EAQs

Which drug is an antihistamine that is considered to be nonsedating

Fexofenadine

Which is the most important nursing intervention for a client that presents with tachycardia, hypotension, anxiety, and restlessness after a burn injury

Fluid replacement

Which cranial nerve would a nurse suspect has been injured in a client is unable to clench the teeth after a motor vehicle collision

Trigeminal nerve

Which statement would the nurse expect a client with early left ventricular heart failure to make

'I have trouble breathing when I walk fast'

Which answer is the nurse's best reply to a client prescribed 'bathroom privileges only' who asks the nurse whether it is really necessary to stay in bed so much

'Rest helps your body direct energy to healing'

Which action would the nurse take for a client with hypertension who states, 'My tongue feels thick' after the initial dose of an angiotensin converting enzyme (ACE) inhibitor

Contact the health care provider immediately

Which information would the nurse include for a client with glaucoma who asks about future treatment and precautions

Continuation of therapy for life

Damage to which cranial nerve may lead to a decrease in the client's olfactory acuity

Cranial nerve I

Which vaccination is given to young children to provide protection against tetanus and diphtheria but not pertussis

DT

Which value is within the normal range of values for arterial pH

7.44

Which leukocyte is responsible for the allergic response

Basophils

Which vaccine provides protection from precancerous lesions and cancers of the vulva, cervix, and vagina in young girls and women

Gardasil

The nurse identifies that which lab is part of the complete blood count (CBC)

Hemoglobin(Hb)

Which finding would the nurse expect in a client with mitral insufficiency

High-pitched, systolic murmur

Which condition is described by a client reporting the inability to see objects in close range

Hyperopia

Which antibody is the first to be formed after exposure to an antigen

IgM

Which strategy to warm affected areas during a vasoconstrictive episode in a client with Raynaud disease would the nurse find concerning

Immersion in hot water

Which compensatory mechanism would the nurse expect to observe in a client with acute anemia

Increased heart rate

Which finding would indicate increasing intracranial pressure to the nurse monitoring a client with a severe head injury

Increased restlessness

Which action would the nurse take on finding a client unconscious and unresponsive

Initiate a code

Which alternative to water would the nurse suggest to a client recovering from a major burn injury

Protein drinks

Which statement describes the action of tetanus immune globulin prescribed for a client with a swollen and painful puncture site after stepping on a rusty nail

Provides antibodies

Which immediate action would the nurse take when a client in a hypertensive crisis develops nausea and vomiting

Raising and padding the client's rails

Which nursing action is confidential and protected from legal action

Reporting incidents of suspected child abuse to the appropriate authorities

Which loss relates to the definition of anosmia

Sense of smell

Which cells release lymphokines

T cells

Which task would the nurse delegate to an unlicensed health care worker

Vital signs on a client 4 hours after delivery

Which lobe of the cerebrum includes the client's Broca area, which is responsible for speech

frontal

A client's pupils are equal and reactive to light after a stroke. The nurse later assesses that the right pupil is reacting more slowly than the left and the systolic blood pressure is beginning to rise. Which complication would the nurse suspect is developing

increasing intracranial pressure

On which part of the client's skull would the nurse view Battle sign

mastoid

Which factor does the nurse determine is most relevant to the legal aspects of a do not resuscitate (DNR) order

policies of the agency establish the status of DNR orders

Which response would a nurse expect in a client with cerebellar dysfunction

uncoordinated movement

Which term would a nurse to document difficulty in communicating by writing observed in a client with Alzheimer disease

Dysgraphia

Which score in the Glasgow coma scale (GCS) is assigned when the client has no eye response after a head injury

1

Which is the maximum length of time the nurse can allow an older adult with a cerebrovascular accident to remain in one position

1 to 2 hours

Which response would the nurse give to a client who asks, "How long before ischemia produces irreversible damage to my heart"

20 minutes

Which client is most likely to report fatigue

A client with increased oxygen demand

Which blood type can be used by the client with type A-negative blood

A negative or O negative

Which circumstance would legally prevent a client scheduled for surgery from giving consent

Administration of a sedative type medication occurred recently

Which response would the nurse give to a client who asks, "What is the difference between angina and myocardial infarction(MI)

Angina occurs when myocardial oxygen demand exceeds supply, and MI is the death of cardiac muscle tissue from a prolonged lack of blood supply

Which client care activity would a nurse safely delegate to an unlicensed health care worker

Assisting a client who is recovering from an abdominal hysterectomy to the bathroom

Which condition may result from immunoglobulin IgE antibodies on mast cells reacting with antigens

Asthma, Hay fever

Which area would the nurse palpate to determine the status of a client's carotid pulse

At the anterior neck, lateral to the trachea

Which condition unrelated to cardiac disease is the major cause of right ventricular failure

Chronic obstructive pulmonary disease (COPD)

Which nursing action is appropriate when a client with a hemoglobin of 6g/dL is refusing blood because of religious reasons

Notify the primary health care provider of the client's refusal of blood products

Which condition seen in a client immediately after surgical repair of an abdominal aortic aneurysm would most concern the nurse

Decreased urine output

Which action would the nurse take when a client's left foot is cool to the touch, is pale, and has an absent pedal pulse

Notifying the surgeon

Which strategy may help a nurse accomplish therapeutic communication with an adolescent

Establishing a relationship over time

Which substance would the nurse expect to be deficient in a client with hemophilia A

Factor VIII

Which statement is true about active immunity

It develops as the body defends itself from the presence of an active infection

Which statement is true about immunocompetence

It is the malfunction of the system caused by disruption of homeostasis

Which would be the cause of dyspnea in a client with hypertension

Left heart failure

which statement is true regarding wound healing?

Leukocytes begin to engulf bacteria, fungi, and viruses

Where would the nurse place the pulse oximetry probe when assessing a client with Raynaud disease

On the earlobe

A client undergoes removal of a pituitary tumor through a transsphenoidal approach. Which action would the nurse implement postoperatively

Maintain the head of the bed at a 30-degree angle continuously

A client with diabetes mellitus reports vision changes. Which factor would the nurse determine is causing the client's symptoms

Neovascularization of the retina

Which condition would be suspected in a client's with rigidity, tremor, bradykinesia, and impaired postural reflexes

Parkinson disease

Which complication would the nurse anticipate in a client who recently underwent gastric bypass surgery

Pernicious anemia

Which condition is caused by a decrease in elasticity of the client's lens

Presbyopia

Why would a nurse tell a 71-year-old client with dyspnea, orthopnea, pulmonary crackles, wheezing, and frothy, pink sputum upon coughing to avoid strenuous activity

To prevent fatigue