n360 kahoot and practice questions

A nurse is preparing to administer metoclopramide 15 mg PO QID before meals and at bedtime for a client who has GERD. The amount available is metoclopramide 5 mg/5mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ______ mL

15 mL

.A nurse is preparing to administer liquid famotidine 20 mg PO every 6 hr for a client who has GERD. Available is famotidine 40 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) ______ mL

2.5 mL

69.A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client? A. A room with air exhaust directly to the outdoor environment B. A room with another nonsurgical client C. A room in the ICU D. A room that is within view of the nurses' station

A. A room with air exhaust directly to the outdoor environment Rationale:A room with air exhaust directly to the outside environment eliminates contamination of other client-care areas. This type of ventilation system is referred to as an airborne infection isolation room.

73.A nurse in a provider's office is assessing a client. The nurse should identify that which of the following findings are manifestations of pulmonary tuberculosis? (Select all that apply) A. Night sweats B. Low-grade fever C. Weight gain D. Flushed cheeks E. Blood in the sputum

A. Night sweats B. Low-grade fever E. Blood in the sputum

56.A nurse is planning to administer digoxin to a client who has heart failure. Which of the following laboratory results is the priority for the nurse to review prior to administering the medication? A. Potassium B. Hemoglobin C. Creatinine D. Blood urea nitrogen

A. Potassium Rationale: Digoxin is a cardiac glycoside medication used to improve myocardial contractility, increasing stroke volume and cardiac output in a client who has heart failure. During therapy, the nurse should closely monitor the client's potassium level as hypokalemia increases the risk of digitalis toxicity and cardiac arrhythmias.

11.A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication? A. Reduce edema of the brain. B. Provide fluid hydration. C. Increase cell size in the brain. D. Expand extracellular fluid volume.

A. Reduce edema of the brain. Rationale:An osmotic diuretic is used to decrease intracranial pressure by moving fluid out of the ventricles into the bloodstream.

21.A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client? A. "Do have a history of chronic alcohol abuse?" B. "Have you had a recent influenza infection?" C. "Have traveled overseas recently?" D. "Are you taking a multivitamin?"

B. "Have you had a recent influenza infection?" Rationale: The nurse should ask the client about a recent Haemophilus influenzae infection. The cause of GBS is unknown, but it usually follows a viral infection.

76.A nurse is caring for a client who is 12 hr postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations? A. Constant bubbling in the suction-control chamber B. Continuous bubbling in the water-seal chamber C. Bloody drainage in the collection chamber D. Fluid-level fluctuations in the water-seal chamber

B. Continuous bubbling in the water-seal chamber Rationale: Continuous or excessive bubbling in the water-seal chamber indicates an air leak between the water seal and the client's chest. However, gentle bubbling on forceful exhalation or coughing is normal.

70.A nurse is instructing a client who is newly diagnosed with pulmonary tuberculosis (TB) about the use of antitubercular medications. Which of the following information should the nurse include in the teaching? A. Medications will need to be taken for the rest of the client's life, even if the client feels better. B. Medications will need to be taken until the Mantoux test is negative. C. A typical course of treatment involves 6 to 9 months of consistent medication use. D. The client's family will also need to take medications to prevent infection.

C. A typical course of treatment involves 6 to 9 months of consistent medication use. Rationale:Pulmonary TB is a contagious bacterial infection caused by Mycobacterium tuberculosis. Active TB is usually treated with the simultaneous administration of a combination of medications to which the organisms are susceptible. Such therapy is continued until the disease is controlled. A 6- to 9-month regimen consisting of two, and often four, different medications is used. The client should not drink alcohol during this time.

75.A nurse is caring for a client who is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? A. Continue to monitor the client as this is an expected finding. B. Add more water to the suction control chamber of the drainage system. C. Verify that the suction regulator is on and check the tubing for leaks. D. Milk the chest tube and dislodge any clots in the tubing that are occluding it.

C. Verify that the suction regulator is on and check the tubing for leaks. Rationale:A lack of bubbling may indicate that either the suction regulator is turned off or that there is a leak in the tubing.

60.A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication? A. analgesic B. anti-inflammatory C. antiplatelet aggregate D. antipyretic

C. antiplatelet aggregate Rationale:Aspirin is used to decrease the likelihood of blood clotting. It also is used to reduce the risk of a second heart attack or stroke by inhibiting

79.A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions? A. Maintaining a semi-Fowler's position as often as possible B. Administering oxygen via nasal cannula at 2 L/min C. Helping the client select a low-salt diet D. Encouraging the client to drink 2 to 3 L of water daily

D. Encouraging the client to drink 2 to 3 L of water daily Rationale: COPD is a term for two diseases of the respiratory system: chronic bronchitis and emphysema. Maintaining hydration through the consumption of adequate fluids will help liquefy thick secretions and facilitate their expectoration.

80.A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan? A. Restrict the client's fluid intake to less than 2 L/day. B. Provide the client with a low-protein diet. C. Have the client use the early-morning hours for exercise and activity. D. Instruct the client to use pursed-lip breathing.

D. Instruct the client to use pursed-lip breathing. Rationale:Pursed-lip breathing lengthens the expiratory phase of respiration and also increases the pressure in the airway during exhalation. This action reduces airway resistance and decreases trapped air for clients who have COPD.

11. which one of the following is NOT a way to prevent HAP? a. Keep the patient supine b. Give them the full course of antibiotics c. Look for high risk patients on admission d. Assist with mouth care

a

1. The patient has an external fixator, what is an appropriate nurisng intervention? a. Make sure the weights don't tough the ground- this is traction no x-fix b. Ensure the patient wears it for at lest 10 hours a day c. Clean pin sites every 6-8 hours d. Tighten the pins 2 turns every shift

c

64.A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a myocardial infarction? (Select all that apply.) A. Troponin I B. Troponin T C. Plasma low-density lipoproteins (LDL) D. CPK E. Myoglobin

A. Troponin I B. Troponin T D. CPK E. Myoglobin

55.A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? A. Jugular venous distention B. Abdominal distension C. Dependent edema D. Hacking cough

D. Hacking cough Rationale:A hacking cough is a manifestation of left-sided heart failure that occurs due to pulmonary congestion.

17. pH- 7.31 O2- 84 CO2- 61 HCO3- 25 a. respiratory alkalosis b. metabolic acidosis c. respiratory acidosis d. metabolic alkalosis

c

18. your uncle calls to ask what he can take for a cold. What do you assess for? a. ED b. Psoriasis c. HTN d. alopecia

c

24. A patient is admitted with an MI, which one is NOT an appropriate intervention? a. Administer aspirin b. Administer O2 c. Administer dopamine d. Administer morphine

c

26. Your patients stool looks dark and smells funny, what should you do? a. Offer a stool softener b. Make them NPO c. Collect a stool specimen d. Administer an enema

c

29. Which medication can I use to treat H-pylori? a. Calcium carbonate b. Fluconazole c. Clarithromycin d. Prednisone

c

32. What is the priority with seizure management? a. Tracheal suction during a seizure b. Insert tongue depressor into the mouth to hold down tongue c. Turn patient on their side and protect head d. Give Ativan PO to stop seizure

c

49.A nurse in a provider's office is reviewing the laboratory results of a client who takes furosemide for hypertension. The nurse notes that the client's potassium level is 3.3 mEq/L. The nurse should monitor the client for which of the following complications? A. Cardiac dysrhythmias B. Hypoglycemia C. Seizures D. Neurogenic shock

A. Cardiac dysrhythmias This client's potassium level is below the expected reference range. Hypokalemia can cause a number of cardiac effects including flattened T waves, prominent U waves, and S-T depression.

57.A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following instructions should the nurse include in the teaching? A. Exercise at least three times per week. B. Take diuretics early in the morning and before bedtime. C. Notify the provider of a weight gain of 0.5 kg (1 lb) in a week. D. Take naproxen for generalized discomfort.

A. Exercise at least three times per week. Rationale: The nurse encourage the client to stay as active as possible and to develop a regular exercise regimen. Clients who have heart failure who remain active appear to have improved outcomes. The client should try to walk at least three times per week and should slowly increase the amount of time walked over several months. Regular exercise strengthens the heart and cardiovascular system, thereby improving circulation and lowering blood pressure.

77.The nurse is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly? A. Fluctuation of the fluid level within the water seal chamber B. Absence of fluid in the drainage tubing C. Continuous bubbling within the water seal chamber D. Equal amounts of fluid drainage in each collection chamber

A. Fluctuation of the fluid level within the water seal chamber Rationale: Fluctuation of fluid within the water seal chamber occurs with

54.A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect? A. Frothy sputum B. Dependent edema C. Nocturnal polyuria D. Jugular distention

A. Frothy sputum Rationale:Left-sided heart failure reduces cardiac output and raises pulmonary venous pressure. Manifestations include hacking cough, frothy sputum, wheezing, fatigue, and weakness.

42.A nurse is caring for a client 4 hr following a cardiac catheterization. Which of the following actions should the nurse take? A. Have the client lie flat in bed. B. Keep the affected leg slightly flexed. C. Elevate the head of the bed 45°. D. Keep the client NPO for 4 hr.

A. Have the client lie flat in bed. Rationale: The nurse should have the client on lie flat in bed. Clients who had manual or mechanical pressure after catheter removal require 6 hr of bed rest. Those who had a closure device or patch only need 2 hr of bed rest.

78.A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Saturation 80% Bicarbonate 26 mEq/L A. Respiratory acidosis B. Metabolic acidosis C. Metabolic alkalosis D. Respiratory alkalosis

A. Respiratory acidosis

22.A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first? A. Review the client's electrolyte values. B. Check the client's perianal skin integrity. C. Investigate the client's emotional concerns. D. Obtain a dietary history from the client.

A. Review the client's electrolyte values. Rationale: The greatest risk to this client is injury from impaired function of cardiac or respiratory muscles; therefore, the first action the nurse should take is to review the client's electrolyte values. The client might have low sodium, potassium, and chloride from frequent diarrhea.

26.A nurse is teaching a client who has a hiatal hernia about dietary recommendations. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.) A. "I will lie down for one half hour after meals." B. "I will consume less caffeine and fewer spicy foods." C. "I will sleep with the head of my bed elevated." D. "I will try not to gain weight." E. "I will drink less fluid."

B. "I will consume less caffeine and fewer spicy foods." C. "I will sleep with the head of my bed elevated." D. "I will try not to gain weight."

33.A nurse is instructing a client who has GERD about positions that can help minimize the effects of reflux during sleep. Which of the following statements indicates to the nurse that the client understands the instructions? A. "I will lie on my left side to sleep at night." B. "I will lie on my right side to sleep at night." C. "I will sleep on my back with my head flat." D. "I will sleep on my stomach with my head flat."

B. "I will lie on my right side to sleep at night." Rationale:Sleeping in a right side-lying position helps reduce the manifestations of nighttime reflux. The client can also elevate the head of the bed about 15 cm (6 in) on blocks.

39.A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first? A. Notify the provider. B. Check the tubing for kinks. C. Adjust the rate of the bladder irrigant. D. Irrigate the catheter

B. Check the tubing for kinks. Rationale: When providing client care, the nurse should first use the least restrictive intervention; therefore, the nurse should check the catheter tubing for kinks. The nurse must ensure constant flow of the bladder irrigant into the catheter and outward drainage from the catheter to prevent clotting, which could occlude the catheter lumen.

72.A nurse is preparing for the admission of client who has suspected active tuberculosis. Which of the following precautions should the nurse plan to implement to safely care for this client? A. Have staff and visitors wear gowns, masks, and gloves while in the client's room. B. Place the client in a private room with a special ventilation system. C. Assign the client to a room with other clients who require droplet precautions. D. Modify the protocol for donning and removing personal protective equipment before entering or leaving the client's room.

B. Place the client in a private room with a special ventilation system. Rationale: Clients who have active tuberculosis should be assigned to private rooms with negative-pressure airflow via HEPA filtration systems. In these rooms, the air is not returned to the inside ventilation system but is filtered and exhausted directly to the outside.

66.A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering? A. Furosemide B. Dexamethasone C. Heparin D. Atropine

C. Heparin Rationale:A pulmonary emboli is a condition in which the pulmonary blood flow is obstructed, resulting in hypoxia and possible death. Most often caused by a blood clot, treatment such as heparin, an anticoagulant, is used to prevent the enlargement of the existing clot or formation of new clots

62.A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction? A. Check the client's blood pressure. B. Auscultate heart tones. C. Perform a 12-lead ECG D. Determine if pain radiates to the left arm.

C. Perform a 12-lead ECG Rationale: The nurse should perform a 12-lead ECG when a client complains of chest pain to determine if the client is experiencing a myocardial infarction.

23.A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider? A. Stoma oozing red drainage B. Shiny, moist stoma C. Purplish-colored stoma D. Rosebud-like stoma orifice

C. Purplish-colored stoma Rationale:A stoma that is purplish in color indicates ischemia. The nurse should notify the provider immediately.

41.The nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. Which of the following pulses should the nurse palpate? A. Brachial pulse in the left arm B. Brachial pulse in the right arm C. Radial pulse in the left arm D. Radial pulse in the right arm

C. Radial pulse in the left arm Rationale:Palpating the client's pulse distal to the insertion site is essential for evaluating possible thrombophlebitis and vessel occlusion. The left radial pulse should be strong and essentially equal to the right radial pulse.

29.A nurse is assessing a client who has peritonitis. Which of the following findings should the nurse expect? A. Hyperactive bowel sounds B. Increased urinary output C. Rigid abdomen D. Frequent bowel movements

C. Rigid abdomen Rationale:A rigid, boardlike abdomen is a manifestation of peritonitis.

58.A nurse is preparing to administer warfarin to a client. Which of the following information should the nurse recognize prior to administering the medication? A. Warfarin is compatible with heparin. B. The client's aPTT should be monitored. C. The client should be observed for manifestations of hemorrhage. D. Warfarin can be administered along with NSAIDS.

C. The client should be observed for manifestations of hemorrhage. Rationale: The nurse should observe for manifestations of hemorrhage because it is an adverse side effect of warfarin, which has anticoagulant and anti-inflammatory actions.

2. You need to delegate some medicatipn administration to an LPN, what can they do? a. Hang new bag of TPN b. Administer subcutaneous Humalog c. Start blood transfusion d. Administer IV morphine

b

9. My patient is taking steroids, what is priority patient education? a. Monitor for weight loss b. Monitor blood sugar levels c. Do not take with orange or apple juice d. Chew pill thoroughly

b

21. the patient with heart failure starts digoxin, what is important to emphasize? a. Monitor weight daily b. Hold if HR is less than 70 c. Abdominal pain is a normal side effect d. Symptoms of visual disturbance

d

22. Nursing interventions for a patient with a DVT... a. Administer aspirin b. Ambulate BID c. Massage affected calf d. Put on bed rest

d

27. A patient with GERD says it is worse at night. What can they do to help? a. Drink some orange juice before bed b. Sleep without a pillow c. Take some calcium 30 min before bed d. Don't eat or drink 2 hours before bed

d

3. You give intermediate acting insulin, when would you be at highest alert for hypoglycemia? a. 30 minutes after administration b. 1-1.5 hours later c. 2-3 hours later d. 4-6 hours later

d

30. How do I position my patient with increase ICP? a. Left side fetal position b. Trendelenburg c. Prone with head elevated d. HOB semi fowlers with head midline

d

7. What lab results would signify hypothyroidism? a. Elevated AST/ALT b. Elevated ADH c. Decreased TSH d. Increased TSH

d

59.A nurse is reinforcing teaching with a client regarding reduction of risk factors for coronary artery disease. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.) A. "I must stop smoking." B. "I should limit my exercise." C. "I will stop consuming alcohol." D. "I need to monitor my weight." E. "I am limiting my intake of fast foods."

A. "I must stop smoking." D. "I need to monitor my weight." E. "I am limiting my intake of fast foods."

A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which of the following client statements indicates a need for further teaching? A. "I will need to wipe my perineal area from back to front after urination." B. "I will need to empty my bladder regularly and completely." C. "I will need to drink apple cider vinegar each day." D. "I need to drink 8 cups of liquid each day."

A. "I will need to wipe my perineal area from back to front after urination." Rationale: Wiping the perineal area from back to front increases the risk for urethral contamination and a resulting UTI.

40.The nurse asks a client who is about to have a cardiac catheterization about any allergies. The client states, "I always get a rash when I eat shellfish." Which of the following is the priority nursing action? A. Notify the provider of the client's allergy. B. Attach a wrist band indicating the client's allergy. C. Ask the client if any other foods cause such a reaction. D. Notify the dietary department of the client's allergy.

A. Notify the provider of the client's allergy. Rationale: The greatest risk to the client is an allergic reaction to the iodine-containing contrast agent the client will receive IV for the procedure, because shellfish also contains iodine. A steroid and/or antihistamine will be given to a client with an iodine allergy to prevent or minimize a reaction.

.A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority? A. Provide the client with antipyretic therapy. B. Administer antibiotics to the client. C. Increase the client's protein intake. D. Teach relaxation breathing to reduce the client's pain.

B. Administer antibiotics to the client. Rationale: The greatest risk to this client is bacteremia caused by the infection which can lead to septic shock; therefore, the priority intervention is antibiotic therapy. The client might require multiple antibiotics for an extended time.

46.A nurse is providing discharge instructions to a client following a cardiac catheterization. Which of the following information should the nurse include? A. "You can resume regular exercise as soon as tomorrow." B. "The dressing should be changed within 12 hours of the procedure." C. "You will notice a small hematoma at the incision site." D. "Pain medication will not be necessary."

C. "You will notice a small hematoma at the incision site." Rationale:Bruising and a small hematoma at the incision site are expected.

24.A nurse is assessing a client who has a colostomy. Which of the following findings should the nurse report to the provider? A. The stool is yellow-green. B. The ostomy is draining frequently. C. The stoma is pale in color. D. The skin around the stoma is red.

C. The stoma is pale in color. Rationale: The stoma should be pinkish to cherry red in color

20. A patient is starting a new bp med, what patient teaching is important? a. Stand up slowly monitor for dizziness b. Since it is a new med, there is no need to check bp or hr c. Weigh daily at night d. Treat colds with OTC medications

a

10. Adrenal glands have been removed, what medicine do I expect my patient to take? a. Calcitonin b. Potassium c. Calcium d. steroids

d

13. What is some patient teaching for someone with COPD a. When smoking turn oxygen down b. Only make short term goals c. Thick yellow sputum is normal d. Avoid hot/cold temperatures

d

67.A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first? A. Give morphine IV. B. Administer oxygen therapy. C. Start an IV infusion of lactated Ringer's. D. Initiate cardiac monitoring.

B. Administer oxygen therapy. Rationale:

.A nurse is teaching a client who is starting to take alendronate effervescent tablets to treat osteoporosis. Which of the following information should the nurse include? A. "Sit upright or stand for at least 30 minutes after taking this medication." B. "Take this medication with food." C. "Take this medication with orange juice." D. "Chew or suck on the tablet."

A. "Sit upright or stand for at least 30 minutes after taking this medication." Rationale: The nurse should instruct the client to sit or stand for 30 minutes after administration of this medication to reduce prolonged contact of the medication with the esophageal mucosa that can cause esophagitis.

14.A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility? A. A reddened area over the sacrum B. Stiffness in the lower extremities C. Difficulty moving the upper extremities D. Difficulty hearing some types of sounds

A. A reddened area over the sacrum Rationale:A reddened area over bony prominence is a stage 1 pressure ulcer, a complication of immobility. If the nurse recognizes it at this stage and implements measures to avoid additional pressure, it might not progress to the next stage.

43.A nurse is caring for a client who just had a cardiac catheterization. Which of the following nursing interventions should the nurse include in the client's plan of care? (Select all that apply.) A. Check peripheral pulses in the affected extremity. B. Place the client in high-Fowler's position. C. Measure the client's vital signs every 4 hr. D. Keep the client's hip and leg extended. E. Have the client remain in bed up to 6 hr

A. Check peripheral pulses in the affected extremity. D. Keep the client's hip and leg extended. E. Have the client remain in bed up to 6 hr.

20.A nurse is caring for a client following surgical treatment for a supratentorial brain tumor. Which of the following interventions should the nurse take? A. Elevate the head of the bed to 30&deg. B. Notify the provider for drainage greater than 80 mL/8hr. C. Place the client in a flat, lateral position. D. Provide passive range-of-motion exercises to the neck.

A. Elevate the head of the bed to 30&deg. Rationale: The client who has surgery to treat a supratentorial brain tumor is at risk for increased intracranial pressure (ICP). Elevation of the head of the bed to 30&deg assists in promoting venous and CNS fluid drainage from the head to prevent increased ICP.

13.A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program? A. Establish the ability to communicate effectively. B. Compensate for loss of depth perception. C. Learn to control impulsive behavior. D. Improve left-side motor function.

A. Establish the ability to communicate effectively. Rationale:A CVA is an interruption of the blood supply to any part of the brain, resulting in damaged brain tissue. The left hemisphere is usually dominant for language. Because this client had a left-side CVA, the nurse should anticipate the client will have some degree of aphasia and will require speech therapy to establish communication.

18.A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? (Select all that apply.) A. Loosen restrictive clothing. B. Insert a bite stick into the client's mouth. C. Place the client into a supine position. D. Place a pillow under the client's head. E. Apply restraints.

A. Loosen restrictive clothing. D. Place a pillow under the client's head

74.A nurse is teaching a client who has tuberculosis and is to start combination drug therapy. Which of the following medications should the nurse plan to administer? (Select all that apply.) A. Rifampin B. Isoniazid C. Acyclovir D. Pyrazinamide E. Montelukast

A. Rifampin B. Isoniazid D. Pyrazinamide

71.A nurse is caring for a client who is hospitalized with active pulmonary tuberculosis and is started on ethambutol therapy. The nurse should understand that which of the following should be monitored? A. Visual acuity B. Skin color C. Urine output D. Cardiac rhythm

A. Visual acuity Rationale:A significant adverse effect of ethambutol is optic neuritis, vision loss, and loss of color discrimination, especially red and green. Baseline vision testing should be performed before use, and visual acuity monitored at regular intervals.

27.A nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate? A. "Don't worry; most clients dislike the prep more than the procedure itself." B. "Before the examination, your provider will give you a sedative that will make you sleepy." C. "I know you're anxious, but this procedure is recommended for people your age." D. "After you have signed the consent form, we can talk more about this."

B. "Before the examination, your provider will give you a sedative that will make you sleepy." Rationale: This therapeutic response appropriately addresses the client's concerns. The client is seeking information and this response provides the client with accurate information. It can also lead to further discussion about the procedure.

38.A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection? A. Replace the catheter every 3 days. B. Check the catheter tubing for kinks or twisting. C. Irrigate the catheter once each shift. D. Clean the perineal area with an antiseptic solution daily

B. Check the catheter tubing for kinks or twisting. Rationale: The nurse should check the catheter for twisting or kinks in the tubing. These obstructions can affect the flow of urine causing pooling in the tubing that could backflow into the bladder.

30.A nurse is providing teaching for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The client asks about foods he should avoid eating. Which of the following foods should the nurse tell him to avoid A. Nonfat milk B. Chocolate C. Apples D. Oatmeal

B. Chocolate Rationale: The client should avoid foods that reduce pressure on the lower esophageal sphincter. These include fatty and fried foods, chocolate, caffeine, alcohol, and carbonated drinks.

53.A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect? A. Decreased brain natriuretic peptide (BNP). B. Elevated central venous pressure (CVP). C. Increased pulmonary artery wedge pressure (PAWP). D. Decreased specific gravity

B. Elevated central venous pressure (CVP).

.A nurse is caring for a client who has multiple long bone fractures caused by a motor-vehicle crash that happened 24 hr ago. The client tells the nurse he is short of breath and experiencing chest pain. The nurse should assess the client further for which of the following potential complications? A. Hypovolemic shock B. Fat embolism syndrome C. Compartment syndrome D. Venous thromboembolism

B. Fat embolism syndrome Rationale:A client who has multiple long bone fractures is at high risk for developing a fat embolism syndrome. The nurse should assess the client for additional manifestations—such as an altered mental status, tachypnea, and tachycardia—and report the findings to the provider.

52.A home health nurse is making a home visit to a client who takes a daily diuretic for heart failure. Which of the following manifestations should the nurse identify as indicating the client is hypokalemic? A. Pitting edema B. Fatigue C. Dyspnea D. Oliguria

B. Fatigue Rationale: The nurse should expect to find the client with fatigue due to muscle weakness with hypokalemia.

44.A nurse is collecting a medication history from a client who is scheduled to have a cardiac catheterization. Which of the following medications taken by the client interacts with contrast material and places the client at risk for acute kidney injury? A. Atorvastatin B. Metformin C. Nitroglycerin D. Carvedilol

B. Metformin Rationale: Metformin interacts with contrast dye and can cause acute kidney damage.

9.A nurse is planning care for a newly admitted client who has skeletal traction for a fractured femur. Which of the following interventions should the nurse include in the plan? A. Instruct the client to flex and extend the ankle twice daily. B. Monitor the client's pedal pulses every hour. C. Remove the weights every four hours. D. Evaluate pressure points daily.

B. Monitor the client's pedal pulses every hour. Rationale: The nurse should assess the neurovascular status of the client's affected extremity including assessing pulses, color, and capillary refill hourly for the first 24 hours following the placement of skeletal traction to prevent complications such as compartment syndrome or circulatory compromise.

47.A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take? A. Suggest that the client use a salt substitute. B. Obtain a 12-lead ECG. C. Advise the client to add citrus juices and bananas to her diet. D. Obtain a blood sample for a serum sodium level.

B. Obtain a 12-lead ECG. Rationale: This client's potassium level is above the expected reference range of 3.5-5.0 mEq/L and is at risk for dysrhythmias as well as cardiac arrest. Therefore, the nurse should obtain a 12-lead ECG to monitor for cardiac changes.

45.A nurse is planning care for a client following a cardiac catheterization accessed through his femoral artery. Which of the following actions should the nurse plan to take? A. Instruct the client to perform range-of-motion exercises to his lower extremities. B. Perform neurovascular checks with vital signs. C. Ambulate the client 1 hr following the procedure. D. Restrict the client's fluid intake.

B. Perform neurovascular checks with vital signs. Rationale: The nurse should assess color, temperature, and pulse in the affected extremity and monitor the client for neurovascular changes that can indicate a stroke, such as slurred speech and visual disturbances.

17.A nurse enters a client's room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take? A. Insert a padded tongue blade into the client's mouth. B. Place a pillow under the client's head. C. Gently restrain the client's extremities. D. Apply a face mask for oxygen administration.

B. Place a pillow under the client's head. Rationale: The nurse should place a small pillow or other soft padding under the client's head to protect the client from injury during the seizure, and turn his head to the side

16.A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take? A. Insert a tongue blade in the client's mouth. B. Place the client on his side. C. Hold the client's arms and legs from moving. D. Place the client back in bed.

B. Place the client on his side. Rationale: The nurse should place the client on his side. This position drops the tongue to the side of the client's mouth and prevents the client's airway from being obstructed.

48.A nurse is reviewing the serum laboratory findings for a client who has hypertension and is prescribed hydrochlorothiazide. Which of the following findings should the nurse report to the provider? A. Sodium 136 mEq/L B. Potassium 2.3 mEq/L C. Chloride 99 mEq/L D. Calcium 10 mg/dL

B. Potassium 2.3 mEq/L Rationale:A serum potassium below 3 mEq/L is a critical laboratory value. The nurse should report this finding to the provider immediately and monitor the client for dysrhythmias.

7.A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device if which of the following occurs? A. The client complains of pain. B. The client develops a life-threatening situation. C. The client needs to have an x-ray of the femur performed. D. The client has to be repositioned in the bed.

B. The client develops a life-threatening situation. Rationale: Traction weights, which are to hang freely at all times, are never to be removed without a specific provider prescription unless there is a life-threatening situation

28.A nurse is assessing a client who received IV conscious sedation for a colonoscopy. Which of the following findings indicated that the client is ready for discharge? A. The client is restless. B. The client is cooperative and oriented. C. The client shows a brisk response to stimulus. D. The client shows a sluggish response to stimulus.

B. The client is cooperative and oriented. Rationale:A client who is cooperative, oriented, and calm will have a Ramsay Sedation score of 2, which indicates the client has recovered adequately to go home with a responsible adult.

8.A nurse is assessing a client who is in skeletal traction. The nurse should correct which of the following findings? A. The ropes are in the center of the wheel grooves. B. The weights rest against the foot of the bed. C. The weights are equal on each side. D. The ropes are securely attached to the pins.

B. The weights rest against the foot of the bed. Rationale: Weights that rest against the foot of the bed or on the floor do not apply the amount of traction essential for maintaining alignment and immobilizing the bone.

32.A nurse is providing teaching for a client who has gastroesophageal reflux disease (GERD) about ways to manage his condition. Which of the following instructions should the nurse include? A. "Sleep on your left side." B. "Drink milk to soothe your stomach." C. "Eat four small meals each day." D. "Wait to go to bed for 1 hr after eating."

C. "Eat four small meals each day." Rationale: The client should avoid eating large meals because of the pressure it places on the stomach. Instead, he should eat four to six small meals per day.

.A nurse is providing teaching for a client who has experienced an acute episode of gastritis. Which of the following instructions should the nurse include in the teaching? A. Limit drinking milk. B. Take NSAIDs for pain. C. Avoid drinking alcohol. D. Limit strenuous exercise.

C. Avoid drinking alcohol. Rationale: The nurse should teach the client to avoid drinking alcohol because it increases manifestations of gastritis.

51.A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse the client is developing this condition? A. Anorexia B. Weight gain C. Breathlessness D. Distended abdomen

C. Breathlessness Rationale: Manifestations of left-sided heart failure include crackles or wheezes and breathlessness due to pulmonary congestion.

15.A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include? A. Encourage brief exercise before meals to promote appetite. B. Place food in the affected side of the mouth. C. Encourage the client to take small bites. D. Place the client with the head reclined back to facilitate swallowing.

C. Encourage the client to take small bites. Rationale: The family members should encourage the client to take small bites and chew food thoroughly in order to prevent choking.

65.A nurse is providing discharge instructions to a client who developed deep-vein thrombosis (DVT) postoperatively and is prescribed anticoagulant therapy. Which of the following instructions should the nurse include? A. Applying cool compresses to her legs B. Wearing loose, non-constricting stockings C. Flexing her knees and feet frequently D. Taking an NSAID tablet daily

C. Flexing her knees and feet frequently Rationale:Leg, ankle, and foot exercises can help improve circulation and prevent venous stasis while the client is resting.

5.A nurse is assessing a client who has a puncture wound on his foot. Which of the following findings is a manifestation of acute osteomyelitis? A. Numbness of toes on the affected foot B. Hypothermia C. Localized erythema D. Bradycardia

C. Localized erythema Rationale:Swelling and localized erythema are manifestations of acute osteomyelitis.

50.A nurse is reviewing blood pressure classifications with a group of nurses at an in-service meeting. Which of the following should the nurse include as a risk factor for the development of hypertension? A. High-density lipoprotein (HDL) level of 70 mg/dL B. A diet high in potassium C. Obstructive sleep apnea (OSA) D. Taking benazepril

C. Obstructive sleep apnea (OSA) Rationale: The nurse should include OSA as a risk factor in the development of hypertension. OSA is a condition in which the client's airway becomes blocked by the relaxation of the tongue and muscles of the oropharynx, effectively obstructing the airway. The obstructed airway results in surges in the both the systolic and diastolic pressure during sleep and, in some clients, through the waking hours even when breathing is normal.

.A nurse is teaching a client about medications that prevent osteoporosis. The nurse should instruct the client that which of the following medications is prescribed to prevent osteoporosis? A. Levothyroxine B. Calcitonin C. Raloxifene D. Allopurinol

C. Raloxifene Rationale: Raloxifene is prescribed for the prevention and treatment of osteoporosis in postmenopausal women.

61.A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the troponin levels report, the client asks what this blood test will show. Which of the following explanations should the nurse provide the client? A. Troponin is an enzyme that indicates damage to brain, heart, and skeletal muscle tissues. B. Troponin is a lipid whose levels reflect the risk for coronary artery disease. C. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart. D. Troponin is a protein that helps transport oxygen throughout the body.

C. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart. Rationale: Troponin is a myocardial muscle protein that releases into the bloodstream when there is injury to the myocardial muscle. Troponin levels are specific point-of-care testing for clients who are having a myocardial infarction.

31.A nurse is teaching a client about strategies to manage gastroesophageal reflux disease (GERD). Which of the following statements should the nurse include? A. "Elevate the head of your bed by 18 inches." B. "Avoid snacking between meals." C. "Limit foods that are high in fiber." D. "Lie on your right side when sleeping."

D. "Lie on your right side when sleeping." Rationale: The nurse should instruct the client to lie on the right side when sleeping to prevent nighttime reflux.

25.A nurse is providing teaching to a client who has a new colostomy. Which of the following information should the nurse include in the teaching? A. "You can expect fecal output within 24 hours." B. "You will need to increase your dietary intake of raw vegetables." C. "You can expect the stoma to be purplish in color for the first week." D. "You may experience a small amount of bleeding around the stoma."

D. "You may experience a small amount of bleeding around the stoma." Rationale:A small amount of bleeding around the stoma and its stem can occur. However, the client should report an increase in bleeding to the surgeon.

68.A nurse in the emergency department is assessing an older adult client who has community- acquired pneumonia. Which of the following findings should the nurse expect? A. Unequal pupils B. Hypertension C. Tympany upon chest percussion D. Confusion

D. Confusion Rationale: Confusion due to hypoxemia is an expected finding for an older-adult who has pneumonia.

6.A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites? A. Serosanguineous drainage B. Mild erythema C. Warmth D. Fever

D. Fever Rationale: Manifestations of inflammation and infection at the pin sites include fever, purulent drainage, odor, loose pins, and tenting of the skin around the pin sites.

63.A nurse in an emergency department is planning care for a client who is having an acute myocardial infarction (MI). The nurse should plan to administer which of the following medications after the initial acute phase to manage the client's pain and anxiety? A. Nitroglycerin B. Aspirin C. Oxygen D. Morphine

D. Morphine Rationale: Morphine is the medication of choice for managing the pain and anxiety of an acute MI. By reducing preload and afterload, it decreases the work of the heart.

19.A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first? A. Check the client for a fecal impaction. B. Examine the client for areas of skin breakdown. C. Check the client's bladder for distention. D. Place the client in a sitting position.

D. Place the client in a sitting position. Rationale: The nurse should use the least invasive intervention first. Therefore, the nurse should place the client in a sitting position to decrease the manifestation of hypertensio

10.A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)? A. Tachycardia B. Amnesia C. Hypotension D. Restlessness

D. Restlessness Rationale:Increased intracranial pressure is a condition in which the pressure of the cerebrospinal fluid or brain matter within the skull exceeds the upper limits for normal. Signs of increasing ICP include restlessness, irritability and confusion along with a change in level of consciousness, or a change in speech pattern.

12.A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take? A. Instruct the client to cough and deep breathe. B. Place the client in a supine position. C. Place a warming blanket on the client. D. Use log rolling to reposition the client.

D. Use log rolling to reposition the client. Rationale: Treatment of increased ICP focuses on decreasing the pressure. An important intervention includes positioning the client in a neutral position and avoiding flexion of the neck and hips. In order to avoid hip flexion, the client should be log rolled when repositioned

25. Which medication is typical med for a patient with ESRD? a. Sevelamer b. Neulasta c. Sulfasalazine d. Potassium

a

4. What insulin can I give IV? a. Regular b. Detemir c. Lispro d. byetta

a

8. My patient has SIADH what is NOT priority assessment? a. Blood glucose level b. Intake and output c. Neurological status d. Serum phosphorus and cortisol

a

12. How do you prevent barotrauma? a. Suctions Q1 hr b. Monitor cuff pressure c. Have the patient TCDB

b

15. My patient with a pneumothorax needs an intervention, what supplies do I prepare? a. Thoracentesis needle and US b. Chest tube c. Central line d. paracentesis

b

19. which is NOT a priority for someone with TB? a. Notify the health department and place in isolation b. Monitor BP and pulse c. Monitor liver enzymes d/t medications d. Medication education and compliance

b

23. Your patient has had a stent placed via L. femoral artery. What assessment data is concerning? a. Right leg is pale and cold b. Absence of pulse in the left foot

b

28. Which is NOT an intervention to prevent UTIs? a. Wear cottone underwear b. Douche 2X a month c. Avoid caffeine d. Urinate after sex

b

31. What is a nursing intervention to prevent increased ICP? a. Limit fluid intake b. Provide stool softener c. Instruct pt to sneeze 2x an hour d. Administer o2 via NRB

b

5. Which of the following is NOT a treatment for hypoglycemia a. Amp of D50 b. Glucagon c. Sodium bicarbonate d. D10NS

c

6. Foot care rules, which statement signifies your patient understand teaching? a. I can wear my crocs without socks b. I can go barefoot but only in the spring and fall c. I don't put lotion between my toes d. I can go and get pedicures every other week

c

14. Your patient presents with deviated trachea and SOB, what do you guess is wrong? a. Jugular vein distention b. Pleural effusion c. Atelectasis d. Tension pneumothorax

d

16. your patient with a femur fracture suddenly is panicked, sweaty and SOB, what is your priority? a. EKG b. 1 large bore IVs c. Start antibiotics STAT d. Start a NC at 2-4 L of O2

d