Trainer Test 1
What statement is documented by the nurse to reflect a client's emotional adjustment to being hospitalized in the ICU?
"The client constantly calls for nurses and cries uncontrollably."
The parents of a child diagnosed with hemophilia ask the nurse to explain the cause of the disease. Which response by the nurse is best?
"The mother transmits the gene to her son."
The nurse cares for clients in the outpatient clinic. What order will the nurse return messages?
1. The "soft spot" on the head of the 4-day-old feels slightly elevated when asleep 2. The circumcision site of the 3-day-old is slightly swollen 3. The umbilical cord of the 5-day-old is soft and draining exudate 4. When bed is bumped, a 2-day-old rapidly extends the extremities.
The nurse cares for a client receiving docusate 100 mg through a gastric tube. The solution contains 150 mg/15 mL. The nurse should administer how many mLs of the solution to the client?
10 mL
The nurse cares for the client receiving d5 0.45% NS 1,000 mL to run from 0900 to 1700. The drip factor on the delivery tubing is 20 gtt/mL. At what rate does the nurse set the IV to drip?
42 gtt/min
The nurse leads a parenting class for a group of expectant clients. How many extra calories a day does the nurse advise the clients to consume to support breastfeeding?
500
The nurse on a psychiatric unit of the hospital declines the client's request to oragnize a party on the unit for the client's friends. The client becomes angry and uses abusive language toward the nurse. What indicates the nurse has an understanding of the client's behavior?
Abusive language is one of the behaviors symptomatic of the client's illness
The child is in the early stages of nephrotic syndrome. The nurse discusses which dietary change with the parents?
Adequate protein, low sodium intake
The nurse cares for the newborn infant diagnosed with fetal alcohol syndrome. The nurse expects to see what characteristics?
An infant with a small head circunference, low birth weight, and undeveloped cheekbones.
In the process of a normal adjustment to a terminal illness, the nurse knows that the client's initial denial and isolation will give way to the second stage. The second stage is characterized by what behavior?
Anger
The nurse is discussing growth and development with the parents of a 4-year-old child. The nurse identifies what type of play as characteristic of this age group?
Associative play
The nurse cares for the postoperative client diagnosed with type 2 diabetes controlled with oral antihyperglycemic agents. The client asks why the health care provider ordered subcutaneous insulin injections after surgery. The nurse's response is based on knowing what physiological process?
Being NPO inhibits normal blood glucose control
The nurse cares for clients in a drug rehabilitation facility. What complication of IV drug abuse is the nurse most likely to observe?
Cellulitis
The nurse knows that cortisol is responsible for what action?
Converting proteins and fat into glucose
The 7-year-old child is seen in the clinic with a diagnosis of pituitary dwarfism. What clinical manifestation is the nurse most likely to observe?
Delicate features
The middle-aged client is admitted to an inpatient psychiatric unit. The client reports a family member is trying to steal the client's property. The client is diagnosed with paranoid disorder. The nurse suspects the client is demonstrating what symptom?
Delusions of persecution
The nurse prepares the adult client diagnosed with intellectual delay for discharge. The health care provider ordered warfarin sodium, 5 mg each day. To maintain client safety, what action does the nurse take first?
Determines the client's comprehension of the medication administration
The nurse collects the following data: anger directed by client toward staff in the form of frequent sarcastic or crude comments, increased wringing of hands, and purposeless pacing, particularly after the client has used the telephone. On the basis of the data, the nurse makes what nursing diagnosis?
Difficulty with coping
The nurse identifies the primary reason for elderly adults to have problems with constipation is because of what process?
Elderly adults engage in less activity and have decreased GI muscle tone
The nurse cares for a client receiving chlorpromazine. The nurse notes the client is restless, unable to sit still, and reports insomnia and fine tremors of the hands. Which does the nurse identify as the best explanation for these symptoms occurring?
Extrapyramidal adverse effects resulting from this medication
The client, gravida 2 para 1, is admitted with hypertension. The client reports her wedding band is tight. The nurse assesses for what indications of mild pre-eclampsia?
Facial swelling and proteinuria
The nurse recognizes what symptoms are early signs of lithium toxicity?
Fine motor tremors N/V Diarrhea
The health care provider orders naproxen sodium for the elderly client. The nurse assesses the client for what symptoms?
Fluid retention and dizziness
What type of foods does the nurse encourage for the client diagnosed with hypoparathyroidism?
Foods rich in calcium
The health care provider orders hydromorphone hydrochloride 15 mg IM for a client. The nurse observes for what adverse effects?
Hypotension and respiratory depression
The nurse provides care for a client with a tracheostomy. What is the priority nursing diagnosis for this client?
Inadequate airway clearance
The health care provider inserts a temporary pacemaker in a client following a myocardial infarction. The nurse knows that which outcome is the primary purpose of the pacemaker?
Increases cardiac output
The 18-month-old is admitted to the unit with a diagnosis of laryngotracheobronchitis (LTB). During the initial assessment, the nurse expects to find what early symptoms?
Inspiratory stridor and restlessness
The nurse cares for the prenatal client at 8 weeks gestation with a positive VDRL. When the nurse prepares the teaching plan, it is most important for the nurse to include which information?
Instruct the client about the importance of taking all the medication
What action is the best way for the nurse to assess the fluid balance of an elderly client?
Maintain an accurate intake and output
The adolescent is brought to the hospital for treatment of deep partial thickness and full thickness burns sustained in a house fire. An intravenous infusion is started in the client's left forearm. The nurse identifies what reason as the primary purpose for the IV?
Maintain fluid balance
The nurse cares for a 3-month-old infant scheduled for a barium swallow in the morning. Prior to the procedure, it is most appropriate for the nurse to take what action?
Make the infant NPO for 3 hours
The toddler diagnosed with lead poisoning is admitted to the pediatric unit. The health care provider writes an order to encourage fluids. Which fluid is best for the nurse to offer to the toddler?
Milk
The nurse knows which mood-altering drug is most often associated with an increased risk for HIV infection related to IV drug use?
Narcotics
The parent of a child with chickenpox asks the clinic nurse why the child will not come down with chickenpox again if exposed to the virus at school at a later date. What explanation does the nurse give?
Natural active immunity occurs because the child's body actively makes antibodies against the chickenpox virus.
The adult client is preparing for a plasma cholesterol screening. What instruction does the nurse give to the client?
Only take sips of water for 12 hours before the test
The client had a kidney transplant yesterday, and the client's adult child has come to visit. The nurse instructs the adult child to take what action?
Perform good hand washing
A postoperative cataract client is cautioned about not making sudden movements or bending over. The nurse understands that the rationale for this recommendation is to prevent what complication?
Pressure on the ocular suture line
A client comes to the outpatient psychiatric clinic for treatment of a fear of heights. The nurse knows that phobias involve which behaviors?
Projection and displacement
The nurse performs range of motion (ROM) exercises for an elderly client recently immobilized. The nurse identifies what statement as correct about range-of-motion?
ROM assists the elderly to carry out activities of daily living (ADLs)
The nurse cares for the child diagnosed with pediculosis capitis (head lice) who is being treated with permethrin 1% cream rinse. The nurse includes what information when instructing the child's parents?
Repeat the application of the cream rinse in 7 days if nits are still present.
The nurse cares for a client receiving a blood transfusion for approximately 30 minutes. What symptom indicates a severe allergic reaction is occuring?
Respiratory wheezing
What observation suggests to the nurse that the client has developed an Addisonian crisis?
Restlessness and rapid, weak pulse
The home care nurse visits a new parent and a 2-week-old infant. The client asks the nurse which solid foods to give the child first. What response does the nurse give?
Rice cereal is usually the first solid food and is started around 4 to 5 months.
What information does the nurse recognize as being the most pertinent to the diagnosis of cholecystitis?
Right upper abdominal pain
The 6-month-old is brought to the clinic for a well-baby checkup. During the exam, the nurse expects to observe what assessment findings? (select all)
Sitting with support Playing peek-a-boo Rolling from back to abdomen
The nurse cares for a client with ataxia. What action would be most important?
Supervise ambulation
Prior to sending a client for a cardiac catheterization, it is most important for the nurse to report what information?
The client has an allergy to shellfish
The nursing team consists of an RN who has been practicing for 6 months, an LPN/LVN who has been practicing for 15 years, and a nursing assistive personnel who has been caring for clients for 3 years. The RN cares for what client?
The client ordered to receive 2 units of packed cells.
The nurse cares for the client diagnosed with type 1 diabetes reporting decreased vision. The client asks the nurse what caused the visual changes. The nurse's response is based on what statement?
The client's decreased vision is caused by gradual destruction and degeneration of the retina.
The nurse administers oral verapamil to a client. What assessment does the nurse make before administering the medication?
The client's heart rate
What is most important for the rehabilitation nurse to assess during a new client's admission?
The client's personal goals for rehabilitation
The nurse prepares a teaching plan regarding colostomy irrigation. The nurse includes what information?
The colostomy needs to be irrigated at the same time every day
The nurse cares for the client diagnosed with pneumothorax resulting from a motor vehicle accident three days ago. The client has a chest tube connected to a three-chamber water-seal drainage system with 20 cm suction. The nurse determines the lung has re-expanded if what observation is made?
The fluid in the water-seal chamber does not fluctuate with respirations
The nurse prepares the older client for an intravenous pyelogram (IVP). The client asks the nurse to explain the reason why the procedure is performed. The nurse's response is based on what explanation?
The health care provider is able to examine the urinary tract by x-ray
The nurse cares for the elderly client admitted with a possible fractured right hip. During the initial nursing assessment, which observation of the right leg validates this diagnosis?
The leg appears to be shortened and is adducted and externally rotated.
The outpatient nurse cares for an elderly client diagnosed with type 1 diabetes. Because the client is unwilling to perform blood glucose monitoring, the client tests urine for glucose and acetone. The nurse knows that blood glucose monitoring is preferred over urine testing for glucose because of what reason?
The renal threshold for glucose is elevated in the elderly
At 32 weeks gestation, the client has an order for an ultrasound. The nurse determines that the client understands the procedure if the client makes what statement?
The results will inform us of the baby's size
The nurse performs the Rinne test on a client. What is an accurate statement of how the first part of this test is performed?
The stem of the vibrating tuning fork is held against the mastoid bone until the client indicates sound can no longer be heard.
The client develops a postoperative infection and receives ceftriaxone sodium IV every day. It is most important for the nurse to monitor for what changes?
The surface of the tongue
During the mother's fourth stage of labor, the nurse palpates the client's fundus in what location?
The umbillicus
The health care provider writes an order for a stat dose of morphine 4 mg IV for pain. Three hours later the client again reports pain, and the nurse administers a second injection of morphine. What best describes the nurse's liability?
There is no order for a second dose of medication; the nurse is liable.
The client in labor is monitored with an internal fetal monitor. The nurse knows what is the most important reason for the fetal monitor?
To monitor the oxygen status of the fetus during labor
What symptoms alert the nurse to consider an alcohol problem in a client diagnosed for a physical illness?
Tremors Elevated temperature Nocturnal leg cramps
The health care provider orders mannitol for the client with a closed head injury. What response does the nurse recognize as desired to this medication?
Urinary output increases to 175 mL/hr
Several days after the delivery of a stillborn, the parents say, "We wish we could talk with other couples who have gone through this trauma." Which response by the nurse is best?
"SHARE will provide you with this opportunity"
The nurse cares for a client diagnosed with gastric reflux due to a hiatal hernia. The client asks the nurse why food and fluids should be withheld just before going to bed. What response by the nurse is most appropriate?
"You are less likely to awaken during the night with heartburn if the stomach is empty."
The nurse identifies what finding has the greatest impact on the elderly's ability to complete activities of daily living (ADLs)?
Apraxia
The client is evaluated for infertility, and the health care provider prescribes clomiphene citrate 50 mg daily for 5 days. The client asks the nurse how the medication works. What response by the nurse is best?
Clomiphene citrate induces ovulation by changing hormonal effects on the ovary
The nurse cares for the client admitted with a diagnosis of a stroke and facial paralysis. Nursing care is planned to prevent what complication?
Corneal abrasion
The nurse knows that according to Erikson's stages of psychosocial development, which developmental stage best represents a 50-year-old client?
Generativity versus stagnation
A client with an endotracheal tube requires suctioning. What statement is an accurate description of how the nurse performs the procedure?
Inserts the suction catheter until resistance is met, and then withdraws it slightly. Applies suction intermittently as the catheter is withdrawn.
The nurse cautions the client with hypothyroidism to avoid what implementation?
Narcotic sedatives
The nurse supervises an LPN/LVN administering an enema to a client. The nurse determines the LPN/LVN's actions are appropriate if what action is observed?
The LPN/LVN positions the client in the left Sims' position
The nurse cares for an older client scheduled for a colon resection this morning. The nurse notes the client had polyethylene glycol-electrolyte solution and soapsuds enema the previous evening. This morning the client passes a medium amount of soft brown stool. What conclusion by the nurse is accurate?
The bowel preparation is incomplete
