Test A 2019

A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After ensuring a patent airway, which of the following nursing interventions is the priority?

Applying oxygen via face mask

A nurse is providing teaching to a client who is perimenopausal and has a prescription for hormone replacement therapy. For which of the following adverse effects should the nurse instruct the client to notify the provider?

Calf pain Numbness in the arms Intense headache

A nurse is performing a dressing change for a client who is recovering from a hemicolectomy. When removing the dressing, the nurse notes that a large part of the bowel is protruding through the abdomen. Which of the following actions should the nurse take first?

Call for help.

A nurse is caring for a client who is receiving plasmapheresis through a venous access site. Which of the following action should the nurse take?

Check electrolyte levels before and after therapy.

A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the following actions should the nurse take first?

Check for the type and number of units of blood to administer.

A nurse is providing teaching to a female client who has a history of urinary tract infections (UTIs). Which of the following information should the nurse include in the teaching?

Clean the perineum form front to back.

A nurse is planning care for a client who is postoperative following a laparotomy and has a closed-suction drain. Which of the following actions should the nurse take to manage the drain?

Compress the drain reservoir after emptying.

A nurse is caring for a client who has hypothyroidism. Which of the following manifestations should the nurse expect?

Constipation

A nurse is checking the ECG rhythm strip for a client who has a temporary pacemaker. The nurse notes a spike (pacemaker artifact) followed by a QRS complex. Which of the following actions should the nurse take?

Document that depolarization has occurred.

A nurse is providing teaching to a client who has a new prescription for psyllium. Which of the following information should the nurse include in the the teaching?

Drink 240 mL of water after administration.

A nurse is assessing a client who has had a suspected cerebrovascular accident. The nurse should place the priority on which of the following findings?

Dysphagia

A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following interventions should the nurse include in the plan?

Encourage the client to take deep breaths after the procedure.

A nurse is reviewing the medical record of a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect.

Facial butterfly rash

A nurse is teaching an older adult client about osteoporosis prevention. The nurse should instruct the client that which of the following medications can increase her risk for developing osteoporosis?

Fludocortisone

A nurse is caring for a client who has DKA. Which of the following findings should indicate to the nurse that the client's condition is improving?

Glucose 272 mg/dL

A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The client's initial vital signs were heart rate 80/min, blood pressure 130/70 mm Hg, respiratory rate 16/min, and temperature 36C. Which of the following vital sign changes should alert the nurse that the client might be hemorrhaging?

Heart rate 110/min

A nurse is providing teaching to a client who has IBS. Which of the following instructions should the nurse include in the teaching?

Increase fiber intake to at least 30 g per day.

A nurse is performing a cardiac assessment for a client who had a myocardial infarction 2 days ago. Which of the following actions should the nurse take first after hearing the following sound?

Listen with the client on his left side.

A nurse in a provider's office is assessing a client who has migraine headaches and is taking feverfew to prevent her headaches. The nurse should identify that which of the following client medications interacts with feverfew?

Naproxen

A nurse is caring for client who is experiencing supraventricular tachycardia. Upon assessing the client, the nurse observes the following findings: heart rate 200/min, blood pressure 78/40 mm Hg, and respiratory rate 30/min. Which of the following actions should then nurse take?

Perform synchronized cardioversion.

A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?

Place a pillow between the client's legs.

A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse take?

Place a pressure bag around the flush solution.

A nurse is reviewing the medication history of client who is to undergo allergy testing. The nurse should instruct the client to discontinue which of the following medications before the testing?

Prednisone

A nurse in an emergency department is planning care for a client who has a flail chest on the right side following a motor-vehicle crash. Which of the following actions should the nurse plan to take?

Prepare the client for positive pressure ventilation.

A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the following results should the nurse expect?

PsCO2 56

A nurse is assessing a client following the completion of hemodialysis. Which of the following findings is the nurse's priority to report to the provider?

Restlessness

A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube. The nurse should recognize that which of the following complications is associated with long-term mechanical ventilation?

Stress ulcers

A nurse in a provider's office is providing teaching to a client who has a urinary tract infection and a new prescription for ciprofloxacin. Which of the following instructions should the nurse include?

"Avoid taking magnesium-containing antacids with this medication."

A nurse is caring for a client who had a nephrostomy tube inserted 12 hr ago. Which of the following findings should the nurse report to the provider?

The client reports back pain.

A nurse is teaching a client who has end-stage kidney disease about organ donation. Which of the following information should the nurse include in the teaching?

The client who receives a kidney form a live donor has a lower rate of transplant rejection.

A nurse is assessing a client while suctioning the client's tracheostomy tube. Which of the following findings should indicate to the nurse the client is experiencing hypoxia?

The client's heart rate increases.

A nurse is assessing a client who has Graves' disease. Which of the following images should indicate to the nurse that the client has exopthalmos?

The last one

A nurse is preparing to assist with the insertion of a nontunneled percutaneous central venous catheter into a client's subclavian vein. The nurse should plan to place the client in which of the following positions?

Trendelenburg

A nurse is providing discharge teaching to a client who has heart failure and a new prescription for a potassium-sparing diuretic. Which of the following information should the nurse include in the teaching?

Try to walk at least three times per week for exercise.

A nurse is caring for a client who is having a seizure. Which of the following interventions is the nurse's priority?

Turn the client to the side.

A nurse is obtaining a medication history from a client who is scheduled to undergo cataract surgery. The nurse should recognize that which of the following client medications is a contraindication for the surgery and notify the provider?

Warfarin

A nurse on a med-surg unit is receiving change-of-shift report on four clients. Which of the following clients should the nurse identify as having the greatest risk for developing an infection?

A client who has COPD and is receiving steroid therapy

A nurse is caring for a client who is receiving TPN. A new bag is not available when the current infusion is nearly completes. Which of the following action should the nurse take?

Administer dextrose 10% in water until the new bag arrives.

A nurse is providing discharge instructions to a client who has laryngeal cancer and is receiving radiation treatment. Which of the following statements by the client indicates an understanding of the teaching?

"I will avoid direct exposure to the sun."

A charge nurse is instructing a newly licensed nurse about caring for a client who has MRSA. Which of the following statements by the new nurse indicates an understanding of the teaching?

"I will leave assessment equipment in the room to use on this client."

A nurse is providing teaching to an older adult client who as cancer and a new prescription for an opioid analgesic for pain management. Which of the following information should the nurse include in the teaching?

"You should increase your fiber intake to prevent constipation."

A nurse is caring for client who is on bed rest and has a new prescription for enoxaparin subcutaneous. Which of the following action should the nurse take?

Administer the medication at the same time each day.

A nurse is caring for a client who has a new prescription for TPN. The client is to receive 2,000 kcal per day. The TPN solution has 500 kcal/L. The IV pump should be set at how many mL/hr?

167 mL/hr

A nurse is assessing a client who has hypokalemia. Which of the following manifestations should the nurse expect?

Decreased peristalsis

A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect?

Hair loss on the lower legs

A nurse is providing teaching to a client who has AIDS. Which of the following statements by the client indicates an understanding to the teaching?

"I will take my temperature once a day."

A nurse providing dietary teaching to a client who is postoperative following a thryoidectomy with removal of the parathyroid glands. The nurse should instruct the client to include which of the following foods that has the greatest amount of calcium in her diet?

12 almonds

A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish an ureterostomy. Which of the following statements should the nurse include in the teaching?

"Cut the opening of the skin barrier 1/8-inch wider than the stoma."

A nurse is providing teaching to an older adult female client who has stress incontinence and a BMI of 32. Which of the following statement by the client indicates an understanding of the teaching.

"I am dieting to lose weight."

A nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. Which of the following statements by the client indicates an understanding of the teaching?

"I am taking this medication to increase my energy level."

A nurse is providing instructions to a client who has type 2 DM and a new prescription for metformin. Which of the following statements by the client indicates an understanding of the teaching?

"I should take this medication with a meal."

A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron supplement. Which of the following statements by the client indicates an understanding of the teaching?

"I will eat more high-fiber foods."

A nurse is providing teaching to a client who has type 2 diabetes mellitus and a new prescription for insulin lispro. Which of the following statements by the client indicates an understanding of the teaching?

"I will need to take the lispro in addition to my other prescribed insulin."

A nurse is providing discharge to a client who is to self-administer heparin subcutaneously. Which of the following responses by the client indicates an understanding of the teaching?

"I will use an electric razor to shave."

A nurse is teaching a client who has venous insufficiency about self-care. Which of the following statements should the nurse identify as an indication that the client understands the teaching?"

"I will wear clean graduated compression stockings every day."

A nurse is teaching a client who has atrial fibrillation about the purpose of wearing a Holter monitor. Which of the following information should the nurse include in the teaching?

"This device can detect when you have an irregular heart rate."

A nurse in a provider's office is caring for a client who requests sildenafil to treat erectile dysfunction. Which of the following statements should the nurse make?

"You will not be able to use sildenafil if you are taking nitroglycerin."

A nurse is caring for a client who is exhibiting manifestations of a febrile reaction while receiving a blood transfusion. Which of the following medications should the nurse administer?

Acetaminophen

A nurse is caring for client who has a new diagnosis of hyperthyroidism. Which of the following is the priority assessment finding that the nurse should report to the provider?

Blood pressure 170/80

A nurse is assessing a male client for an inguinal hernia. Which of following areas should the nurse palpate to verify that the client has an inguinal hernia?

C

A nurse in an emergency department is assessing an older adult client who has a fractured wrist following a fall. During the assessment, the client states, "Last week I crashed my car because my vision suddenly became blurry." Which of the following actions is the nurse's priority?

Check the client's neurologic status.

A nurse is providing preoperative teaching for a client who his scheduled for an open cholecystectomy. Which of the following actions should the nurse take?

Demonstrate ways to deep breathe and cough.

A nurse in an emergency department is admitting a client who reports dyspnea and shortness of breath. Which of the following actions is the priority for the nurse to perform prior to administering oxygen?

Determine if the client has a history of COPD.

A nurse an acute care facility is caring for a client who is at risk for seizures. Which of the following precautions should the nurse implement?

Ensure that the client has a patent IV.

A nurse is preparing the present a program about prevention of atherosclerosis at a health fair. Which of the following recommendations should the nurse plan to include?

Follow a smoking cessation program. Maintain an appropriate weight. Eat a low-fat diet.

A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following juices should the nurse instruct the client to avoid?

Grapefruit

A nurse is an emergency department is caring for a client who report vomiting and diarrhea for the past 3 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit?

Heart rate 110/min

A nurse is caring for a client who presents to a clinic for a 1-week follow-up visit after hospitalization for heart failure. Based on the information in the client's chart, which of the following findings should the nurse report to the provider?

Heart rate 55/min

A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following laboratory values should the nurse report to the provider?

Hgb 8 g/dL

A nurse is providing teaching to a client who has asthma about the use of a metered-dose inhaler. The nurse should identify that which of the following client actions indicates an understanding of the teaching?

Holding breath for 10 seconds after inhaling

A nurse is caring for a client who has chronic glomerulonephritis with oliguria. Which of the following findings should the nurse identify as a manifestation of chronic glomerulonephritis?

Hyperkalemia

A nurse in an emergency department is caring for a client who has full-thickness burns over 20% of his total body surface area. After ensuring a patent airway and administering oxygen, which of the following items should the nurse prepare to administer first?

IV fluids

A nurse is caring for a client who has a positive culture for C-diff. Which of the following action should the nurse take?

Implement contact precautions for the client.

A nurse is caring for a client who recently had a stroke of the right hemisphere. Which of the following manifestations should the nurse expect?

Impulsive behavior

A nurse is reviewing the lab results of a client who has a new diagnosis of acute leukemia. Which of the following findings should the nurse identify as an expected finding?

Increased WBC count

A nurse is planning care for a client who his having a modified radical mastectomy of the right breast. Which of the following interventions should the nurse include in the plan of care?

Instruct the client that the drain is removed when there is 25 mL of output or less over a 24-hr period.

A nurse is caring for a client who has a prescription for enalapril. The nurse should identify which of the following findings as an adverse effect of the medication?

Orthostatic hyptension

A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of the following findings should the nurse identify as a manifestation of this condition?

Pain that increases with passive movement

A nurse is providing medication teaching to a group of clients who have seizure disorders. Which of the following information should the nurse include about phenytoin?

Phenytoin decreases the effectiveness of oral contraceptives.

A nurse is planning care for a client who is postoperative following a parathyroidectomy. Which of the following actions should the nurse identify as the priority?

Place a tracheostomy tray at the bedside.

A nurse is caring for a client who has bilateral pneumonia and an SaO2 of 85%. The client is dyspneic with a productive cough and is using accessory muscles to breathe. Which of the following actions should the nurse take first?

Place the client in high-fowlers position.

A nurse is caring for a client who has a leg cast and is returning demonstration on the proper use of crutches while climbing stairs. Identify the sequence the client should follow when demonstration crutch use.

Places body weight on the crutches. Advances the unaffected leg onto the stair. Shifts weight form the crutches to the unaffected leg. Brings the crutches and the affected leg up to the stair.

A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The client is unable to void on the bedpan. Which of the following actions should the nurse take first?

Scan the bladder with a portable ultrasound.

A nurse is providing follow-up care for a client who sustained a compound fracture 3 weeks ago. The nurse should recognize that an unexpected finding for which of the following laboratory values is a manifestation of osteomyelitis and should be reported to the provider?

Sedimentation rate

A nurse is reviewing the medical record of a client who has osteomyelitis and a prescription for gentamicin. Which of the following findings from the client's medical record should indicate to the nurse the need to withhold the medication and notify the provider?

Serum creatinine.

A nurse is providing discharge teaching to a client who has active TB. Which of the following information should the nurse include in the instructions.?

Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures.

A nurse is caring for a client following extubation of her endotracheal tube 10 min ago. Which of the following findings should the nurse report to the provider immediately?

Stridor

A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for omeprazole. The nurse should instruct the client that the medication provides relief by which of the following actions?

Suppressing gastric acid production

A nurse is planning discharge teaching for a client who has an external fixation device for a fracture of the lower extremity. Which of the following instructions should the nurse include in the plan of care?

Use crutches with rubber tips.

A nurse is reviewing the laboratory results of a client who has aplastic anemia. Which of the following findings indicates a potential complication?

WBC 2,000/mm3