QT 2

The nurse prepares the client for an IV pyelogram (IVP) scheduled in 2 hours. The nurse contacts the health care provider if the client makes which statement? A. "I take metformin for type 2 diabetes." B. "I completed the bowel prep last evening. C. "I ate a light meal last evening." D. "I had an IVP 3 years ago."

A. "I take metformin for type 2 diabetes."

The client has a nasogastric tube connected to intermittent low suction. At 07:00, the nurse documents 235 mL of greenish drainage in the suction container. At 15:00, there is 445 mL of greenish drainage in the suction container. Twice during the shift, the nurse irrigates the tube with 30 mL of normal saline. Which is the actual amount of drainage from the nasogastric tube for 07:00 to 15:00? A. 150 mL. B. 210 mL. C. 295 mL. D. 385 mL.

A. 150 mL.

The nurse cares for the client receiving haloperidol. The nurse anticipates which adverse effects? A. Blood dyscrasia and extrapyramidal symptoms. B. Hearing loss and unsteady gait. C. Nystagmus and vertical gaze palsy. D. Alteration in level of consciousness and increased confusion.

A. Blood dyscrasia and extrapyramidal symptoms.

The nurse plans care for the client diagnosed with paranoid schizophrenia. The nurse knows that questioning the client about the client's false ideas will elicit which response? A. Cause the client to defend the idea. B. Help the client clarify thoughts. C. Facilitate better communication. D. Lead to a breakdown of the defense.

A. Cause the client to defend the idea.

The nurse cares for a client admitted 2 days ago with a diagnosis of closed head injury. If the client develops diabetes insipidus, the nurse will observe which symptoms? Select all that apply. A. Glucosuria. B. Cracked lips. C. Weight gain of 5 lb. D. BP 160/100, pulse 56. E. Urinary output of 4 L/24 hours. F. Urine specific gravity of 1.004.

A. Glucosuria. E. Urinary output of 4 L/24 hours. F. Urine specific gravity of 1.004.

The client receives a blood transfusion and experiences a hemolytic reaction. The nurse anticipates which assessment findings for this client? (Select all that apply.) A. Hypotension. B. Low back pain. C. Wet breath sounds. D. Fever. E. Urticaria. F. Severe shortness of breath.

A. Hypotension. B. Low back pain. D. Fever

The nurse cares for the client diagnosed with a recurrent urinary tract infection. The health care provider prescribes ciprofloxacin. The nurse instructs the client to limit intake of which fluid? A. Milk. B. Cranberry juice. C. Water. D. Tea.

A. Milk.

The health care provider prescribes estrogen 0.625 mg daily for the 43-year-old woman. The nurse identifies which symptom as a common initial adverse effect of this medication? A. Nausea. B. Visual disturbances. C. Tinnitus. D. Ataxia.

A. Nausea.

The health care provider prescribes lithium carbonate 300 mg PO QID for the adult client. The nurse in the outpatient clinic instructs the client about the medication. The nurse encourages the client to maintain an adequate intake of which substance? A. Sodium. B. Protein. C. Potassium. D. Iron.

A. Sodium

The nurse prepares discharge teaching for the parents of the newborn. Which information does the nurse provide regarding the accuracy of a PKU (phenylketonuria) test? A. The initial specimen should be collected as close to discharge as possible but not later than 7 days. B. The infant can have water but should not have formula for 6 hours before the test. C. The test will need to be repeated at 6 weeks and at the 3-month check-up. D. Blood will be drawn at three 1-hour intervals; there is no specific preparation.

A. The initial specimen should be collected as close to discharge as possible but not later than 7 days.

The school nurse conducts a class on childcare at the local high school. During the class, one of the participants asks the nurse what age is best to start toilet training a child. Which is the best response by the nurse? A. 11 months of age. B. 14 months of age. C. 17 months of age. D. 20 months of age.

B. 14 months of age.

The adult client receives dexamethasone for chronic lymphocytic leukemia. It is most important for the nurse to report which finding to the health care provider? A. Prothrombin time (PT) 12 seconds and hemoglobin (Hgb) 15 g/dL (150 g/L). B. Blood urea nitrogen(BUN) 18 mg/dL (6.4 mmol/L) and creatinine 1.0 mg/dL (88 µmol/L). C. Serum potassium (K) 3.4 mEq/L (3.4 mmol/L) and serum calcium (Ca) 7.8 mg/dL (2 mmol/L) . D. Aspartate aminotransferase (AST) 18 U/L and alanine aminotransferase (ALT) 12 U/L.

B. Blood urea nitrogen(BUN) 18 mg/dL (6.4 mmol/L) and creatinine 1.0 mg/dL (88 µmol/L).

The nurse cares for a client during an acute manic episode. The nurse identifies which client behaviors as most characteristic of mania? Select all that apply. A. Paranoia. B. Grandiose delusions. C. Somatic difficulties. D. Difficulty concentrating. E. Agitation. F. Distorted perceptions.

B. Grandiose delusions. D. Difficulty concentrating. E. Agitation.

The client is diagnosed with pneumonia secondary to chronic pulmonary disease. Which nursing goal is most appropriate? A. Maintain and improve the quality of oxygenation. B. Improve the status of ventilation. C. Increase oxygenation of peripheral circulation. D. Correct the bicarbonate deficit.

B. Improve the status of ventilation.

The nurse plans care for the 20-year-old client. Which psychosocial stage does the nurse identify as the priority to consider? A. Identity versus identity diffusion. B. Intimacy versus isolation. C. Integrity versus despair and disgust. D. Industry versus inferiority.

B. Intimacy versus isolation.

The nurse recognizes which symptoms as characteristic of a panic attack? Select all that apply. A. Decreased blood pressure. B. Palpitations. C. Decreased perceptual field D. Bradycardia E. Diaphoresis F. Fear of going crazy

B. Palpitations. C. Decreased perceptual field E. Diaphoresis F. Fear of going crazy

The nurse observes the student nurse auscultate the right middle lobe (RML) lung of a client. The nurse knows the student nurse is auscultating correctly if the stethoscope is placed in which position? A. Posterior and anterior base of right side. B. Right anterior chest between the fourth and sixth intercostal spaces. C. Left of the sternum, midclavicular, at fifth intercostal space. D. Posterior chest wall, midaxillary, right side.

B. Right anterior chest between the fourth and sixth intercostal spaces.

The nurse cares for the client diagnosed with Ménière's syndrome. The nurse stands directly in front of the client when speaking. Which best describes the rationale for the nurse's position? A. This enables the client to read the nurse's lips. B. The client does not have to turn the head to see the nurse. C. The nurse will have the client's undivided attention. D. There is a decrease in client's peripheral visual field.

B. The client does not have to turn the head to see the nurse.

The client is diagnosed with Cushing syndrome. Which assessment finding does the nurse recognize as pertinent to this diagnosis? A. Low blood pressure and weight loss. B. Thin extremities with easy bruising. C. Decreased urinary output and decreased serum potassium. D.Tachycardia with reports of night sweats..

B. Thin extremities with easy bruising.

The nurse obtains a specimen from the client for sputum culture and sensitivity (C and S). Which instruction is best? A. After pursed lip breathing, cough into a container. B. Upon awakening, cough deeply and expectorate into a container. C. Save all sputum for three days in a covered container. D. After respiratory treatment, expectorate into a container.

B. Upon awakening, cough deeply and expectorate into a container.

The nurse cares for the client the first day postoperative after a transurethral prostatectomy (TURP). The client has a continuous bladder irrigation (CBI). The client's spouse asks why the client has the CBI. Which response by the nurse is best? A. "The CBI prevents urinary stasis and infection." B. "The CBI dilutes the urine to prevent infection." C. "The CBI enables urine to keep flowing." D. "The CBI delivers medication to the bladder."

C. "The CBI enables urine to keep flowing."

The client diagnosed with metastatic lung cancer is admitted to the hospital. The client's orders include do not resuscitate (DNR) and morphine 2 mg/h by continuous IV infusion. The client's BP is 86/50, respirations are 8, and the client is nonresponsive. Naloxone hydrochloride 0.4 mg IV is ordered stat. It is important for the nurse to consider which action? A. The BP and respirations will need to increase before a second dose of naloxone can be given. B. Naloxone should not be given to the client because of the DNR status. C. A dose of naloxone may need to be repeated in 2 to 3 minutes. D. Naloxone is effective in treating respiratory changes caused by opiates, barbiturates, and sedatives.

C. A dose of naloxone may need to be repeated in 2 to 3 minutes.

A client returns from surgery after a right mastectomy. An IV of 0.9% NS is infusing at 100 mL/hour into the lower portion of the left forearm. The IV infiltrates several hours later. The nurse supervises the student nurse preparing to insert a new peripheral IV catheter. The nurse intervenes in which situation? A. A site is selected with soft, elastic veins. B. A site is selected proximal to the site of infiltration on the left arm. C. A site is selected close to the wrist joint. D. The skin is held taut prior to insertion of the catheter.

C. A site is selected close to the wrist joint.

The client receives parenteral nutrition (PN) for several weeks. If the PN is abruptly discontinued, the nurse expects the client to exhibit which signs and symptoms? A. Tinnitus, vertigo, blurred vision. B. Fever, malaise, anorexia. C. Diaphoresis, confusion, tachycardia. D. Hyperpnea, flushed face, diarrhea.

C. Diaphoresis, confusion, tachycardia.

The client is admitted with a tentative diagnosis of late stage AIDS dementia complex. The nursing assessment is most likely to reveal which finding? A. Hyperactive deep tendon reflexes. B. Peripheral neuropathy affecting the hands. C. Disorientation to person, place, and time. D. Impaired concentration and memory loss.

C. Disorientation to person, place, and time.

The nurse cares for the client with a radium implant. During the removal of the implant, it is most important for the nurse to take which action? A. Clean the radium implant carefully with a disinfectant (alcohol or bleach) using long forceps. B. Handle the radium carefully using forceps and rubber latex gloves. C. Document the date and time of removal together with the total time of implant treatment. D. Double-bag the radium implant before the person from radiology removes it from the room.

C. Document the date and time of removal together with the total time of implant treatment.

The client at 16 weeks gestation has an amniocentesis. The client asks what will be learned from this procedure. The nurse responds that which condition can be detected? A. Tetralogy of Fallot B. Talipes equinovarus. C. Hemolytic disease of the newborn. D. Cleft lip and palate.

C. Hemolytic disease of the newborn

The client returns from surgery. There is a fine, reddened rash around the area where providone iodine prep was applied prior to surgery. The nursing notation in the client's record includes which observation? A. Time and circumstances under which the rash was noted. B.Explanation given to the client and family of the reason for the rash. C. Notation on an allergy list and notification of the health care provider. D.The need for application of corticosteroid cream to decrease inflammation.

C. Notation on an allergy list and notification of the health care provider.

A continent adult client undergoes admission to the hospital with a diagnosis of hepatitis A. Which precautions does the nurse include in the client's overall care during hospitalization? A. Contact precautions. B. Airborne precautions. C. Standard precautions. D. Droplet precautions.

C. Standard precautions.

The client has a history of hypertension and angle-closure glaucoma. Which medication order does the nurse question? A. Propranolol 80 mg PO QID. B. Verapamil 40 mg PO TID. C. Tetrahydrozoline 2 drops in each eye TID. D. Timolol 1 drop in each eye once daily.

C. Tetrahydrozoline 2 drops in each eye TID.

Respiratory syncytial virus requires which type of precautions?

Contact and standard precautions

The nurse cares for the client diagnosed with hypoparathyroidism. Which nursing action has the highest priority for this client? A. Develop a teaching plan. B. Plan measures to deal with cardiac dysrhythmias. C.Take measures to prevent a respiratory infection. D. Assess laboratory results.

D. Assess laboratory results.

The client is diagnosed with myasthenia gravis. It is most important for the nurse to consider which action? A. Prevent accidents from falls as a result of vertigo. B. Maintain fluid and electrolyte balance. C. Control situations that could increase intracranial pressure and cerebral edema. D. Assess muscle groups toward the end of the day.

D. Assess muscle groups toward the end of the day.

The client is newly diagnosed with Buerger's disease. The clinic nurse obtains a health history. The nurse expects the client's history to include which symptom? A. Heart palpitations. B. Dizziness when walking. C. Blurred vision. D. Digital sensitivity to cold.

D. Digital sensitivity to cold.

The nurse assesses the client immediately after an exploratory laparotomy. Which nursing observation indicates the complication of intestinal obstruction? A. Protruding soft abdomen with frequent diarrhea. B. Distended abdomen with ascites. C. Minimal bowel sounds in all four quadrants. D. Distended abdomen with reports of pain.

D. Distended abdomen with reports of pain.

The nurse evaluates the nutritional intake of an adolescent female client attending camp. The client receives three balanced meals per day and consumes 100% of each meal with an average nutritional intake per meal of 900 calories with 3 mg of iron. The adolescent menstruates monthly and is of average weight for height. Which best describes the adolescent's nutritional intake? A. Low in calories and high in iron. B. Low in calories and low in iron. C. High in calories and low in iron. D. High in calories and high in iron.

D. High in calories and high in iron.

Which assessment information indicates to the nurse the client has hypocalcemia? A. Constipation. B. Depressed reflexes. C. Decreased muscle strength. D. Positive Trousseau's sign.

D. Positive Trousseau's sign.

A Miller-Abbott tube is ordered for the client. The nurse knows this tube is inserted for which main reason? A. Provides an avenue for nutrients to flow past an obstructed area. B. Prevents fluid and gas accumulation in the stomach. C. Administers medications that can be absorbed directly from the intestinal mucosa. D. Removes fluid and gas from the small intestine.

D. Removes fluid and gas from the small intestine.

The nursing team consists of one RN, two LPNs/LVNs, and three nursing assistive personnel (NAP). The RN cares for which client? A. The client with a chest tube who is ambulating in the hall. B. The client with a colostomy requiring assistance with an irrigation. C. The client with a right-sided stroke requiring assistance with bathing. D. The client declining medication to treat cancer of the colon.

D. The client declining medication to treat cancer of the colon.

Promethazine hydrochloride 25 mg IV push is ordered for the client. Prior to administering this medication, the nurse makes which assessment? A. The color of the medication solution. B. The client's pulse and temperature. C. The time of the last analgesic dose the client received. D. The patency of the client's vein.

D. The patency of the client's vein.

What type of equipment is used for contact precautions?

Gloves, gown, mask

Signs and symptoms of autonomic dysreflexia

severe pounding headache profuse sweating severe hypotension nasal congestion