RN Question trainer test 1

The nurse cares for a client diagnosed with gastric reflux due to a hiatal hernia. The client asks the nurse why food and fluids should be withheld just before going to bed. Which response by the nurse is most appropriate? 1. You are less likely to awaken during the night with heartburn if the stomach is empty 2. Early morning vomiting will be less of a problem if the stomach is empty 3. drinking or eating before lying down causes decreased respirations due to increased pressure on the lungs 4.You may develop fluid overload if fluids are taken just before going to bed

1. You are less likely to awaken during the night with heartburn if the stomach is empty

The nurse cares for the client receiving docusate 100mg through a gastric tube. The solution contains 150mg/15ml. The nurse administers how many MLs of the solution to the client?

10

The client had a kidney transplant yesterday, and the client's adult child has come to visit. The nurse instructs the adult child to take which action?

Perform good hand washing

A client comes to the outpatient psychiatric clinic for treatment of a fear of heights. The nurse knows that phobias involve which behaviors?

Projection and displacement (projection is a blaming on an external object and displacement involves ventilation of an intense feeling)

The client, gravida 2 para 1, is admitted with hypertension at 32 weeks gestation. The client reports her wedding band is tight. The nurse assesses for which additional indications of preeclampsia? 1. general edema and visual disturbances 2. epigastric pain and headache 3. proteinuria and retinal vascular constriction 4. polyuria and hypertonic reflexes

Proteinuria and retinal vascular constriction

The nurse cares for the client receiving 55NS 1,000 mL to run from 0900 to 1700. The drip factor on the delivery tubing is 20 gtt/min. At what rate does the nurse set the IV to drip?

42 gtt/min

The nurse leads a parenting class for a group of expectant clients. How many extra calories a day does the nurse advise the clients to consume to support breastfeeding? 1. 200. 2. 300. 3. 400. 4. 500.

500

The nurse prepares the adult client diagnosed with intellectual delay for discharge. The health care provider ordered warfarin sodium, 5mg each day. To maintain client safety, which action does the nurse take first?

Determines the clients comprehension of the medication administration

The health care provider orders hydromorphone hydrochloride 15mg IM for a client. The nurse observes for which adverse effects? 1. photosensitivity and constipation 2. hypotension and respiratory depression 3. tardive dyskinesia and diplopia 4. dry mouth and tinnitus

Hypotension and respiratory depression

The adult client is preparing for a plasma cholesterol screening. Which instruction does the nurse give to the client?

Only take sips of water for 12 hours before the test

Which observation suggests to the nurse the client has developed an Addisonian crisis?

Restlessness and rapid, weak pulse

The nurse performs ROM exercises for an elderly client recently immobilized. The nurse identifies which statement as correct about range of motion? 1. Passive rom exercises increase muscle strength 2. a full ROM must be completed for the elderly client 3. exercises should be completed to the point of discomfort 4. ROM assists the elderly to carry out activities of daily living. ADLS

ROM assists the elderly to carry out activities of daily living. ADLS

The nurse administers oral verapamil to a client. Which assessment does the nurse make before administering the medication?

The clients heart rate

The nurse cares for the elderly client admitted with a possible fractured right hip. During the initial nursing assessment, which observation of the right leg validates this diagnosis?

The leg appears to be shortened and is adducted and externally rotated

The 6 month old is brought to the clinic for a well-baby checkup. During the exam, the nurse expects to observe which assessment findings?

Sitting with support bears weight when held in standing position rolling from back to abdomen

The nurse supervises an lpn/lvn administering an enema to a client. The nurse determines the LPN's actions are appropriate if which action is observed?

The LPN positions the client left Sims position

Prior to sending a client for a cardiac catheterization, it is most important for the nurse to report which information? 1.The client has an allergy to shellfish 2. the client has diminished palpable peripheral pulses 3. the client has cool lower extremities bilaterally 4. the client is anxious about the pending procedure

The client has an allergy to shellfish

The nursing ream consists of an RN who has been practicing for 6 months, an LPN/LVN who has been practicing for 15 years, and a nursing assistive personnel who has been caring for clients for 3 years. The RN cares for which client?

The client ordered to receive two units of packed cells

At 32 weeks gestation, the client has an order for an ultrasound. The nurse determines that the client understands the procedure if the client makes which statement?

The results will inform us of the baby's size

Which is most important for the rehabilitation nurse to assess during a new client's admission?

The clients personal goals for rehabilitation

In the process of a normal adjustment to a terminal illness, the nurse knows that the clients initial denial and isolation will give way to the second stage. The second stage is characterized by which behavior?

Agner

The nurse is discussing growth and development with the parents of a 4-year old child. The nurse identifies which type of play as characteristic of this age group? 1. solitary play 2. parallel play 3. associative play 4. aggressive play

Associative play

The client is evaluated for infertility, and the health care provider prescribes clomiphene citrate 50mg daily for 5 days. The client asks the nurse how the medication works. Which response by the nurse is best?

Clomiphene citrate induces ovulation by changing hormonal effects on the ovary

The nurse knows that cortisol is responsible for which action? 1. Preparing the body for "flight or fight" 2. regulating the calcium metabolism 3. Converting proteins and fat into energy sources 4. enhancing musculoskeletal activity

Converting proteins and fat into energy sources

The nurse cares for the client admitted with a diagnosis of a stroke and facial paralysis. Nursing care is planned to prevent which complication? 1. inability to talk 2. loss of the gag reflex 3. inability to open the affected eye 4.Corneal abrasion

Corneal abrasion

A 7 year old child is seen in the clinic with a diagnosis of pituitary dwarfism. Which clinical manifestation is the nurse most likely to observe? 1. abnormal body proportions 2. early sexual maturation 3. delicate features 4. coarse dry skin

Delicate features

The nurse identifies the primary reason for elderly adults to have problems with constipation is because of which process?

Elderly adults engage in less activity and have decreased GI muscle tone

The nurse recognizes which symptoms are early signs of lithium toxicity?

Fine motor tremors Nausea and vomiting Diarrhea

The health care provider orders naproxen sodium for the elderly client. The nurse assesses the client for which symptoms? 1. Stomatitis and photosensitivity 2. bradycardia and dry mouth 3. fluid retention and dizziness 4. gynecomastia and impotence

Fluid retention and dizziness

Which type of foods does the nurse encourage for the client diagnosed with hypoparathyroidism? 1. Foods high in phosphorus. 2. Foods high in calcium. 3. Foods low in sodium. 4. Foods low in potassium.

Foods high in calcium

The nurse knows that according to Erikson's stages of psychosocial development, which developmental stage best represent a 50 year old client?

Generativity versus stagnation

The nurse provides care for a client with a tracheostomy. Which is the priority nursing diagnosis for this client? 1. problem with verbal communication 2. inadequate airway clearance 3. possible skin integrity impairment 4. acute pain

Inadequate airway clearance

The 18 month old is admitted to the unit with a diagnosis of laryngotracheobronchitis LTB. During the initial assessment, the nurse expects to find which early symptoms? 1. Kussmaul respirations and bradycardia 2. Elevated temperature and slow respiratory rate 3. Expiratory wheezing and substernal retractions 4. Inspiratory stridor and restlessness

Inspiratory stridor and restlessness

The nurse knows which mood altering drug is most often associated with an increased risk for HIV infection related to intravenous drug use?

Narcotics

The client develops a postoperative infection and receives ceftriaxone sodium IV every day. It is most important for the nurse to monitor for which changes? 1. the surface of the tongue 2. hemoglobin and hematocrit 3. skin surfaces in skin folds 4. changes in urine characteristics

The surface of the tongue

The nurse cares for clients in the outpatient clinic. In which order will the nurse return the messages?

1. The "soft spot" on the head of the 4 day old newborn feels elevated and taut when asleep 2. The circumcision should have yellowish exudate at this time, but swelling is not normal and may interfere with urination. The nurse needs to establish that the newborn is still urinating 3. The umbilical cord should be dry and hard. A soft cord that is draining indicates a possible infection and needs to be assessed 4. when bed is bumped, a 2 day old newborn rapidly extends the extremities

The parent of a child with chickenpox asks the clinic nurse why the child will not come down with chickenpox again if exposed to the virus at school at a later date. Which explanation does the nurse give? 1. Natural passive immunity occurs because the child receives antibodies from outside the body 2. artificial active immunity occurs because the child receives specific antigens against the chickenpox virus 3.Natual active immunity occurs because the child's body actively makes antibodies against the chickenpox virus 4. Artificial passive immunity occurs because of the inflammatory process of chickenpox

3.Natual active immunity occurs because the child's body actively makes antibodies against the chickenpox virus

A school aged child client is in the early stages of nephrotic syndrome. The nurse discusses which protein adjustments with the parents? 1. Adequate protein, low sodium intake 2. Low protein, low potassium intake 3. high protein, high potassium intake 4. limited protein, high sodium intake

Adequate protein, low sodium intake

The nurse cares for the newborn infant diagnosed with fetal alcohol syndrome. The nurse expects to see which characteristics? 1. An infant large for gestational age, craniofacial abnormalities, and hydrocephalus 2. an infant with a small head circumference, low birth weight, and undeveloped cheekbones 3. An infant with a large head circumference, low birth weight, and excessive rooting and sucking behaviors 4. An infant with a normal head circumference, low birth weight, and respiratory distress syndrome

An infant with a small head circumference, low birth weight, and undeveloped cheekbones

The nurse identifies which finding has the greatest impact on the elderly clients ability to complete activities of daily living?

Apraxia (Loss of purposeful movement in the absence of motor or sensory impairment, when it affects an ADL, such as dressing, the client may not be able to put clothes on properly)

The nurse cares for the postoperative client diagnosed with type 2 diabetes controlled with oral antihyperglycemic agents. The client asks why the health care provider ordered subcutaneous insulin injections after surgery. The nurses response is based on knowing which physiological process?

Being NPO inhibits normal blood glucose control

The nurse cares for clients in a drug rehabilitation facility. Which complication of IV drug abuse is the nurse most likely to observe?

Cellulitis

A middle aged client is admitted to an inpatient psychiatric unit. The client reports a family member is trying to steal the clients property. The client is diagnosed with paranoid disorder. The nurse suspects the client is demonstrating which symptom? 1. Delusions of persecution 2. command hallucinations 3. delusions of reference 4. persecution hallucinations

Delusions of persecution (the delusion of persecution is a strongly held belief that is not validated by reality, such as the idea that someone is spying on the client to inflict harm)

The nurse collects the following data: anger directed by client toward staff in the form of frequent sarcastic or crude comments, increased wringing of hands, and purposeless pacing, particularly after the client has used the telephone. On the basis of the data, the nurse determines which client problem? 1. difficulty with social interactions 2. potential intolerance to activity 3. loss of personal power 4. difficulty with coping

Difficulty with coping

A client is diagnosed with an aggressive behavior. The nurse declines the clients request to organize a party on the unit for the clients friends. The client becomes angry and uses abusive language toward the nurse. Which statement indicates the nurse has an understanding of the clients behavior?

Expressing empathy toward the clients frustration and feelings in not planning a party

The nurse cares for a client receiving chlorpromazine. The nurse notes the client is restless, unable to sit still, and reports insomnia and fine tremors of the hands. Which does the nurse identify as the best explanation for these symptoms occuring?

Extrapyramidal adverse effects resulting from this medication

The health care provider inserts a temporary pacemaker in a client following a myocardial infarction. The nurse knows that which outcome is the primary purpose of the pacemaker? 1. Increases the force of myocardial contraction 2. Increases the cardiac output 3. Prevents premature ventricular contractions (PVCS) 4. Prevents systemic overload

Increases the cardiac output

A client with an endotracheal tube requires suctioning. Which statement is an accurate description of how the nurse performs the procedure?

Inserts the suction catheter until resistance is met, and then withdraws it slightly. Applies suction intermittently as the catheter is withdrawn

The nurse cares for the prenatal client at 8 weeks gestation. The client has a positive Venereal Disease Research Lab test (VDRL). It is determined the client is in the tertiary stage. When the nurse prepares the teaching plan, it is most important for the nurse to include which information?

Instruct the client to return for the additional 2 injections of medication

Which action is the best way for the nurse to assess the fluid balance of an elderly client?

Maintain an accurate intake and output

The adolescent is brought to the hospital for treatment of deep partial thickness and full thickness burns sustained in a house fire. An intravenous infusion is started in the clients left forearm. The nurse identifies which reason as the primary purpose for the iv? 1. provide a route for pain medications 2. maintain fluid balance 3. prevent gastrointestinal upset 4. obtain blood specimens for analysis

Maintain fluid balance

The nurse cares for a 3 month old infant scheduled for a barium swallow in the morning. Prior to the procedure, it is most appropriate for the nurse to take which action? 1. offer the infant only clear liquids 2. make the infant NPO for 3 hours 3. feed the infant regular formula 4. maintain the infant npo for 6 hours

Make the infant NPO for 3 hours

The toddler diagnosed with lead poisoning is admitted to the pediatric unit. The health care provider writes an order to encourage fluids. Which fluid is best for the nurse to offer to the toddler? 1. milk 2. water 3. orange juice 4. fruit punch

Milk (Milk contains calcium, calcium binds to lead and inhibits its absorption)

The nurse cares for the child diagnosed with pediculosis capitis (head lice) who is being treated with permethrin 1% cream rinse. The nurse includes which information when instructing the child's parents? 1. apply the cream rinse every other day for 1 week 2. wash the childs clothing and personal belongings in soap and cool water 3. Repeat the application of the cream rinse in 7 days if nits are still present 4. comb the childs hair weekly with a nit comb

Repeat the application of the cream rinse in 7 days if nits are still present

The nurse cares for the client receiving a blood transfusion. After 30 minutes, the nurse assesses the client. Which symptom indicates a severe allergic reaction is occuring?

Respiratory wheezing

Which information dose the nurse recognize as being the most pertinent to the diagnosis of cholecystitis?

Right upper abdominal pain

Several days after the delivery of a stillborn, the parents say, "We wish we could talk with other couples who have gone through this trauma." Which response by the nurse is best? 1. "SIDS will provide you with this opportunity." 2. "SHARE will provide you with this opportunity." 3. "RESOLVE will provide you with this opportunity." 4. "CANDLELIGHTERS will provide you with this opportunity."

Share will provide you with this opportunity

The home care nurse visits a new parent and a 2 week old infant. The client asks the nurse which solid foods to give the child first. Which response does the nurse give? 1. solid foods are started at about 6 months when the infant shows signs of readiness 2. strained frits are well tolerated as the first solid food and infants like them 3. introduction of solid foods is not important at this time 4. begin with several foods at one time to see which the infant likes best

Solid foods are started at about 6 months when the infant shows signs of readiness

The nurse cares for the client with ataxia. Which action is most important?

Supervise ambulation

The nurse cares for an older client scheduled for a colon resection this morning. The nurse notes the client had polyethylene glycol-electrolyte solution and a soapsuds enema the previous evening. This morning the client passes a medium amount of soft brown stool. Which conclusion by the nurse is most accurate?

The bowel preparation is incomplete. Colon should not have remaining soft stool

Which statement is documented by the nurse to reflect a client's emotional adjustment to being hospitalized in the intensive care unit? 1.The client is unable to complete activities of daily living without assistance 2. the client appears to be depressed and anxious regarding impending surgery 3. The client constantly calls for nurses and cries uncontrollably 4. the family is unable to visit more often than once a week because they live far away

The client constantly calls for nurses and cries uncontrollably ( this statement is objective and contains information that is observable. It gives an objective description of the clients behavior and affect)

The nurse cares for the client diagnosed with type 1 diabetes reporting decreased vision. The client asks the nurse what caused the visual changes. The nurses response is based on which statement? 1. the clients decreased vision is caused by bleeding into the inner ocular chamber of the eye 2. the clients decreased vision is caused by gradual separation of the retina from the base of the eye 3. the clients decreased vision is cause by an increase in the size of the vessels 4. The client's decreased vision is caused by gradual destruction and degeneration of the retina

The client's decreased vision is caused by gradual destruction and degeneration of the retina

The nurse prepares a teaching plan regarding colostomy irrigation. The nurse includes which information? 1. The colostomy needs to be irrigated at the same time every day 2. irrigate the colostomy after meals to increase peristalsis 3. insert the catheter about 20 inches into the stoma 4. the solution should be at least 110 to increase dilation and flow

The colostomy needs to be irrigated at the same time every day. This helps establish a normal pattern of elimination

The nurse cares for the client diagnosed with a pneumothorax resulting from a motor vehicle accident three days ago. The client has a chest tube connected to a three-chamber water seal drainage system with 20cm suction. The nurse determines the lung has re-expanded if which observation is made? 1. There is no drainage in the collection chamber for 3 hours 2. The fluid in the water seal chamber does not fluctuate with respirations 3. There is continuous bubbling in the water seal chamber 4. There is gentle bubbling in the suction control chamber

The fluid in the water seal chamber does NOT fluctuate with respirations

The nurse prepares the older adult client for an IVP. The client asks the nurse to explain the reason why the procedure is performed. The nurse's response is based on which explanation? 1. The health care provider is able to directly observe the kidney pelvis 2. An IVP assesses the glomerular filtration rate 3.The health care provider is able to examine the urinary tract by x-ray. 4. medication is injected into the urinary system

The health care provider is able to examine the urinary tract by x-ray.

The parents of a child diagnosed with hemophilia ask the nurse to explain the cause of the disease. Which response by the nurse is best? 1. The father transmits the gene to the son 2. Both the mother and the father carry a recessive trait 3. the mother transmits the gene to her son 4. there is a 50% chance that the mother will pass the trait to each of the daughters

The mother transmits the gene to her son

The outpatient clinic nurse cares for an elderly client diagnosed with type 1 diabetes. Because the client is unwilling to perform blood glucose monitoring, the client tests urine for glucose and acetone. The nurse knows that blood glucose monitoring is preferred over urine testing for glucose because of which reason? 1. The renal threshold for glucose is elevated in the elderly. 2. Blood glucose monitoring is easier and less costly for clients to perform. 3. Urine testing for glucose provides false-positive readings. 4. Determination of the color on a reagent strip varies from person to person.

The renal threshold for glucose is elevated in the elderly

The nurse performs the Rinne test on a client. Which is an accurate statement of how the first part of the test is performed?

The stem of a vibrating tuning fork is held against the mastoid bone until the client indicates sound can no longer be heard.

The client in labor is monitored with an internal fetal monitor. The nurse knows which is most important reason for the fetal monitor? 1. To evaluate the progress of the clients labor 2. to assess the strength and duration of the clients contractions 3. to monitor the oxygen status of the fetus during labor 4. to determine if an oxytocin drip is necessary

To monitor the oxygen status of the fetus during labor

Which symptoms alert the nurse to consider an alcohol problem in a client hospitalized for a physical illness?

Tremors Elevated temperature nocturnal leg cramps

The health care provider orders mannitol for the client with a closed head injury. Which response does the nurse recognize as desired to this medication

Urinary output increases to 175ml/hour

A postoperative cataract client is cautioned about not making sudden movements or bending over. The nurse understands that the rationale for this recommendation is to prevent which complication? 1. impairment of cerebral blood flow and headaches 2. increased intracranial pressure 3. pressure on the ocular suture line 4. displacement of the lens implant

3. pressure on the ocular suture line

The nurse cautions the client with hypothyroidism to avoid which implementation?

Narcotic sedatives

The health care provider writes an order for a stat dose of morphine 4 mg IV for pain. Three hours later the client again reports pain, and the nurse administers a second injection of morphine. Which best describes the nurses libility?

There is no order for a second dose of medication, the nurse is liable

During the 1st hour after birth, the nurse palpates the client's fundus in which location?

typically, the fundus is located at the midline between the umbilicus and the symphysis, but it then slowly rises to the level of the umbilicus during the first hour after birth.