Hurst Readiness Exam 3 #2

A client who has been on bed rest for several days is ambulating for the first time with assistance. Prioritize the actions the nurse should take by placing them in order from first to last. Assess the client's orientation. Assist the client to sit on the side of the bed for 1-2 minutes. Apply a gait belt to the client's waist. Have the client stand by the side of the bed for a few seconds. Ambulate in the room.

- first assess the client's orientation to determine the client's ability to follow instructions. -Second, to avoid orthostatic hypotension, the nurse should assist the client to sit on the side of the bed. -Third, apply the gait belt to ensure safety while ambulating. -- Fourth, assist the client to stand for a few seconds. The fifth action is to ambulate in the room.

The primary healthcare provider prescribed tolbutamide 250 mg orally twice a day. The pharmacy dispensed tolbutamide 0.5 g scored tablets. How many tablets will the nurse administer? Round your answer using one decimal point. Enter the answer for the question below.

0.5

A 72 year old client admitted with a diagnosis of bleeding ulcers has been prescribed ranitidine 50 mg IVPB every 8 hours and omeprazole 10 mg po every morning. Based on this data what intervention should the nurse take first?​ Exhibit 1. Stop the infusion of ranitidine. 2. Send the client for a CT scan of the head. 3. Provide oxygen at 2L/NC. 4. Notify the primary healthcare provider. exhibit: 0900 Client alert and oriented. Denies abdominal pain, discomfort, or nausea and vomiting. Active bowel sounds in all quadrants. Abdomen soft, non-tender to palpation. Ranitidine 50 mg IVPB hung to IV line of NS at 100 mL per hour. No redness or edema noted at IV site. 0930 Client confused to place and time. Oxygen sat 95%. Lungs clear bilaterally. Denies pain. BP 118/78, HR 84/min, RR - 20/min, Temp. - 97.8 F (36.55 C).

1.

A client has been on the mental health unit for three days and is requesting to leave against medical advice (AMA). It has been determined that the client is not suicidal. What should the nurse do? 1. Inform the primary healthcare provider that the client wishes to leave. 2. Make arrangements for a commitment hearing, as soon as possible. 3. Tell the client the primary healthcare provider must discharge the client prior to leaving. 4. Call the primary healthcare provider and request a discharge order.

1.

A client is reporting pain rated an 8 out of 10 on the numeric pain scale. The nurse administers an oral pain medication to the client and starts a CD of the client's favorite relaxing music. Fifteen minutes later, the client rates the pain as 2 out of 10 on the numeric pain scale. What type of nonpharmacologic pain relief intervention has the nurse used? 1. Distraction 2. Biofeedback 3. Progressive relaxation 4. Cutaneous stimulation

1.

A nurse is caring for a client hospitalized with Guillain-Barre syndrome. Which is the most important nursing measure to include in the nursing care plan for this client? You answered this question Correctly 1. Observation and support of ventilation 2. Insertion of indwelling urinary catheter 3. Nasogastric suctioning 4. Frequent assessments of level of consciousness

1.

A staff nurse decides to go to lunch with a friend instead of meeting with a study group for a certification exam. The staff nurse informs the clinical specialist, "Studying more will not do any good anyway." What defense mechanism does the clinical specialist understand that the staff nurse is exhibiting? 1. Rationalization 2. Denial 3. Regression 4. Reaction formation

1.

The nurse is caring for a client following spinal surgery. The client is placed on methylprednisolone. What additional drug therapy would the nurse expect to be prescribed with methylprednisolone? 1. Pantoprazole 2. Phenytoin 3. Imipramine HCI 4. Aminocaproic acid

1.

The nurse is searching for information about the nursing care of a client receiving an experimental drug for the treatment of obesity. Which database is most likely to address this issue? 1. Cumulative Index for Nursing and Allied Health Literature (CINAHL) 2. Cochrane Library 3. Health and Wellness Resource Center 4. MEDLINE

1.

Which nursing task would be appropriate to delegate to an LPN/VN? 1. Obtain a wound culture from a client. 2. Administer regular insulin IV to a client in diabetic ketoacidosis. 3. Monitor a client's closed drainage unit (CDU) for tidaling. 4. Assess a client for tactile fremitus.

1.

Which task should the nurse perform first? 1. Suctioning the tracheostomy. 2. Changing a colostomy bag that is leaking. 3. Performing an admission assessment on a client. 4. Administering pain medication to a postoperative client.

1.

The women's health charge nurse is making assignments for the next shift. The unit is short one staff member and will receive a nurse from the medical surgical unit. Which clients should the charge nurse assign to the medical-surgical nurse? 1. Total abdominal hysterectomy 2. Breast reduction 3. Vaginal delivery with fetal demise 4. 32 week gestation with lymphoma 5. Post-partal with HELLP syndrome

1., & 2.

A nurse who has never had varicella has been exposed to a client diagnosed with herpes zoster. What actions should the nurse take? 1. Notify the infection control nurse. 2. Continue to care for client as varicella and herpes zoster are not related. 3. Go to the lab to have a Tzanck smear performed. 4. Obtain herpes zoster vaccine for protection from this exposure. 5. Receive the varicella-zoster immune globulin within 96 hours of exposure.

1., & 5.

What risk factors should the nurse include when conducting a class about type 2 diabetes mellitus? 1. Fat distribution greater in abdomen than in hips. 2. Being underweight. 3. Having type 1 diabetes as a child increases risk for type 2 diabetes. 4. Caucasians are more likely to develop type 2 diabetes than Hispanics. 5. Polycystic ovary syndrome.

1., & 5.

The nurse determines that a client does not have an advance directive. The daughter is designated to make healthcare decisions in the event that the client becomes incapacitated or unable to make informed decisions. Which nursing actions are appropriate for this client? 1. Document the client's statement in the client's own words. 2. Provide information on advance directives to the client. 3. Inform the client that personnel are available to assist with completing an advance directive. 4. Avoid inquiring about a client's advance directive as this could cause the client anxiety and concern. 5. Ask the daughter if she agrees with her mother's decision.

1., 2. & 3.

What discharge instructions should the nurse provide to the client post abdominal hysterectomy? 1. Ambulate at least 3-4 times per day. 2. Notify the primary healthcare provider if there is a yellow discharge from the surgical wound. 3. Swimming is allowed if staples were used to close the skin. 4. Press a pillow over incision when coughing to ease discomfort. 5. Apply moist heat to surgical site the first couple of days for pain relief.

1., 2., & 4

Which prescriptions are appropriate for the nursery nurse to initiate on a newborn prior to discharge home? 1. Hepatitis B vaccine 2. Erythromycin Ointment 3. Vitamin K 4. Lanolin 5. PKU Screening

1., 2., 3. & 5.

A client diagnosed with mania and hypertension is hospitalized due to confusion and polyuria. Based on current data, what interventions should the nurse implement? Exhibit 1. Hold the lithium carbonate dose. 2. Notify primary healthcare provider of lithium level. 3. Connect client to heart monitor. 4. Administer sodium polystyrene for hyperkalemia. 5. Pad the siderails of the client's bed. exhibit: Ataxia and mild hand tremors noted. BP 120/74, Respirations 18, Heart rate 92.

1., 2., 3., & 5.

A case manager is evaluating a client diagnosed with hemiplegia due to a cerebral vascular accident who will need assistive devices upon discharge. Which devices should the case manager include for this client? 1. Dinner plate food guards 2. Transfer belt 3. Raised toilet seat 4. Long handled shoe horn 5. Wide grip eating utensils 6. Button closures on clothes

1., 2., 3., 4., & 5.

Which assessment findings would be of concern to the nurse who is caring for a client who has an arterial line to the radial artery? 1. Capillary refill: Left hand-2 seconds; Right hand- 4 seconds. 2. Blue tinged color to finger tips of right hand. 3. Warm skin to right and left hand. 4. Left radial pulse-88/min; Right radial pulse-82/min 5. Blanching to right hand.

1., 2., 4., & 5.

A nurse is caring for a client who reports fatigue, weight loss, afternoon fevers, night sweats, cough, and hemoptysis. What interventions should the nurse initiate? 1. Wear an N95 respirator when caring for client. 2. Restrict fluid intake to 500 mL per day. 3. Position client in semi-Fowler's position. 4. Place client in a negative pressure airflow room. 5. Do not allow visitors for 48 hours.

1., 3. & 4.

A nurse is teaching a group of small farm owners how to prevent pesticide exposure for field workers. What points should the nurse include? 1. Importance of hand washing before eating. 2. Wearing protective clothing while working in the field and at home. 3. Removing clothing and shoes worn in the field before entering the home. 4. Washing fruit and vegetables prior to eating. 5. Boiling all vegetables for a minimum of 5 minutes prior to eating.

1., 3. & 4.

The nurse notes that a client has impaired swallowing as a result of a cerebrovascular accident (CVA). Which interventions are appropriate for the nurse to include in the plan of care? 1. Sit the client up at a 90° angle during meals. 2. Assist the client to hyperextend the head when preparing to swallow. 3. Encourage the client to sit up for 30 minutes after eating. 4. Educate a family member on the Heimlich maneuver. 5. Start the client on a thin liquid diet.

1., 3. & 4.

Following a total hip replacement, the nurse provides discharge teaching to the client. The nurse knows that teaching was effective when the client states which activities are safe to perform? 1. Using an abduction pillow while sleeping 2. Crossing the legs 3. Using a toilet extender 4. Showering rather than taking a bath 5. Tying shoes

1., 3., & 4.

Which instructions should the nurse give the unlicensed assistive personnel (UAP) about care needed to reduce the risk of infection when a client has an indwelling catheter? 1. Check catheter for kinks in the tubing when the client is in the bed or chair. 2. Instruct the UAP to disconnect the catheter from the bag when measuring output. 3. Wash hands before providing personal care to the client. 4. Ensure that catheter remains secured to the thigh. 5. Make sure that the drainage bag is always below the level of the bladder.

1., 3., 4. & 5.

A long-term care nurse is planning care for a newly admitted client diagnosed with Alzheimer's disease. What should the nurse include in the plan of care? 1. Assess client's ability to perform activities of daily living. 2. Perform activities of daily living for the client. 3. Place a clock and calendar in client's room. 4. Encourage family to visit client often. 5. Have nursing staff spend time talking and listening to client.

1., 3., 4., & 5.

What should the nurse include when providing education to a client receiving tetracycline? 1. Wear long sleeves when going outside. 2. Take tetracycline on a full stomach. 3. Wait at least two hours after taking tetracycline prior to taking iron supplements. 4. Tetracycline can decrease the effectiveness of birth control pills. 5. Do not take this medicine after the expiration date on the label has passed.

1., 3., 4., & 5.

Which signs and symptoms, if noted by the nurse, would indicate that the client with hyperthyroidism is experiencing thyroid crisis? 1. Hyperkinesis 2. Bradycardia 3. Hypertension 4. Restlessness 5. Confusion

1., 3., 4., & 5.

A home health nurse is assessing the home environment for safety issues concerning ambulation. Which finding would require the nurse to counsel the client and family? 1. Dim hall lighting 2. Grab bar in bath tub 3. Nonskid strips on outside steps 4. Throw rug at front entrance to home 5. Waxed linoleum kitchen floor

1., 4., & 5.

A 68 year old client was admitted two days ago to a long-term care facility. The client has chronic kidney disease, coronary artery disease and chronic obstructive pulmonary disease. Oxygen 2 L/per nasal cannula is being administered. Assistance is needed with activities of daily living. The primary healthcare provider visits today and writes new prescriptions. Who is the best person for the charge nurse to delegate carrying out these prescriptions? Exhibit 1. Unlicensed assistive personnel (UAP) 2. LPN/LVN 3. RN 4. Charge Nurse

2.

A client being treated for osteoporosis with alendronate reports experiencing slight heartburn after taking the medicine. What should the nurse suggest to reduce this side effect? 1. Stop taking the medication and call the primary healthcare provider. 2. Drink plenty of water with the medication. 3. Take the medication before bedtime. 4. Take antacids when taking the medication.

2.

A client comes to the clinic reporting palpitations, as well as nausea and vomiting while taking metronidazole. The nurse notes that the client is flushed and has a heart rate of 118 bpm. Based on this information, what is the most important question for the nurse to ask the client? 1. "Do you take metronidazole on an empty stomach?" 2. "Are you using any products that contain alcohol?" 3. "How long have you had these symptoms?" 4. "What other medications are you currently taking?"

2.

A client is scheduled for plateletpheresis. When taking the client's history, which information is most significant? 1. Allergies to shellfish 2. Date last donated 3. Time of last oral intake 4. Blood type

2.

A client received 2nd and 3rd degree burns on both arms and the anterior trunk when pouring gas on a burning trash pile. With the percentage of burns indicated, what should the nurse anticipate? 1. Movement of fluid out of the cells into the vascular space. 2. Increased capillary permeability and 3rd spacing of fluids. 3. Rapid fluid shift out of the vascular bed 48 hours after the burn. 4. Severe fluid volume excess in the first 24 hours after the burn.

2.

A client, who is having difficulty falling asleep, asks the nurse for a sleeping aid. What is the first action the nurse should provide to the client? 1. Assist client to take a cool bath. 2. Provide a back massage. 3. Administer prescribed triazolam. 4. Give client a crossword puzzle to work.

2.

A nurse drops a bottle of IV fluid, which shatters on the floor in the hallway. What action should the nurse take? 1. Notify housekeeping to clean up the spill. 2. Pick up glass with a broom and dustpan and dispose into a puncture resistant sharps container. 3. Pick up the glass with gloved hands and dispose into a puncture resistant sharps container. 4. Use a wet mop to collect the glass and dispose of it in the garbage can.

2.

A primary healthcare provider informs the nurse to prepare for an amniotomy on a client who's labor has not progressed. What should the nurse assess for prior to the primary healthcare provider performing this procedure? 1. Fetal attitude 2. Fetal engagement 3. Fetal lie 4. Fetal position

2.

A primary healthcare provider prescribed KCL 40 mEq in 100 mL NS to infuse over 30 minutes. What action should the nurse take? 1. Administer the KCL through the lowest IV line port. 2. Clarify the prescription with the primary healthcare provider. 3. Mix KCL 40 mEq into the present infusing bag of NS when it reaches 100 mL. 4. Set the infusion pump to 100 mL / hour.

2.

An emergency department (ED) nurse working triage has assessed four clients. Which client should receive the highest priority? 1. Alert client who fell on the side walk. Skin warm and dry to the touch, with a three inch laceration on the right knee continuously oozing dark red liquid. 2. Elderly client who moans when the nurse asks, "Can you hear me?" Respirations even/nonlabored. Skin slightly cool to touch with pale nailbeds. 3. A client who "passed out" but regained consciousness when feet were elevated. Awake and confused, with warm and dry skin. 4. An alert, responsive client who reports severe abdominal and shoulder pain that began two hours after eating at a local fast food restaurant. Skin is warm and dry.

2.

The client in the manic phase of bipolar disorder begins climbing onto a table in the dayroom and shouts, "I can fly! I can fly! Watch me fly!" What should be the initial intervention by the nurse? 1. Leave the client alone and remove clients from the dayroom. 2. Call for personnel to escort the client out of the day room. 3. Restrain the client, and notify the primary healthcare provider. 4. Tell the client that there is no way that a person can fly.

2.

The nurse is caring for a client who is to receive an IV infusion of heparin. The client's dose is based on a sliding scale prescription. What is the priority lab value to check before initiating the heparin infusion? 1. PT and/or INR 2. aPTT 3. Platelet count 4. WBC count

2.

The oncoming nurse has just received report and is preparing to make initial rounds. Which postpartum client should the nurse see first? 1. A primipara 6 hours postpartum saturating one peripad every two hours 2. A multigravida 1 hour postpartum and reporting intense perineal pain 3. A primigravida 12 hours postpartum with the uterine fundus at the umbilicus 4. A multigravida 72 hours postpartum with a brownish pink lochia discharge.

2.

The six bed Labor and Delivery area is full when the Emergency Department nurse calls for a bed for a woman reporting low back pain, pelvic pressure and increased vaginal discharge at 36 weeks gestation. Which would be the most appropriate action for the charge nurse? 1. Transfer a G4P4 who delivered full-term twins one hour ago to the antepartum/postpartum floor. 2. Transfer a G3 P3 who delivered an 8 lb. newborn three hours ago to the antepartum/postpartum floor. 3. Transfer an 8 hour postpartum G1P1 on Magnesium Sulfate for eclampsia from the LDR unit to the ante/postpartum unit. 4. Request that the new client be admitted to the antepartum/postpartum floor.

2.

When assessing a client, the nurse finds that in response to painful stimuli the upper extremities exhibit flexion of the arm, wrist, and fingers with adduction of the limb, while the lower extremity exhibits extension, internal rotation, and plantar flexion. How would the nurse accurately document this finding? 1. Decerebrate posturing 2. Decorticate posturing 3. Reflex posturing 4. Superficial posturing

2.

Which action by a nurse indicates to the charge nurse that the sterile field has been contaminated? 1. The sterile field is above the level of the waist. 2. Sterile gauze dressing within the one inch border of sterile field. 3. Remains facing the sterile field throughout procedure. 4. Inspects sterile wrapped instruments for tears.

2.

Which electrolyte imbalance would be the nurse's priority concern in the burn client? 1. Hypernatremia 2. Hyperkalemia 3. Hypoalbuminemia 4. Hypermagnesemia

2.

Which menu selection by the client diagnosed with nephrotic syndrome indicates that teaching of proper diet was understood? 1. Pancakes with whipped butter, syrup, bacon, apple juice 2. Scrambled eggs, sliced turkey, biscuit, whole milk 3. Grits, fresh fruit, toast, coffee 4. Bagel with jelly, hash browns, tea

2.

Which nursing intervention should receive priority after a client has returned from having had eye surgery? 1. Administer pain medication around the clock. 2. Maintain head of bed at 35°. 3. Apply warm compresses. 4. Instruct on importance of turning, coughing, and deep breathing.

2.

Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? 1. Check client for signs of skin breakdown. 2. Check client's vital signs after ambulating. 3. Administer 8 ounces of polyethylene glycol electrolyte solution every 10 minutes. 4. Obtain a stool specimen. 5. Determine what activities the client can do independently.

2. & 4.

The nurse is caring for a client with decreased cardiac output secondary to heart failure with fluid volume overload. Which signs/symptoms are an indication to the nurse that treatment goals have not been met? 1. Diuresis 2. Dyspnea on exertion 3. Persistent cough 4. Warm, dry skin 5. Heart rate irregular at 118/min 6. Alert and oriented

2., 3. & 5.

The charge nurse on the pediatric unit is reviewing the protocol for blood administration with a staff nurse. Which actions by the staff nurse indicate understanding of blood administration? 1. The blood infusion time was within 6 hours. 2. A filter was used when administering the blood. 3. A second nurse checked the blood compatibility. 4. A set of vital signs was taken 5 minutes after the blood infusion started. 5. One form of client identification were obtained prior to infusion.

2., 3., & 4.

What should the nurse include when providing teaching to a female client prescribed doxycycline for the treatment of acne? 1. Take this medication with food to maximize absorption. 2. Use a non-hormone method of birth control while taking this medication. 3. Wear protective clothing when outside. 4. Drink plenty of fluids while taking this medication. 5. Iron and calcium supplements can be taken with this medication.

2., 3., & 4.

The nurse is planning health promotion strategies for an older client on a limited, fixed income who is trying to increase activity. The client has been cleared for moderate physical activity by the primary healthcare provider. Which strategies would be appropriate for this client? 1. Suggest that the client join a local gym for access to equipment and support. 2. Suggest contacting a neighbor so that they can walk each day in the neighborhood. 3. Encourage client to get up and walk around the house during each TV commercial break. 4. Suggest the client go to the community senior center for daily strengthening exercises. 5. Encourage client to use one-pound soup cans for muscle toning.

2., 3., 4. & 5.

The nurse's goal is to reduce the risk of flu and its complications by offering a class at the local high school. Which groups of people should be included in the nurse's teaching plan as needing the flu shot? 1. Babies less than 6 months old 2. Any child older than 6 months 3. Pregnant women 4. Parents of young children 5. People with a chronic illness

2., 3., 4. & 5.

The nurse is caring for a client taking benazepril. Which symptoms would be important for the nurse to report to the primary healthcare provider? 1. BP 150/108 decreases to 138/86 2. Weight gain of 5 pounds (2.27 kg) in one week 3. Serum sodium level of 139 mmol/L 4. Angioedema 5. Serum potassium of 5.8 mEq

2., 4., & 5.

What symptoms would the nurse anticipate in a client being admitted to the hospital with a calcium level of 3.2 mg/dL (0.80 mmol/L)? 1. Slowed deep tendon reflexes. 2. Muscle rigidity and cramping. 3. Hypoactive bowel sounds. 4. Positive Chvostek's sign. 5. Seizures 6. Laryngospasms

2., 4., 5., & 6.

A client is hospitalized for chronic renal failure. The nurse will need to notify the primary healthcare provider concerning which findings? 1. Sodium 135 mEq/L 2. Potassium 5.8 mEq/L 3. BP 100/70 4. No weight loss 5. Ionized Calcium 4.0 mg/dL

2., 5.

Which assignments would be most appropriate for the RN to delegate to an LPN/VN? 1. Six year old with new onset diabetes. 2. Ten year old with pneumonia admitted two days ago. 3. Three month old admitted with severe dehydration. 4. Four year old admitted for developmental studies. 5. Twelve year old with post op wound infection taking oral antibiotics.

2.,4. & 5.

A client diagnosed with schizophrenia who is taking monthly haloperidol injections develops slurred speech, shuffling gait and drooling. Which prescribed PRN medication would the nurse administer? 1. Lorazepam 2. Atropine 3. Benztropine 4. Chlorpromazine

3.

A client is hospitalized because of severe malnutrition related to anorexia nervosa. What is the most important goal for this client? 1. Verbalize understanding that eating behaviors are maladaptive. 2. Verbalize the importance of adequate nutrition. 3. Achieve at least 80% of expected body weight. 4. Acknowledge misperception of body image as fat.

3.

A clinic nurse is educating a client diagnosed with Bell's Palsy. What is the most important educational point the nurse must emphasize to the client? 1. Physical therapy will be needed to maintain muscle tone of the face. 2. Massaging the face several times daily using a gentle upward motion. 3. Proper methods of closing eyelids and eye patching. 4. Non-steroidal anti-inflammatory medications are used to alleviate painful muscles.

3.

A new admit arrives to the nursing unit with one thousand dollars in cash. What would be the best action by the nurse to safeguard the client's money? 1. Insist the money go home with the client's visitor. 2. Place the money in the client's bedside table drawer. 3. Put itemized cash in envelope and place in hospital safe. 4. Lock money up in narcotic cabinet with client's identity and room number.

3.

A nurse invites a friend home one evening. On arrival, the friend sees the nurse's large, white, long-haired cat sitting on the couch and begins to experience palpitations, trembling, nausea, shortness of breath, and a feeling of losing control. What should the nurse do first? 1. Stay with the friend until the friend feels better. 2. Have the friend breathe into a paper bag. 3. Remove the cat from the room. 4. Dim the lights in the room.

3.

Following surgery, a client refuses to ambulate as prescribed. What action should the nurse take? 1. Notify the primary health care provider of client's refusal to ambulate. 2. Offer the client pain medication. 3. Explain complications associated with bed rest. 4. Perform passive range of motion exercises.

3.

The client has just returned from electroconvulsive therapy (ECT) and is very drowsy. What is the position of choice for the nurse to place the client in until full consciousness is regained? 1. Supine 2. Fowler's 3. Lateral 4. High Fowler's

3.

The clinical specialist is teaching a group of new staff nurses about therapeutic communication. Which statement by one of the staff nurses indicates to the clinical specialist that further teaching is needed? 1. Effective communication involves feedback to let the sender know that the message was understood by the receiver. 2. An effective message should be clear and complete. 3. Therapeutic communication does not include the use of gestures. 4. I must listen with a "third ear" to be aware of what the client is not saying.

3.

The home health nurse is caring for a client with a neurological urinary tract dysfunction. What information should be included when teaching the client how to perform intermittent self catheterization? 1. Performed in an emergency department (ED). 2. Prevents urinary catheter infections. 3. Perform as a clean procedure. 4. Requires using sterile gloves.

3.

The nurse is assessing pain after surgery in a 3 year old client with a known developmental delay. Which pain scale should the nurse use to assess this client's pain level? 1. CRIES scale 2. Numeric scale 3. FLACC scale 4. FACES scale

3.

The nurse is caring for a client diagnosed with type 2 diabetes who was brought to the emergency department in an unresponsive state. A diagnosis of hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is made. The nurse prepares for the administration of which initial therapy? 1. Oxygen by nasal cannula 2. Long-acting IV insulin 3. Normal saline 4. IV dextran

3.

The nurse is caring for a client taking spironolactone. Which dietary change should the nurse teach the client to make when starting treatment with this medication? 1. Eat extra helpings of bananas. 2. Increase intake of water. 3. Avoid salt substitutes. 4. Increase intake of green leafy vegetables.

3.

The nurse is caring for a client who has taken an acetaminophen overdose. Which symptom is the client most likely to exhibit? 1. Expectorating pink frothy sputum 2. Sudden onset of mid-sternal chest pain 3. Jaundiced conjunctiva 4. Diaphoresis and fever

3.

The nurse is caring for a depressed client. The client has a flat affect, apathy, and slowed physical movement. The client has not bathed in several days and there is a malodorous odor noted. Which intervention would be most appropriate at this time? 1. Explain the rules about daily showers. 2. Leave the client alone since there is slowed movement. 3. Tell the client it is time to take a shower. 4. Ask when he or she would like to take a shower.

3.

The nurse is providing post-operative care to the craniotomy client. Hourly urinary output increases from 100 mL last hour to 500 mL this hour. What action by the nurse takes priority 1. Elevate HOB 90 degrees 2. Auscultate apical pulse 3. Obtain a blood pressure 4. Assess Glasgow Coma Score

3.

The nurse is working with the parents of a preschooler to help promote healthy sleep patterns of approximately 8-12 hours per night. Which intervention should assist the parents to achieve adequate sleep for their preschooler? 1. Offer a time of exercise prior to bedtime. 2. Follow a bedtime routine at least three or four nights per week. 3. Spend about 30 minutes with the preschooler prior to bedtime for stories, prayers, etc. 4. Do not encourage your preschooler to take a toy to bed.

3.

Two days after a myocardial infarction, a client begins reporting orthopnea and dyspnea. Further assessment reveals bi-basilar crackles, jugular venous distension, an S3 heart sound, a BP of 100/60 mm Hg, and apical pulse of 90 beats per minute. The urine output has steadily declined over the past 12 hours. What should the nurse do first? 1. Notify the primary healthcare provider. 2. Increase the IV rate. 3. Elevate the head of the bed. 4. Observe for cardiac arrhythmias.

3.

When caring for a client with hepatitis A, the nurse should take what special precaution? 1. Wear gloves when handling blood and body fluids. 2. Wear a mask and gown before entering the room. 3. Use gloves when removing the client's bedpan. 4. Use caution when bringing food to the client.

3.

Which statement by a student nurse indicates to the nurse educator that teaching regarding witnessing consent signatures has been successful? 1. "Two people must witness a consent signature." 2. "A RN must witness a consent signature." 3. "Signing as a witness implies that the client willingly signed the consent." 4. "A witness must be over the age of 21."

3.

The nurse recognizes that treatment has been successful in resolving fluid volume excess based on which assessment findings? 1. Continued lethargy 2. Heart rate 112/min 3. Decreasing shortness of breath 4. BP 114/78 5. Increased thirst

3. & 4.

Exhibit: Azithromycin 500 mg in 250 ml D5W over one hour IVPB daily Cefriaxone 500 mg in 50 ml of D5W IVPB over 30 minutes BID. D51/2 NS at 125 ml/hr Saline Loc for IVPBs The nurse is caring for a client who has pneumonia and is dehydrated. The primary healthcare provider has prescribed IV fluids and IV antibiotics. Based on the primary healthcare provider's prescription and oral intake, what would be the 24 hour intake for this client? Exhibit Enter the answer for the question below.

3670 mls

A client diagnosed with arachnophobia is prescribed alprazolam 0.5 mg orally three times daily. The nurse knows that teaching about this medication is successful when the client makes what statement? 1. Alprazolam will take up to two weeks to start working. 2. The drug does not cause drowsiness, so my daily activities will not suffer. 3. This medication cannot be taken with food. 4. I should not stop taking alprazolam suddenly.

4.

A client with gestational diabetes delivers an infant with macrosomia. What is the most vital component of the infant's assessment for the nurse to perform? 1. Evaluation of the infant for cephalhematoma. 2. Determining if the infant sustained a clavicle fracture. 3. Observing for arm movement to evaluate for facial palsy. 4. Frequent blood glucose monitoring to ensure stable values.

4.

A client with heart failure and pulmonary edema is given furosemide intravenously. Which assessment indicates that the furosemide has achieved the desired effect? 1. Weight has decreased 2 pounds. 2. Systolic blood pressure has decreased. 3. Urinary output has increased. 4. Lungs have fewer rales on auscultation.

4.

A client, admitted to the medical unit with persistent vomiting, reports weakness and leg cramps. The spouse states that the client is irritable. The primary healthcare provider has prescribed lab work and blood gases. Based on this assessment, the nurse anticipates which acid/base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

4.

A hysterical college student arrives in the emergency department in bloody soiled clothing. The nursing assessment reveals facial bruising and multiple contusions consistent with the client's report of being raped. Which initial nursing intervention takes priority at this time? 1. Notify police of the alleged rape. 2. Allow the client privacy to wash self. 3. Remove clothing and bag for evidence. 4. Encourage client to express fears and anxiety.

4.

A nurse attaches a client to continuous cardiac monitoring due to a potassium level of 2.8 mEq (2.8 mmol). The nurse should monitor for which dysrhythmia? 1. Third degree heart block 2. Atrial fibrillation 3. Premature atrial contractions 4. Premature ventricular contractions

4.

Family members have been asking triage nurses if loved ones were admitted to the hospital during a national emergency situation with massive casualties. What response should be made by the nurses? 1. Tell the family members that information about clients cannot be provided. 2. Ask for the victims' permission before talking with the family members. 3. Instruct the family to wait for public announcements about victims. 4. Inform them if their family members have been admitted.

4.

Post cataract removal a client reports nausea and severe pain in the operative eye. Which nursing intervention takes priority? 1. Administer morphine and ondansetron. 2. Reposition client to non-operative side. 3. Massage the canthus to unblock the lacrimal duct. 4. Notify the primary healthcare provider.

4.

The charge nurse was notified that a client with 2nd degree burns is being admitted to the floor. Which nurse should be assigned this client? 1. A nurse caring for clients with spina bifida and acute gastroenteritis. 2. The new nurse, out of orientation for 2 months, caring for clients diagnosed with tonsillitis and anorexia nervosa. 3. The pregnant nurse caring for clients with cystic fibrosis and staph infection. 4. A nurse caring for clients with irritable bowel syndrome and post op appendectomy.

4.

The nurse assesses a multigravida who is four hours postpartum. Findings include that fundus is firm, 1 centimeter above the umbilicus, and deviated to the right side. The lochia is moderately heavy and bright red. Which nursing intervention has priority? 1. Massage the fundus. 2. Administer intravenous oxytocin. 3. Document these normal findings. 4. Assist the client up to void.

4.

The nurse is assigned to care for a client who has developed intestinal obstruction and has had an NG tube inserted to low suction. Blood gases are pH 7.54, pCO2 52, HCO3 35. Assessment of the client by the nurse reveals that the client is weak, shaky, and reporting tingling of the fingers. The nurse determines that this client is in which acid/base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

4.

The nurse is caring for a Native American client who has returned to the surgical floor following abdominal surgery. The nurse is concerned about the level of discomfort that the client is experiencing. Which comment is the nurse likely to hear upon assessment? 1. "The pain is getting worse. I can't stand it." 2. "I need something for pain as soon as possible." 3. "I hope that the pain will go away soon." 4. "I am doing okay. The pain is not bad."

4.

The nurse is caring for a client who has been diagnosed with dissociative identity disorder. What is the most appropriate short term goal? 1. Recovery of memory deficits. 2. Demonstration of the ability to perceive stimuli correctly. 3. Elimination of causative phobia. 4. Verbal recognition of the existence of multiple personalities.

4.

The nurse is caring for a client with possible hepatic failure. The nurse asks the client to sign a permit for a procedure. The nurse recalls the client's admission signature as legible, but, now observes a jerky, illegible signature. What should the nurse suspect is the cause of this handwriting change? 1. Fetor 2. Ataxia 3. Apraxia 4. Asterixis

4.

The nurse is teaching a client who has been prescribed daily glucocorticoids for the treatment of Addison's disease. What teaching points should the nurse emphasize? 1. Be aware of the development of hypoglycemia. 2. Test the urine for albumin or other proteins. 3. Take the medication 30 minutes prior to bedtime. 4. Maintain the prescribed dose without interruption in therapy.

4.

The nurse is teaching a diabetic client who has been prescribed Lispro insulin about avoiding hypoglycemia. What administration teaching is priority? 1. Take insulin 30 minutes before bedtime 2. Take insulin twice daily in AM and PM 3. Take insulin one hour before meals 4. Take insulin with meals

4.

The nurse makes selections from the hospital menu for a client who is confused and suspicious of others. Which menu choice is best? 1. Ham and vegetable casserole 2. Cheese and crackers 3. Caffeine free tea 4. Packaged sugar free Jell-O

4.

The primary healthcare provider prescribes glycopyrrolate 0.2 mg IM thirty minutes prior to electroconvulsive therapy (ECT). What should be the nurse's response when the client asks why this drug is being given? 1. "The action of the medication is complex." 2. "This drug will prevent you from having a seizure." 3. "This medication will relax your muscles so that you do not break a bone." 4. "Glycopyrrolate will decrease stomach secretions."

4.

Upon receiving a diagnosis of Stage 4 lung cancer, an elderly client expresses regret for having chosen to smoke. Which response by the nurse would best help the client cope at this time? 1. "You are lucky to have lived a very long life." 2. "We have younger clients in worse shape than you." 3. "The doctor will make sure to treat any pain." 4. "You are regretting your decision to smoke."

4.

Which foods should the nurse teach a client to avoid when prescribed a diet limiting purine rich foods? 1. Peanut butter 2. Potatoes 3. Apples 4. Venison 5. Scallops

4., & 5.

In what order, after initially washing hands, should the nurse change a dressing on an infected abdominal surgical wound that has a Penrose drain and a large amount of purulent drainage? Place in priority order from first to last. Apply clean gloves. Remove soiled dressings. Discard soiled dressings and clean gloves in red bag. Don sterile gloves. Clean surgical wound with moistened sterile 4x4's. Clean around Penrose drain using a circular pattern inside to outside. Place dry, sterile 4x4's over surgical wound and Penrose drain. Apply abdominal dressing pad.

First, apply clean gloves. Second, remove soiled dressings. Third, discard soiled dressings and clean gloves in red bag. Fourth, don sterile gloves. Fifth, clean surgical wound with moistened sterile 4x4's. Sixth, clean around Penrose drain using circular pattern inside to outside. Seventh, place dry, sterile 4x4's over surgical wound and Penrose drain. Eighth, apply abdominal dressing pad.