an increase in which level? a. Potassium b. Red blood cells c. Creatinine d. Phosphorus
d
The nurse is assessing a client who is at risk of developing acute kidney injury. The nurse should become most concerned if which findings were noted in the client? a. Urine output, 40 mL/hr for the last 3 hours; BUN, 15 mg/dL (5.4 mmol/L); creatinine, 0.8 mg/dL (70.4 mcmol/L) b. Urine output, 60 mL/hr for the last 3 hours; blood urea nitrogen (BUN), 40 mg/dL (14.4 mmol/L); creatinine, 1.1 mg/dL (97 mcmol/L) c. Urine output, 30 mL/hr for the last 3 hours; BUN, 10 mg/dL (3.6 mmol/L); creatinine, 1.2 mg/dL (105.6 mcmol/L) d. Urine output, 20 mL/hr for the last 3 hours; BUN, 35 mg/dL (12.6 mmol/L); creatinine, 2.1 mg/dL (184.8 mcmol/L)
b
The nurse is caring for a client who sustained a spinal cord injury. During administration of morning care, the client begins to exhibit signs and symptoms of autonomic dysreflexia. Which initial nursing action should the nurse take? a. Place the client in the prone position b. Elevate the head of the bed c. Examine the rectum digitally d. Assess the client's blood pressure.
d
The nurse is caring for a client with a diagnosis of cirrhosis of the liver and is monitoring the client for signs of portal hypertension. Which initial sign, if noted in the client, indicates the presence of portal hypertension? a. Flat neck veins b. Weak pulse c. Hypotension d. Crackles on auscultation of lungs
bcd
The nurse is preparing to administer medications to a client who has been admitted with a stroke with a residual complication of impaired swallowing. What interventions should the nurse initiate to prevent the client from aspirating? Select all that apply. a. Let the client use straws to ease the process of swallowing and to control liquids. b. Administer the pills one at a time, ensuring that each medication is properly swallowed before the next one is introduced. c. Assess the client's ability to swallow and cough, and check for presence of gag reflex d. If unilateral weakness is present, place the medication into the stronger side of the mouth. e. Crush all medications, and put them in applesauce for the client to swallow.
d
The nurse is providing information to the family of a client with left-sided unilateral neglect about caring for the client. The nurse should tell the family that it would be least helpful to implement which action? a. Move the commode and chair to the left side b. Encourage the client to scan the environment c. Place bedside articles on the left side d. Approach the client from the right side
b
The nurse is reviewing a client's admission laboratory results and notes that the client's serum calcium level is 14 mg/dL (3.5 mmol/L). Anticipating the needs of the client and anticipating a prescription from the primary health care provider, which medication should the nurse check for availability in the stock medication supply room? a. Calcium gluconate b. Calcitonin c. Calcium chloride d. Vitamin D
c
The nurse is teaching a client with acute kidney injury to include proteins in the diet that are considered high quality or complete proteins. The nurse determines that the client needs further teaching if he indicates that which food item is considered high quality? a. Eggs b. Fish c. Broccoli d. Chicken
b
The nurse provides instructions to a client who is being discharged after undergoing a percutaneous renal biopsy. Which statement by the client indicates a need to reinforce the instructions? a. "I should not work out at the gym for about 2 weeks." b. "A fever is normal after this procedure." c. "I need to avoid any strenous lifting for about 2 weeks." d. "I will call the primary health care provider if my urine becomes bloody."
c
What assessment finding should the nurse expect to note in a client with cirrhosis who has ascites? a. Serum sodium greater than 150 mEq/L (150 mmol/L) b. Pitting edema in the abdomen c. Dullness to percussion in the abdomen d. Elevated albumin levels
c
he client recovering from an acute kidney injury demonstrates an understanding of the therapeutic dietary regimen when indicating a need to limit which dietary factor? a. Vitamins b. Fats c. Potassium d. Carbohydrates