Hurst Review Questions (6)
What action by the nurse is most helpful when responding to a bomb threat phone call? 1. Ask where and when the bomb is going to explode. 2. Quickly terminate the conversation and call in the bomb threat. 3. Document on the hospital Bomb Threat Checklist. 4. Immediately seek cover and warn others.
1. Ask where and when the bomb is going to explode.
Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? Select all that apply 1. Assist client to brush and floss teeth. 2. Administer sodium polystyrene sulfonate enema. 3. Evaluate pain relief after narcotic administration. 4. Measure urine output when client voids. 5. Gather supplies to prepare room for isolation. 6. Monitor client for pain while assisting with ambulation.
1. Assist client to brush and floss teeth. 4. Measure urine output when client voids. 5. Gather supplies to prepare room for isolation.
A nurse on the unit has had a disagreement with the family of a client regarding the client's dressing change. What is the best action by the nurse manager? 1. Meet with the family member and the RN to discuss the disagreement. 2. Assure the family member that the nurse followed the hospital procedure. 3. Discuss the dressing change procedure with the RN and compare to a current textbook. 4. Report the argument to the hospital administrator.
1. Meet with the family member and the RN to discuss the disagreement.
What should the nurse check when assessing a client's balance? Select all that apply 1. Walking on tiptoes 2. Babinski reflex 3. Romberg test 4. Muscle strength of legs 5. Dorsalis pedis pulses
1. Walking on tiptoes 3. Romberg test 4. Muscle strength of legs
The nurse has just received a client from the special procedures lab for a liver biopsy. What is the position of choice for this client post procedure? 1. Fowler's 2. Right side 3. Left side 4. Prone
2. Right side
How should a nurse prepare to administer a Measles, Mumps, Rubella (MMR) vaccination to a 6 year old child? 1. 3 mL syringe with 23 gauge, 1" needle for IM injection 2. Use a 25 gauge, ¾" needle for subcutaneous (Sub-Q) injection. 3. Prime intranasal spray for administration. 4. Tuberculin (TB) syringe with 28 gauge, 3/8" needle for intradermal injection.
2. Use a 25 gauge, ¾" needle for subcutaneous (Sub-Q) injection.
The labor and delivery charge nurse is making staff assignments, including assignments to a new nurse. What client is most appropriate for the new nurse? 1. A gravida 3 para 2 in active phase of stage one, expecting twins. 2. A gravida 2 para 0 at 41 weeks gestation, awaiting induction. 3. A primigravida in active phase of stage one, waiting for epidural. 4. A 12-hour post Cesarean section needing assistance to ambulate.
3. A primigravida in active phase of stage one, waiting for epidural.
What is the first intervention the emergency department (ED) nurse should implement when caring for a lethargic toddler with a diagnosis of near-drowning? 1. Torso warming 2. Start intravenous infusion 3. Administer oxygen 4. Prepare for nasogastric intubation
3. Administer oxygen
Which nursing intervention will be most helpful to a middle-aged client experiencing insomnia? 1. Instruct the client to initiate an exercise routine during the day. 2. Educate the client on ways to adjust the sleep environment. 3. Instruct the client on progressive relaxation techniques to be used just before bedtime. 4. Instruct the client to decrease caffeine intake.
3. Instruct the client on progressive relaxation techniques to be used just before bedtime.
The nurse is teaching crutch walking to a client with a fractured lower leg with a non weight bearing cast. Which crutch gait would be most appropriate for the nurse to teach? 1. Swing through 2. Two point 3. Three point 4. Four point alternating
3. Three point
A client with a history of eczema has been admitted with cellulitis of the left forearm. Which admission order should the nurse question immediately? 1. Start IV of normal saline at 100 mL per hour. 2. Keep left arm elevated on pillow at all times. 3. Apply ice packs to affected area every shift. 4. Ibuprophen 800 mg po every 6 hours prn pain.
3. Apply ice packs to affected area every shift.
The nurse is preparing to administer Sunday's 1600 medications to a client. How many mg of Warfarin should the nurse administer? Answer using numbers only. (Take 1/2 tab aka 1 mg every Sunday evening)
1
A newborn is admitted to the nursery with a diagnosis of rule out cytomegalovirus (CMV). Which of the following RNs should not be assigned to this baby? 1. A nurse just back from maternity leave. 2. A nurse who is 10 weeks pregnant. 3. A nurse who is breastfeeding her 4 month old. 4. A nurse who is on hormone replacement therapy.
2. A nurse who is 10 weeks pregnant.
A client who has a history of major depression is in the emergency department. Which statement would demonstrate a risk for suicide or self-directed injury? 1. "I can't do anything right anymore." 2. "I am not sure what to do anymore." 3. "I just cannot take this loneliness anymore." 4. "No one cares about me."
3. "I just cannot take this loneliness anymore."
The nurse manager is making rounds in a long-term care facility and discovers an unfamiliar client standing in the hallway in a puddle of liquid. What is the nurse manager's priority action? 1. Ask client to state name and room number. 2. Find dry clothes and clean client completely. 3. Wipe up puddle of liquid and call housekeeping. 4. Contact unit charge nurse to identify the client.
3. Wipe up puddle of liquid and call housekeeping.
The nurse is caring for a client admitted with heart failure. Which prescriptions would necessitate that the nurse seek clarification from the primary healthcare provider? Select all that apply 1. Furosemide 20.0 mg p.o. daily 2. Rosuvastatin 5 mg p.o hs 3. Digoxin 0.125 mg IVP every 8 hours for three doses 4. Folic acid 1 mg daily 5. Heparin 1000 IU subcutaneously daily
1. Furosemide 20.0 mg p.o. daily 4. Folic acid 1 mg daily 5. Heparin 1000 IU subcutaneously daily
What actions should the nurse take when administering fentanyl? Select all that apply 1. Remove old fentanyl patch prior to applying new patch. 2. Cleanse area of old fentanyl patch. 3. Shave hair where fentanyl patch will be applied. 4. Place fentanyl patch over dry skin. 5. Apply adhesive dressing over the fentanyl patch. 6. Dispose of fentanyl patch in trash.
1. Remove old fentanyl patch prior to applying new patch. 2. Cleanse area of old fentanyl patch.. 4. Place fentanyl patch over dry skin.
Which food selections would need to be removed from the tray by the nurse for a client recovering from thyroidectomy? 1. Roasted almonds 2. Mashed vegetables 3. Scrambled eggs 4. Ice cream
1. Roasted almonds
The nurse is caring for a client who has a history of sleep apnea. The client is scheduled for a colon resection the following morning and asks if the sleep apnea machine should be brought to the hospital. What is the nurse's best response? 1. Yes, bring the sleep apnea machine. 2. No, do not bring the sleep apnea machine. 3. It is your choice. 4. Call your primary healthcare provider.
1. Yes, bring the sleep apnea machine.
The nurse is checking a two year old's developmental status. What finding would be of concern to the nurse? 1. Unable to use "me" and "you" correctly. 2. Has trouble focusing on one activity for more than 5 minutes. 3. Does not follow a 3-part command. 4. Does not know what to do with a spoon.
4. Does not know what to do with a spoon.
The nurse is providing care to a client who has returned to the long-term facility following cataract surgery. Which finding would indicate a possible complication? 1. Slightly swollen eyelid 2. Slight discomfort of the eye 3. "Bloodshot" appearance of the eye 4. Extreme pain in the eye
4. Extreme pain in the eye
Which food items, if chosen by a client diagnosed with diverticulosis, would indicate to the nurse that the client understands the prescribed diet? Select all that apply 1. Avocados 2. Acorn squash 3. Applesauce 4. Lima beans 5. Raspberries 6. Cottage cheese
1. Avocados 2. Acorn squash 4. Lima beans 5. Raspberries
Which signs/symptoms would lead a nurse to suspect Fifth disease in a child brought into a pediatric clinic? Select all that apply 1. Erythema on the cheeks. 2. Joint pain. 3. Temperature 102°F (38.88°C). 4. Swollen knees. 5. Pruritic rash on soles of feet.
1. Erythema on the cheeks. 2. Joint pain. 4. Swollen knees. 5. Pruritic rash on soles of feet.
A client in labor is placed on an external fetal monitor. Which interventions should the nurse perform if a late fetal heart rate deceleration occurs? Select all that apply 1. Turn the client to the left side. 2. Administer oxygen. 3. Start an intravenous line. 4. Prep the mother for cesarian section. 5. Notify the primary healthcare provider.
1. Turn the client to the left side. 2. Administer oxygen. 5. Notify the primary healthcare provider.
The nurse is evaluating a client for compliance to the prescribed diabetic program by checking recent lab results. Based on the lab data, what should the nurse conclude regarding the client? Fasting Blood Glucose 90 mg/dL (4.995 mmol/L) Hemoglobin A1C 6.5% 1. At risk for developing hypoglycemia. 2. Demonstrating good control of blood glucose. 3. At risk for developing Somogyi phenomenon. 4. Demonstrating signs of insulin resistance.
2. Demonstrating good control of blood glucose.
Which nursing interventions will help to prevent a contracture post-operatively in a client with a below the knee amputation? Select all that apply 1. Keep the residual limb elevated on a pillow at all times 2. Ensure the residual limb is positioned flat on the bed 3. Position the client prone several times a day 4. Keep head of bed elevated with knees up. 5. Apply anti-embolism stockings to the unaffected leg
2. Ensure the residual limb is positioned flat on the bed 3. Position the client prone several times a day
Which interventions should the nurse include for a client with sickle cell crisis who is experiencing pain? Select all that apply 1. Apply cold compresses to affected joints. 2. Massage affected areas gently. 3. Support and elevate swollen joints. 4. Monitor pain level by looking for BP, respiratory, and heart rate elevation. 5. Place client on Nothing By Mouth (NPO) status. 6. Administer Normal Saline (NS) at 125 mL/hour.
2. Massage affected areas gently. 3. Support and elevate swollen joints. 4. Monitor pain level by looking for BP, respiratory, and heart rate elevation. 6. Administer Normal Saline (NS) at 125 mL/hour.
A nurse is teaching a group of expectant parents about epidural anesthesia. What information should the nurse include? Select all that apply 1. Contraindications for an epidural include a previous cesarean section. 2. Post procedure position should be side lying. 3. Headache is a post procedure side effect. 4. The major complication is hypotension. 5. Usually administered at 3-4 cm dilation.
2. Post procedure position should be side lying. 4. The major complication is hypotension. 5. Usually administered at 3-4 cm dilation.
A nurse is working with community officials to decrease the incidence of violence in the community. Which primary preventive measures might the nurse suggest? Select all that apply 1. Provide a safe haven for victims of violence. 2. Provide educational programs about types of violence. 3. Form a neighborhood watch program. 4. Develop a media campaign identifying risk factors of potential abuse. 5. Provide for the immediate removal of a victim of violence from the home.
2. Provide educational programs about types of violence. 3. Form a neighborhood watch program. 4. Develop a media campaign identifying risk factors of potential abuse.
Which statement by the spouse of a client diagnosed with Alzheimer's indicates to the nurse that the spouse is dealing appropriately with stressors? 1. "I am in charge of every aspect of the care provided." 2. "I do not expect our children who live out of town to help." 3. "I keep a list of small tasks ready for people who ask me if they can help." 4. "I only go to my primary healthcare provider when I am sick."
3. "I keep a list of small tasks ready for people who ask me if they can help."
The nurse is working with the interdisciplinary team in developing a plan of care focused on weight gain for an anorexic client. What intervention would be ineffective for reaching that outcome? 1. Refrain from being critical of client during meals. 2. Permit client to make own food selections on menu. 3. Reward the client with private time for a meal completely eaten. 4. Provide positive reinforcement for each pound gained.
3. Reward the client with private time for a meal completely eaten.
A nurse is caring for a client who has chest pain. Which statement made by the client leads the nurse to suspect angina instead of a myocardial infarction(MI)? 1. I became dizzy when I stood up. 2. I was nauseated and began vomiting. 3. The pain started in my chest and stopped after I sat down. 4. The pain was not relieved after taking 3 nitroglycerine tablets.
3. The pain started in my chest and stopped after I sat down.
A client comes into the after-hours clinic reporting severe abdominal pain. Suspecting appendicitis, where should the nurse assess for tenderness? Place an "x" at the appropriate site:
McBurneys point
The charge nurse is evaluating a newly hired LPN/VN graduate. Before assigning a client to be prepped for a colonoscopy, the nurse asks the LPN/VN to verbalize the correct steps for completing an enema. In what order should the LPN/VN verbalize the steps for an enema? a. Assist client to a side lying position. b. Add warm water to the enema bag. c. Raise enema bag 18" to 20". d. Insert lubricated tip into rectum. e. Explain procedure to the client.
e. Explain procedure to the client. a. Assist client to a side lying position. b. Add warm water to the enema bag. c. Raise enema bag 18" to 20". d. Insert lubricated tip into rectum.
The nurse instructs a client about deep breathing and coughing exercises that will be performed postoperatively. Which statement by the client indicates that teaching has been effective? 1. "Coughing and deep breathing should be performed hourly to prevent pneumonia." 2. "Coughing and deep breathing are needed to prevent blood clots." 3. "Coughing and deep breathing will aide with healing by increasing available oxygen." 4. "Coughing and deep breathing will help resolve any blood clots that have formed. "
1. "Coughing and deep breathing should be performed hourly to prevent pneumonia."
A client who was diagnosed with paranoid delusions has been prescribed a chest x-ray. The client refuses the chest x-ray and states "No, they want to kill me with the rays from the x-ray machine." Which nursing response is appropriate? 1. "Do you think people want to kill you with rays?" 2. "You don't have to worry that someone is going to kill you." 3. "I don't want you to talk about the x-ray technicians." 4. "Where did you get the idea that someone was trying to kill you?"
1. "Do you think people want to kill you with rays?"
The nurse is observing a new RN explain phototherapy to the mother of a newborn with a bilirubin of 12 mg/dL one day after birth. The nurse determines the new RN understands the phototherapy process when what statements are made to the mother? Select all that apply 1. "The infant's eyes must be covered throughout the light session." 2. "The heat from the light may cause some harmless swelling in arms." 3. "Body temperature must be checked frequently to monitor for fever." 4. "It is important to restrict feedings during the phototherapy sessions." 5. "We check bilirubin levels several times daily to be sure it's decreasing."
1. "The infant's eyes must be covered throughout the light session." 3. "Body temperature must be checked frequently to monitor for fever." 5. "We check bilirubin levels several times daily to be sure it's decreasing."
The nurse is caring for a client in the outpatient mental health clinic. The client recounts several incidences of spousal abuse. The client says to the nurse, "I know that he loves me. Sometimes I can be quite irritating." Which response is most appropriate by the nurse? 1. "You are not responsible for the abuse." 2. "Sometimes we can irritate our spouses." 3. "The worst is over now." 4. "You should think about leaving him."
1. "You are not responsible for the abuse."
Following a large hurricane, multiple clients arrive at the emergency room for treatment. The charge nurse must triage and assign clients to appropriate staff. Which clients could be assigned to an LPN? Select all that apply 1. Child with superficial burns on both upper arms. 2. Adolescent with bruising to left upper quadrant. 3. Crying toddler missing both upper front teeth. 4. Adult reporting headache and blurred vision. 5. Elderly adult reporting nausea and heartburn.
1. Child with superficial burns on both upper arms. 3. Crying toddler missing both upper front teeth.
The nurse is caring for a client on the surgical unit. Which prescriptions could the nurse safely administer to the client? Select all that apply 1. Chlordiazepoxide 10 mg p.o. q 4h p.r.n. for agitation 2. Regular insulin 10 U stat 3. MS 2 mg IVP every 2 hours as needed for pain 4. Cefepime 1 gram IVPB every 8 hours 5. Diphenhydramine 25 mg p.o. hour of sleep for three nights
1. Chlordiazepoxide 10 mg p.o. q 4h p.r.n. for agitation 4. Cefepime 1 gram IVPB every 8 hours 5. Diphenhydramine 25 mg p.o. hour of sleep for three nights
Which client would be appropriate for the RN to assign to the LPN? Select all that apply 1. Client scheduled for an MRI of the kidneys. 2. Client requiring administration of antineoplastic medications. 3. Client one day post open cholecystectomy with moderate amount serous drainage on dressing. 4. Client post ileal conduit surgery this AM without drainage in the drainage bag. 5. Client diagnosed with osteoarthritis reporting frequent joint stiffness.
1. Client scheduled for an MRI of the kidneys. 3. Client one day post open cholecystectomy with moderate amount serous drainage on dressing. 5. Client diagnosed with osteoarthritis reporting frequent joint stiffness.
Which assessments will provide the nurse with the most information regarding a client's neurologic function? Select all that apply 1. Level of consciousness 2. Doll's eyes reflex 3. Babinski reflex 4. Reaction to painful stimuli 5. Verbal ability
1. Level of consciousness 5. Verbal ability
What action should the nurse take after mistakenly administering the wrong medication? Select all that apply 1. Notify the nursing supervisor. 2. Inform the primary healthcare provider. 3. Complete an incident (variance) report. 4. Document client assessment and response to medication. 5. Document medication error and incident (variance) report in nurse's notes.
1. Notify the nursing supervisor. 2. Inform the primary healthcare provider. 3. Complete an incident (variance) report. 4. Document client assessment and response to medication.
The nurse is preparing to discharge a client home from the hospital. Which statement made by the client indicates to the nurse that instructions about antibiotic administration have been successful? Select all that apply 1. "I will take the antibiotic until I feel better but save some to take in case the infection returns." 2. "I should follow the instructions on the label." 3. "I need to double the dose for two days so I will get better." 4. "I should double the dose the next time the antibiotic is due after missing a dose." 5. "I will finish all of my antibiotic medication."
2. "I should follow the instructions on the label." 5. "I will finish all of my antibiotic medication."
The nurse is preparing to give a client's prescribed levothyroxine dose. How many tablets will the nurse give to the client? Answer with numbers only. Prescription: Levothyroxine 0.05 mg by mouth every morning. Dose: 25 mcg (0.025mg)
2
The nurse is assessing an adolescent newly diagnosed with obsessive compulsive disorder (OCD). The client is nervously rearranging papers on the desk and stating "why can't I stop this?" What would be the most therapeutic response(s) by the nurse at this time? Select all that apply 1. "We can help you control impulses, but you will never be cured." 2. "You will feel much better after beginning your family therapy." 3. "Tell me what part of your disorder you find the most difficult." 4. "You seem nervous and upset about rearranging those papers." 5. "The goal of behavior control can be accomplished with help."
3. "Tell me what part of your disorder you find the most difficult." 4. "You seem nervous and upset about rearranging those papers." 5. "The goal of behavior control can be accomplished with help."
Which response by the nurse is appropriate when admitting a 5 year old child who is crying and hugging a stuffed animal? 1. "Hello, I am your nurse. I am going to show you to your room." 2. "Don't cry. Let's go to the playroom where you can meet other children." 3. "You are upset. I see you have your stuffed animal." 4. "Can I hold your stuffed animal? Then, would you like to put your stuffed animal in the bed?"
3. "You are upset. I see you have your stuffed animal."
Following a lumbar puncture, the client reports a headache on a pain scale of 8 out of 10. What priority action should the nurse perform? 1. Instruct the client to drink at least 8 ounces of water. 2. Close room blinds to darken the environment. 3. Assist the client into a supine position in bed. 4. Notify primary healthcare provider of client's complaints.
3. Assist the client into a supine position in bed.
The nurse just received an arterial blood gas (ABG) report that shows a borderline high PCO2 on a client who had chest surgery. What should be the priority nursing intervention? 1. Tell the client to breathe faster. 2. Medicate for pain and ambulate. 3. Have client use the incentive spirometer. 4. Prepare to administer bicarbonate to buffer.
3. Have client use the incentive spirometer.
A 20 year old client has been admitted to the hospital with a diagnosis of preeclampsia. The charge nurse has only semiprivate rooms available. What roommate would be most appropriate for this client who is being admitted? 1. An adolescent primigravida with many visitors. 2. A 25 year old post induction for fetal demise. 3. A 35 year old awaiting discharge after a total abdominal hysterectomy (TAH). 4. A 30 year old post dilation and curettage (D&C) who enjoys knitting.
4. A 30 year old post dilation and curettage (D&C) who enjoys knitting.
At a summer pool party, an adult client is found unconscious in the water. Someone calls 911, and a nurse present at the party immediately initiates what priority action? 1. Initiate chest compressions. 2. Assess client for any injuries. 3. Wrap client in warm blankets. 4. Check for any respirations.
4. Check for any respirations
While preparing an information sheet for a client diagnosed with a vancomycin-resistant enterococcus (VRE) urinary tract infection (UTI), the home health nurse should include which instructions? 1. Wash hands with hot water and soap when hands are soiled. 2. Gloves are not needed in the home since contamination with VRE has already occurred. 3. Wash hands before using the bathroom and after preparing food. 4. Clean the bathroom and kitchen with warm water and bleach.
4. Clean the bathroom and kitchen with warm water and bleach.
A client is admitted from the emergency department to a medical unit. What acid base imbalance do the lab values indicate? 1. Metabolic acidosis 2. Compensated metabolic alkalosis 3. Respiratory acidosis 4. Compensated respiratory alkalosis
4. Compensated respiratory alkalosis
A nurse working in a clinic is planning to assess a client for any sensory deficits. What assessments should the nurse include? Select all that apply 1. Ask the client about any recent changes in vision. 2. Observe the client's conversation with others. 3. Assess two-point discrimination. 4. Perform the Rinne test. 5. Test near vision with the Snellen chart.
1. Ask the client about any recent changes in vision. 2. Observe the client's conversation with others. 3. Assess two-point discrimination. 4. Perform the Rinne test.
A pediatric nurse is teaching a group of new parents about what to expect regarding their infants eyes and vision. What points should the nurse include? Select all that apply 1. At 4 weeks of age, the infant should be able to gaze at objects. 2. Infants should have tears by the age of 1 month. 3. Visual acuity is about 20/300 at 4 months of age. 4. During the first 2 months of life, infant's eyes may appear to be crossed. 5. Depth perception begins around the 5th month of age.
1. At 4 weeks of age, the infant should be able to gaze at objects. 3. Visual acuity is about 20/300 at 4 months of age. 4. During the first 2 months of life, infant's eyes may appear to be crossed. 5. Depth perception begins around the 5th month of age.
The nurse is participating in a presentation regarding adolescent violence to middle and high school faculty and staff. What risk factors for violence should the nurse include? Select all that apply 1. Attention deficit disorder 2. Diminished economic opportunities 3. Authoritative parenting style 4. Active in school sports 5. High parental involvement
1. Attention deficit disorder 2. Diminished economic opportunities
A nurse is caring for a client who has been prescribed prednisone. What education should the nurse provide to the client? Select all that apply 1. Avoid crossing legs. 2. Eat a low calcium diet. 3. Take prednisone with food. 4. Taper prednisone dose prior to completion. 5. Instruct the client to use arm rests when rising from a chair.
1. Avoid crossing legs. 3. Take prednisone with food. 4. Taper prednisone dose prior to completion. 5. Instruct the client to use arm rests when rising from a chair.
Following a thyroidectomy, a client reports shortness of breath and neck pressure. Which nursing action is the best response? 1. Remove the dressing and elevate the head of bed. 2. Call a code, open the trach set, and position the client supine. 3. Obtain vital signs. 4. Immediately go to the nurse's station and call the primary healthcare provider.
1. Remove the dressing and elevate the head of bed.
The schizophrenic client tells the nurse, "I am Jesus, and I am here to save the world!" The client is reading from the Bible and warning others of hell and damnation. The other clients on the unit are upset and several are beginning to cry. What nursing intervention is most appropriate? 1. Set verbal limits and have the client return to assigned room. 2. Explain to the client that not all people are Christians. 3. Remove the Bible from the client and explain that the client is not Jesus. 4. Ask the client to share with the group how the client is Jesus.
1. Set verbal limits and have the client return to assigned room.
The nurse has been teaching a client diagnosed with diabetes about self-administration of regular insulin. The first injection was noted by the number 1. The nurse knows that education regarding site rotation was successful when the client chooses which site next? 1 & 2 in LLQ ; 3 in RLQ, 5 on Left upper buttox 1. Site 2 2. Site 3 3. Site 4 4. Site 5
1. Site 2
A 19 year old client preparing to enter college asks the clinic nurse about immunizations. What immunizations should the nurse suggest the client discuss with the primary health care provider? Select all that apply 1. Meningococcal conjugate vaccine 2. Tdap vaccine 3. HPV vaccine 4. Seasonal flu vaccine 5. Hepatitis B 6. Polio
1. Meningococcal conjugate vaccine 2. Tdap vaccine 3. HPV vaccine 4. Seasonal flu vaccine 5. Hepatitis B
The community health nurse is planning to teach nutritional education to a group of adults attending a health fair. What tips about health eating should the nurse include? Select all that apply 1. Pay attention to fullness cues during meals. 2. Make one fourth of the plate fruits and vegetables. 3. Drink sweet tea rather than soft drinks with meals. 4. Eat foods low in dietary fiber. 5. Consume less than 30% of calories from saturated fatty acids. 6. Use a smaller plate for meals.
1. Pay attention to fullness cues during meals. 6. Use a smaller plate for meals.
What should the nurse include when planning discharge teaching for a client post scleral buckling of the right eye? Select all that apply 1. Redness, tenderness and swelling should be gone within 2 days. 2. Teach to report seeing flashes of light immediately. 3. Place eye drops onto the cornea of the affected eye. 4. Wear eye shield during naps, and at night. 5. Have client demonstrate the correct technique for instilling eye drops.
2. Teach to report seeing flashes of light immediately. 4. Wear eye shield during naps, and at night. 5. Have client demonstrate the correct technique for instilling eye drops.
Which assignment by the charge nurse would be most appropriate for a general pediatric nurse being reassigned to the hematology/oncology pediatric unit? Select all that apply 1. Child dying with leukemia who has been on the hematology/oncology unit for two weeks. 2. Teenager with sickle cell disease in for pain management. 3. Child admitted following a bicycle accident that has idiopathic thrombocytopenic purpura (ITP). 4. New admit scheduled for bone marrow transplant. 5. Child diagnosed with leukemia admitted for stomatitis.
2. Teenager with sickle cell disease in for pain management. 3. Child admitted following a bicycle accident that has idiopathic thrombocytopenic purpura (ITP). 5. Child diagnosed with leukemia admitted for stomatitis.
What signs/symptoms would the nurse expect to assess in a client diagnosed with Guillain-Barre' Syndrome? Select all that apply 1. Opisthotonos 2. Seizures 3. Paresthesia 4. Hemiplegia 5. Hypotonia 6. Muscle aches
3. Paresthesia 5. Hypotonia 6. Muscle aches
Which assessment by the nurse indicates a tension pneumothorax? 1. Sudden hypertension and bradycardia 2. Productive cough with yellow mucus 3. Tracheal deviation and dyspnea 4. Sudden development of profuse hemoptysis and weakness
3. Tracheal deviation and dyspnea
The nurse manager on a medical-surgical unit receives official notification that staff overtime must be decreased as a cost-saving measure. In order to reorganize staffing, the nurse manager should initiate which action first? 1. Announce the new changes at the monthly staff meeting. 2. Ask for any staff objections to rearranging work hours. 3. Invite staff to contribute ideas on scheduling changes. 4. Explain administration is demanding a decreased overtime.
3. Invite staff to contribute ideas on scheduling changes.
A client diagnosed with a hemorrhagic stroke is being transferred to the medical unit from the intensive care unit. Which nursing intervention should the nurse initially implement? 1. Administer an osmotic diuretic. 2. Complete a neurological assessment. 3. Maintain the head of the bed at 30 degrees. 4. Instruct the client to take a stool softener daily.
3. Maintain the head of the bed at 30 degrees.
A client is being discharged with halo traction. What should the nurse teach about home care of this traction? Select all that apply 1. Showering is permitted. 2. Apply baby powder under the halo vest to prevent irritation. 3. Never pull on any part of the halo traction. 4. Clean around pins at least twice a day using sterile technique. 5. Driving is allowed after discharge.
3. Never pull on any part of the halo traction. 4. Clean around pins at least twice a day using sterile technique.
Which statement by a client would indicate to the nurse that education about alendronate has been successful? 1. "It is recommended that I recline for 15 minutes after taking my medication." 2. "Food should be eaten immediately after taking alendronate." 3. "My medication tablet should be chewed for rapid absorption." 4. "I should drink a full 8 ounce glass of water with my medication."
4. "I should drink a full 8 ounce glass of water with my medication."
A client is to be discharged following cataract removal with lens implantation. What statement by the client indicates to the nurse that teaching has been successful? 1. "I must keep both eyes covered till my check-up." 2. "I should only have pain for about two days." 3. "I will no longer have to wear reading glasses." 4. "My vision will be blurry for a couple weeks."
4. "My vision will be blurry for a couple weeks."
A client who is scheduled for a total hip replacement surgery in the morning begins to verbalize anxiety related to the surgery. Arrange the client's comments in order as the client's anxiety advances beginning with mild to panic anxiety. a. "Can I wear my wedding ring during the surgery?" b. "I know those hip exercises after the surgery are painful." c. "Having trouble thinking about anything, but the surgeon cutting on my hip." d. "My Dad died on the operating table, and I keep thinking I will die too."
a. "Can I wear my wedding ring during the surgery?" b. "I know those hip exercises after the surgery are painful." c. "Having trouble thinking about anything, but the surgeon cutting on my hip." d. "My Dad died on the operating table, and I keep thinking I will die too."
The nurse is caring for a client in the 8th week of pregnancy. The client is spotting, has a rigid abdomen and is on bedrest. What is the most important assessment at this time? 1. Protein in the urine 2. Fetal heart tones 3. Cervical dilation 4. Hemoglobin and hematocrit levels
4. Hemoglobin and hematocrit levels
Which nursing intervention should the nurse include when caring for a client with Alzheimer's disease being admitted to a long term care facility? 1. Offer multiple environmental stimuli at the same time to provide distraction. 2. Encourage the client to participate in activities such as board games. 3. Restrain the client in a chair to prevent falls when sundowning occurs. 4. Involve the client in supervised walking as a routine.
4. Involve the client in supervised walking as a routine.
The nurse is making an initial home visit to a client newly diagnosed with diverticulitis. The client had been on a liquid diet but is now to begin solid foods appropriate for the disease process. The nurse knows dietary teaching has been successful when the client selects which meal? 1. Hamburger on sesame roll, macaroni and cheese, tossed salad 2. Lamb chop with brown rice, cooked broccoli, baked potato 3. Pork with sauerkraut, baked beans, and coconut cake 4. Spaghetti with meatballs, fruit cocktail, garlic bread
4. Spaghetti with meatballs, fruit cocktail, garlic bread
The crisis line nurse answers a call from a client who is voicing intent to commit suicide. The client tells the nurse, "I am sitting here with a bottle of pain killers in my hand." What is the nurse's most appropriate response? Select all that apply 1. "I want to help you to resolve the problem." 2. "You should drive yourself to the emergency room." 3. "You did the right thing by calling." 4. "I want you to stay on the phone with me." 5. "Have another person call 911 for an ambulance."
1. "I want to help you to resolve the problem." 3. "You did the right thing by calling." 4. "I want you to stay on the phone with me." 5. "Have another person call 911 for an ambulance."
A school-age child with Asperger's Syndrome has been receiving out-patient behavioral and cognition therapy to improve socialization skills. However, recent symptoms and a positive Covid test resulted in the child's hospitalization. The nurse is aware what important measures should be implemented to help this client cope with hospital admission? Select all that apply 1. Allow the client to arrange personal items in the room. 2. Have a parent stay with the child. 3. Maintain consistent daily nursing care routine for client. 4. Keep TV and lights on to distract client from hospital noise. 5. Describe simple details of treatments in advance with client.
1. Allow the client to arrange personal items in the room. 2. Have a parent stay with the child. 3. Maintain consistent daily nursing care routine for client. 5. Describe simple details of treatments in advance with client.
The nursing supervisor is notified by staff in the sterilization room that a foul odor has been noted. Upon inspecting the room, the nurse notes a small amount of sewage seeping up thru the floor drain. What priority actions should the supervisor initiate? Select all that apply 1. Evacuate staff from the room and lock the door. 2. Tell staff to remove any equipment already sterilized. 3. Report the incident to the administrative Chief Executive Officer (CEO). 4. Call maintenance to thoroughly clean the room. 5. Initiate 'internal disaster protocols' immediately.
1. Evacuate staff from the room and lock the door. 3. Report the incident to the administrative Chief Executive Officer (CEO). 5. Initiate 'internal disaster protocols' immediately.
The son of an elderly diabetic client reports that his mother is frequently having low blood sugar. What should the nurse teach this family member about symptoms of hypoglycemia in the elderly? Select all that apply 1. Elders may not be aware that blood sugar is dropping due to decreased release of epinephrine in response to the lowered blood sugar. 2. Suggest that the client and family check with primary healthcare provider to ensure that the medication prescribed has low incidence of hypoglycemic episodes. 3. Symptoms of hypoglycemia may be averted if the client maintains routines and regular meal schedules. 4. Stress the importance of proper foot care and regular eye exams. 5. Check blood glucose levels if client becomes unsteady, has difficulty concentrating, or is tremulous.
1. Elders may not be aware that blood sugar is dropping due to decreased release of epinephrine in response to the lowered blood sugar. 2. Suggest that the client and family check with primary healthcare provider to ensure that the medication prescribed has low incidence of hypoglycemic episodes. 3. Symptoms of hypoglycemia may be averted if the client maintains routines and regular meal schedules. 5. Check blood glucose levels if client becomes unsteady, has difficulty concentrating, or is tremulous.
The family of an elderly woman is concerned that their mother is not getting restful sleep. As a result, the family members' sleep is disturbed. Which questions would be important for the nurse to ask? Select all that apply 1. Has there been any change in your mother's state of health? 2. Can family members take naps during the day? 3. Does she take routine diuretics? 4. Has there been an increase in noise levels? 5. Can the family take turns in managing the mother's sleep problems?
1. Has there been any change in your mother's state of health? 3. Does she take routine diuretics? 4. Has there been an increase in noise levels?
A 9 month old client is admitted to the hospital with a diagnosis of pertussis. Which interventions should the nurse initiate? Select all that apply 1. Initiate droplet precaution. 2. Place client under mist tent with low humidity. 3. Administer erythromycin 10 mg/kg/dose 4 times daily for 7 days. 4. Use client dedicated and disposable equipment. 5. Keep NPO.
1. Initiate droplet precaution. 3. Administer erythromycin 10 mg/kg/dose 4 times daily for 7 days. 4. Use client dedicated and disposable equipment.
A licensed practical nurse (LPN) on the Labor and Delivery unit is assisting the nurse with multiple admissions. What tasks could the LPN complete until the nurse is available? Select all that apply 1. Take initial vital signs. 2. Measure cervical dilation. 3. Check fundal height and fetal heart rate (FHR). 4. Obtain urine for protein and glucose. 5. Collect vaginal swab to test for chlamydia.
1. Take initial vital signs. 4. Obtain urine for protein and glucose. 5. Collect vaginal swab to test for chlamydia.
A child weighing 75 lbs. (34.1 kg) is admitted to the unit with a diagnosis of bacterial meningitis. The child has been started on an IV of D5 NS at 100 mL per hour and IV antibiotic therapy has been initiated. Which assessment finding would need to be reported immediately to the healthcare provider? Select all that apply 1. Urinary output of 28 mL/hr. 2. Change in the level of consciousness. 3. Temperature of 101.2 degrees F (38.4 degrees C). 4. Increase of 5 mm Hg in systolic BP from baseline. 5. Sodium level of 130 mEq/L (130 mmol/L).
1. Urinary output of 28 mL/hr. 2. Change in the level of consciousness. 5. Sodium level of 130 mEq/L (130 mmol/L).
An elderly client has been admitted to the hospital with a diagnosis of cerebral vascular accident (CVA) with right-sided paralysis. When the nurse instructs staff to reposition client every two hours, the family asks about the purpose of this action. What is the best explanation by the nurse? 1. Improves circulation to the affected side of the body. 2. Decreases potential skin breakdown from immobility. 3. Prevents blood stasis in the client's lower extremities. 4. Alleviates sensory deprivation by varying environment.
2. Decreases potential skin breakdown from immobility.
The client with ulcerative colitis calls the clinic and reports increasing abdominal pain and increased frequency of loose stools. The client asks the nurse to clarify foods that can be eaten with ulcerative colitis. What foods should the nurse suggest? Select all that apply 1. Dried beans 2. Fish 3. Apples 4. Yogurt 5. Scrambled eggs
2. Fish 5. Scrambled eggs
A nurse is caring for a multipara client in active labor who received morphine 4 mg IVP for pain. Thirty minutes later, the client had a precipitous delivery. What should the nurse prepare to administer to the newborn? 1. Oxygen 2. Naloxone 3. Glucose 4. Vitamin K
2. Naloxone
The nurse is discharging a client who had a kidney transplant and the primary healthcare provider has prescribed mycophenolate. Which nursing instruction is priority regarding this medication? 1. Take the medication with food 2. Notify primary healthcare provider at first signs of an infection 3. Nausea, vomiting, and diarrhea are common side effects 4. Use sunscreen when planning to be outdoors
2. Notify primary healthcare provider at first signs of an infection
A female client has been ordered a radioactive iodine uptake test (RAIU) to evaluate for Graves' Disease (hyperthyroidism). What priority actions should the nurse complete before the test? Select all that apply 1. Insert IV to administer conscious sedation. 2. Remove all jewelry or metal before the test. 3. Obtain urine specimen to check for pregnancy. 4. Confirm client is NPO for two hours before the test. 5. Verify client stopped anti-thyroid meds for one week.
2. Remove all jewelry or metal before the test. 3. Obtain urine specimen to check for pregnancy. 5. Verify client stopped anti-thyroid meds for one week.
An elderly client living in a long-term care facility fell 8 hours ago causing a laceration on the occipital area of the skull and steri-strips were applied for closure. Which signs/symptoms would indicate to the nurse that the client should be transferred to the emergency department? Select all that apply 1. Purposeful movement. 2. Sudden emotional outbursts. 3. Client report of blurred vision. 4. Pupils equal, react to light, and accommodation. 5. Bright red blood oozing from the wound. 6. Headache unrelieved by acetaminophen.
2. Sudden emotional outbursts. 3. Client report of blurred vision. 6. Headache unrelieved by acetaminophen.
A new nurse enters the linen room for supplies and finds a pile of sheets on fire. What type of fire extinguisher is most appropriate for the nurse to use in this situation? 1. Foam type 2. Water only 3. Dry powder 4. Carbon dioxide
2. Water only
A client is admitted with new onset hyperthyroidism. Which medication is of concern to the nurse while reviewing the client's routine medications? 1. Ranitidine 2. Furosemide 3. Amiodarone 4. Propranolol
3. Amiodarone
The nurse is caring for a heart failure client taking spironolactone. Which snack choices would indicate to the nurse that the client understands proper dietary choices while on this medication? Select all that apply 1. Bananas 2. Cheese and crackers 3. Apples 4. Sweet potatoes 5. Grapes
3. Apples 5. Grapes
The nurse in the pediatric intensive care unit (PICU) is caring for a preschool child three days after open heart surgery. What assessment finding should the nurse report immediately to the primary healthcare provider? 1. Increased episodes of fussy crying. 2. A hacking, non-productive cough. 3. Oral temperature of 100.9°F (38.3°C). 4. Chest tube draining 30 mL per shift.
3. Oral temperature of 100.9°F (38.3°C).
A client diagnosed with hypothyroidism has received dietary education from the nurse. Which snack selection chosen by the client would indicate that education has been successful? 1. Cup of almonds 2. Cheese and crackers 3. Popcorn 4. Sweet potato fries
3. Popcorn
A nurse is caring for a client admitted to the hospital for a total hip replacement. In preparing the post-operative plan of care for this client, the nurse recognizes which goal as the highest priority? 1. Prevent complications of shock. 2. Prevent dislocation of prosthesis. 3. Prevent respiratory complications. 4. Prevent skin breakdown.
3. Prevent respiratory complications.
The nurse is caring for a client diagnosed with pneumonia. The primary healthcare provider has prescribed erythromycin ER. What teaching points should the nurse plan to teach the client regarding this medication? Select all that apply 1. Crush the medication if unable to swallow capsule. 2. Take erythromycin 1 hour after eating. 3. Report clay-colored stools. 4. Do not take erythromycin with grapefruit juice. 5. Keep capsules in bathroom cabinet.
3. Report clay-colored stools. 4. Do not take erythromycin with grapefruit juice.
How does the nurse identify the correct size of crutches for a client? 1. Turn the crutches upside down and measure from the heel to the shoulder. 2. Obtain a set of crutches and adjust the height until the client can stand comfortably while resting the axilla on the crutch pad. 3. Measure the client while standing upright from the axilla to the heel then adjust the crutches so that the elbow flexion is a 30-degree angle. 4. Measure the client from 2 inches below the axilla to 6 inches lateral to the client's heel.
4. Measure the client from 2 inches below the axilla to 6 inches lateral to the client's heel.
The nurse is teaching a group of clients who have osteoarthritis how to protect joints. What should the nurse include? Select all that apply 1. Use small joints and muscles. 2. Turn doorknobs clockwise. 3. Sit in a chair that has a low, straight back. 4. Push off with the palms of hands when getting out of bed. 5. Use hairbrush with extended handle.
4. Push off with the palms of hands when getting out of bed. 5. Use hairbrush with extended handle.
The nurse is preparing to administer subcutaneous injection. Place an X over the correct syringe position for this injection.
45 Degree angle
A client weighing 140 pounds (63.64 kg) has been admitted to the telemetry unit with a diagnosis of Class III pulmonary hypertension. The primary healthcare provider prescribes digoxin. How many micrograms should the nurse administer now? Round to the whole number.
477 63.64 X 15 = 477.27
