Week 4 Test
After receiving a unit of red blood cells, a child reports tingling in the ears, nose, fingers, and toes. Which electrolyte imbalance does the nurse suspect the client is experiencing? 1- Hypocalcemia. 2- Hypercalcemia. 3- Hyponatremia. 4- Hypernatremia.
1
The nurse provides care to a client who experienced prolonged cold exposure. For which complication does the nurse closely monitor this client? 1- Ventricular fibrillation. 2- Hypertension. 3- Metabolic alkalosis. 4- Shivering
1
The nurse uses a paper-based documentation system to write a client care note. The previous nurse's documentation appears incomplete. Which action should the nurse take next? 1- Draw a line through any empty space and continue documenting. 2- Mark out the previous nurse's entry, initial, and continue documenting. 3- Complete an incident report for the nurse manager to review. 4- Call the previous nurse at home and ask if the documented entry is complete.
1
The nurse assesses a client's sleep patterns. The client tells the nurse, "I am so tired in the morning. How do I know if I have sleep apnea?" Which clinical manifestation does the nurse explain to the client as indicative of sleep apnea? (Select all that apply.) 1- Awakening at night. 2- Snoring. 3- Irritability. 4- Vivid dreams. 5- Hyperactivity.
1) snoring & changes in blood gasses stimulate pt to wake up suddenly. 2) when pt goes to sleep, muscles relax and upper airway can obstruct, causing snoring 3) personality changes & irritability seen d/t sleep deprivation
The nurse provides care for a client who reports fatigue, has dry skin, and a poorly healing wound. Which health problem will the nurse consider the client to be experiencing? 1- Anemia. 2- Malnutrition. 3- Activity intolerance. 4- Peripheral vascular disease.
2
The nurse provides care for a client who sustained a burn injury. The nurse notes that the client has absent bowel sounds, abdominal distention, belching, mild nausea, and a reduced appetite. Which complication should the nurse suspect the client has developed? 1- Curling ulcer. 2- Paralytic ileus. 3- Large bowel obstruction. 4- Translocation of bacteria.
2
A preschool-age client experiences a sudden cardiac arrest. Which action will the nurse take when performing cardiopulmonary resuscitation (CPR)? 1- Deliver 12 breaths per minute. 2- Compress the sternum with both hands at a depth of 2 inches (4 to 5 cm). 3- Use the heel of one hand for sternal compressions. 4- Use two fingers for sternal compressions.
3
The nurse auscultates the heart of a client experiencing increasing shortness of breath. Which finding causes the nurse the most concern? 1- S1 heart sound. 2- S2 heart sound. 3- S3 heart sound. 4- S4 heart sound.
3
The nurse prepares to administer fondaparinux to a client. Which laboratory test result will the nurse monitor in the client receiving this medication? 1- International normalized ratio. 2- Prothrombin time. 3- Creatinine level. 4- Partial thromboplastin time.
3) Fondaparinux [anticoagulant] is excreated by kidneys; monitor creatinine periodically. Stop drug in pts who develop unstable kidney function or sever renal impairment.
The nurse delivers a kosher lunch to a client who is Jewish. Which nursing action is most appropriate when assisting the client? 1- Moving the food from paper plates to glass plates. 2- Unwrapping the eating utensils for the client. 3- Replacing the plastic utensils with metal utensils. 4- Asking the client to unwrap the eating utensils and to prepare the meal for eating.
4
The nurse provides care for a client with an enteral feeding tube. The nurse discovers that the client's continuous enteral tube feeding is 100 mL behind the prescribed infusion schedule. Which action should the nurse take first? 1- Flush the tube. 2- Reposition the tube. 3- Increase the flow rate. 4- Measure residual volume.
4) high gastric residual volume may be why prescribed amount has not infused --after (4) if still sluggish, then flush tube to determine patency increasing flow rate (3) could lead to AE from receiving too much/too rapid of feeding solution.
The nurse provides care for a client who was in a car accident as the result of falling asleep at the wheel. The client reports only being able to sleep 3 to 4 hours a night over the past month, due to stress. The client reports waking up frequently during the night. Which outcome is most appropriate for the nurse to include in the client's plan of care? 1- Client will verbalize a plan to implement a sleep promoting program within the next week. 2- Client will fall asleep with less difficulty over the next 2 weeks. 3- Client will achieve a more normal sleep pattern within 2 to 4 weeks. 4- Client will achieve an improved sense of adequate sleep over the next 4 weeks.
1
The nurse teaches the client about skin care during radiation therapy. The nurse includes which teaching point? (Select all that apply.) 1- Use lukewarm water and gentle soap to bathe. 2- Rub the affected skin with lotion as needed. 3- Wear loose-fitting clothing made from natural fibers. 4- Shave the area using non-alcohol-based products. 5- Wear sunblock when engaging in outdoor activities.
1) CORRECT — Hot water and harsh or fragrant soaps irritate skin; therefore, the nurse teaches this client to use lukewarm water and a gentle soap when bathing. 2) Friction and use of typical lotions can be irritating; therefore, this is not recommended. 3) CORRECT— Tight clothing and artificial fibers can cause skin damage; therefore, the nurse recommends the use of loose-fitting clothing made with natural fibers. 4) The nurse should teach the client to avoid shaving the irradiated area. 5) CORRECT — Damaging effects of radiation are compounded by the effects of sun; therefore, the nurse teaches the client to use sunblock when engaging in outdoor activities.
The nurse provides care for a client diagnosed with type 2 diabetes. The health care provider has ordered exenatide for the client. When will the nurse administer this medication? 1- Twice a day within 1 hour before morning and evening meals. 2- Once a day before bedtime. 3- Twice a day within 2 hours before morning and evening meals. 4- Twice a day within 1 hour after morning and evening meals.
1) Exenatide stimulates the pancreas to secrete insulin when sugar level are high. Give twice/day w/in 1 hr b4 breakfast and dinner.
The nurse learns that a client was not prescribed a treatment for a disease process because of age. For which principle violation will the nurse bring this issue to the organization's ethics committee? 1- Justice. 2- Veracity. 3- Beneficence. 4- Nonmaleficence
1) Justice-- pts treated fairly & receive fair Tx. 2) Veracity-- telling truth 2) Beneficence-- "do good"
The nurse plans to teach a local community group about chronic obstructive pulmonary disease (COPD). Which information does the nurse include? (Select all that apply.) 1- Uncontrolled COPD can lead to cardiac disease. 2- Asthma in childhood leads to COPD later in life. 3- Cigarette smoking is the leading COPD risk factor. 4- More females are affected by COPD than males. 5- Co-existing illness may cause COPD exacerbation.
1) R-sided HF results from uncontrolled COPD 3) cig smoking is major RF 5)HF, GERD, & pneumonia may lead to COPD exacerbation more males than females are affected by COPD
The nurse provides care for a client diagnosed with diabetic ketoacidosis (DKA). The nurse receives a prescription to transition the client from a regular insulin infusion to insulin glargine. Which action does the nurse take first? 1- Continue the insulin infusion for 1 to 2 hours after the glargine is started. 2- Check the client's blood glucose every 30 minutes for 24 hours. 3- Discontinue the insulin infusion as soon as the glargine is administered. 4- Monitor the client closely for signs of seizure activity.
1) insulin glargine is long-acting, given SC. onset is 1-1.5 hrs. --we want it to take effect b4 D/C R insulin & prevent hyperglycemia.
The nurse provides care to a client of Asian descent having surgery later in the day. Which action will be most appropriate for the nurse to take when assessing this client? 1- Observe the client's use of eye contact. 2- Look directly at the client when interacting. 3- Avoid eye contact with the client. 4- Ask a family member about the client's cultural beliefs.
1) is most useful in determining best way to communicate effectively
The nurse provides care for a client diagnosed with cervical cancer and spinal metastasis. The client is prescribed dexamethasone three times daily. Which client statement would indicate to the nurse that treatment has been effective? 1- "The pain in my pelvic area is less." 2- "My appetite seems to be better." 3- "I have more energy now." 4- "I'm not as nauseated as I was before."
1) palliative reduction of pain is goal of steroid therapy in metastatic cancer
The nurse delegates vital sign measurement to the nursing assistive personnel (NAP). Which statement provides the best information for the nurse to give when delegating this task? 1 "Please obtain blood pressure, heart rate, respiratory rate, temperature, and pulse oximetry. Let me know if anyone's systolic blood pressure is <100 or >160, heart rate <60 or >100, respiratory rate <12 or >20, temperature >100.50F (40.60C), or pulse oximetry <95%." 2 "Please obtain blood pressure, heart rate, respiratory rate, temperature, and pulse oximetry. Report any readings outside the normal ranges." 3 "Please obtain blood pressure, heart rate, respiratory rate, temperature, pain rating, and pulse oximetry. Let me know if anyone's systolic blood pressure is <100 or >160, heart rate <60 or >100, respiratory rate <12 or >20, temperature >100.50F (40.60C), pain level >5/10, or pulse oximetry <95%." 4 "Please obtain blood pressure, heart rate, respiratory rate, temperature, and pulse oximetry. Let me know if anyone's blood pressure is <100 or >160, heart rate <50, respiratory rate <12, temperature >100.50F (45.60C), or pulse oximetry <93%."
1) safe principles of delegation includes giving specific instructions including reporting parameters to ensure clear communication.
The nurse reviews care needs for assigned clients. Which client will the nurse assess first? 1- Client who had a vaginal hysterectomy 2 days ago and is reporting that the right calf is warm to touch. 2- Client who received a dose of prescribed warfarin while receiving a heparin infusion. 3- Client with chronic obstructive pulmonary disease who is using pursedlip breathing. 4- Client who had an abdominal aortic aneurysm repaired 10 hours ago and has bronchial breath sounds over the trachea.
1) warm calf--> DVT, can be life-threatening if it becomes embolus (hysterectomy is a RF for DVT) --(4) bronchial breath sounds are considered normal over trachea.
The nurse educator plans an educational program to review transmission-based precautions with unit staff. Which substance is included on the list of potential sources of infection as outlined by the Centers for Disease Control and Prevention (CDCP)? (Select all that apply.) 1- Blood. 2- Vaginal secretions. 3- Sputum. 4- Non-intact skin. 5- Sweat.
1,2,3,4
The nurse provides care for a child who ingested an unknown substance. The client is unconscious with a respiratory rate of 10 breaths/min, pulse oximeter reading is 88%, and the heart rate is 160 beats/min. The nurse determines which nursing diagnosis is the highest priority for this client? 1- Decreased cardiac output. 2- Ineffective breathing pattern. 3- Ineffective tissue perfusion. 4- Impaired cerebral tissue perfusion.
2
The nurse plans for the discharge of a client with Parkinson disease. Which outcome is appropriate for collaboration between the nurse and the physical therapist? (Select all that apply.) 1- Maintain physical strength and mobility. 2- Bladder training to increase bladder capacity. 3- Optimal use of extremities in performing activities. 4- Proper use of ambulatory assistive devices. 5- Monitor skin for alterations in integrity.
1,3,4
The nurse reviews care needs for a shift assignment. Which client task will the nurse delegate to newly hired nursing assistive personnel (NAP)? (Select all that apply.) 1- Client diagnosed with a fractured hip being discharged tomorrow. 2- Client receiving blood after a total abdominal hysterectomy that was admitted to the care area 10 minutes ago. 3- Client diagnosed with a fractured tibia who had surgery 2 days ago. 4- Client diagnosed with cellulitis to the lower leg. 5- Client who had a resection of the prostate this morning with a 3-way indwelling urinary catheter for irrigation.
1,3,4
The nurse provides care for a client who takes a cyclobenzaprine hydrochloride extended release capsule once a day. Which finding indicates to the nurse that this medication is effective? 1- Experiences patchy hair loss. 2- Bends over to tie shoes. 3- Demonstrates hyperactive bowel sounds. 4- Experiences a 2 kg weight loss in 3 weeks.
2
The nurse teaches a class on suicide prevention to high school students. Which risk factor is accurate with regard to suicide in adolescent clients? (Select all that apply.) 1- Possessions that are given to friends. 2- A low grade point average. 3- Statements like, "I may not be around anymore." 4- Access to a gun at home. 5- Frequent thoughts of suicide.
1,3,4,5
The nurse assesses a client with obsessive compulsive personality disorder. Which finding will the nurse expect to observe? (Select all that apply.) 1- Requires excessive support from others when making decisions. 2- Believes is able to know what others are thinking. 3- Possesses exaggerated feelings of helplessness when alone. 4- Demonstrates unwillingness to delegate tasks unless others follow strict rules. 5- Imposes perfectionism in own completion of tasks.
1,4,5
The nurse prepares teaching for a client prescribed alendronate sodium. Which information will the nurse include in this teaching? (Select all that apply.) 1- "Take this medication with at least 8 ounces of water." 2- "Take this medication while ingesting the first bite of food in the morning." 3- "Wait 30 minutes after eating before taking this medication." 4- "Sit upright for at least 30 minutes after taking the medication." 5- "Take this medication 30 minutes before food or other medications."
1,4,5
The nurse provides care for an alcohol-dependent client diagnosed with pancreatitis. Which sign leads the nurse to determine that the client is experiencing alcohol withdrawal? (Select all that apply.) 1 Hallucinations. 2 Apathy. 3 Depression. 4 Seizures. 5 Gross tremors.
1,4,5
When performing a sterile dressing change, the nurse removes the saturated dressing, notes the wound is clean, applies a new dressing, and discards the used gloves. Which action does the nurse take next? 1- Put on sterile gloves. 2- Open the sterile gauze packaging. 3- Perform hand hygiene. 4- Date and initial the new dressing.
3
The nurse auscultates heart sounds in a school-age client. Where does the nurse place the stethoscope to listen to the aortic area of the heart? 1- Second left intercostal space. 2- Second right intercostal space. 3- Fifth intercostal space, left midclavicular line. 4- Fifth right and left intercostal spaces.
2
The nurse notes that a client's heart rate decreases from 55 to 45 beats/min. Which action does the nurse take first? 1- Notify the health care provider (HCP). 2- Determine if the client is lightheaded. 3- Administer 0.5 mg of intravenous (IV) atropine. 4- Prepare for transcutaneous pacing.
2
A parent asks the nurse about the best time to begin toilet training a 22-month-old child. Which nursing response is most appropriate? 1- "When your child turns 2 years old." 2- "When your child expresses interest in toilet training." 3- "When you are ready to begin toilet training." 4- "When your child turns 3 years old."
2
Before delegating tasks to nursing assistive personnel (NAP), a new nurse asks the manager to explain "the right circumstance" of delegation. Which response will the manager make to the nurse? 1- "Delegating the right circumstance is ensuring the person you delegate to is capable of handling the delegated task." 2- "Delegating the right circumstance is ensuring the client is stable." 3- "Delegating the right circumstance is intervening when the person the task was delegated to is not doing the delegated task correctly." 4- "Delegating the right circumstance is asking the person delegated if they completed the task assigned."
2
The nurse admits a child with fever, malaise, headache, and a vesicular rash on the scalp, face, and trunk. Which transmission-based precaution does the nurse implement for this child? 1- Contact precautions. 2- Airborne and contact precautions. 3- Airborne and droplet precautions. 4- Droplet precautions.
2
The nurse assess a client who is in the 24th week of gestation. Which finding is a priority for the nurse to follow-up? 1- Fetal heart rate of 130 to 140 beats/min. 2- Fundal level at 3 fingers below the umbilicus. 3- Fetal movements felt faintly on lower part of abdomen. 4- Client reports backache and leg cramps when sleeping.
2
The nurse provides care for a hospitalized client receiving ethambutol, isoniazid, pyrazinamide, and rifampin for active tuberculosis (TB). The client states, "I want to go home! I refuse to stay here another day!" Which statement by the nurse is most appropriate? 1- "You must remain in the hospital until you have finished the antibiotics." 2- "I will notify the health care provider of your request." 3- "You will have to wear a mask around sick people." 4- "Let's test your sputum again for the presence of tuberculosis."
2
The nurse reviews the daily lab results of four clients. Which client does the nurse delegate to the LPN/LVN to provide care? 1- Client with a brain natriuretic peptide (BNP) level of 300 pg/mL. 2- Client with an erythrocyte sedimentation rate of 10 mm/h. 3- Client with a C-reactive protein (CRP) level of 4 mg/L. 4- Client with an international normalized ratio (INR) level of 8.0.
2
An older client with Medicare insurance asks the nurse to explain the "donut hole" in prescription drug coverage. Which response by the nurse is best? 1- It is a $20 co-payment for all prescriptions. 2- It is a temporary limit on what the drug plan will pay for covered drugs. 3- There is 20% decrease in prescription payment after six prescriptions per year. 4- There is no prescription drug coverage after age 85.
2) coverage begins after pt has spent a certain amount for covered drugs in a year.
The nurse provides care for a client with an oral temperature of 90 °F (32 °C). Which nursing diagnosis will the nurse use first to guide this client's care? 1- Risk for impaired cognition. 2- Risk for cardiac dysrhythmia. 3- Risk for acid-base imbalance. 4- Risk for shivering and spasm.
2) severe hypothermia--> cardiac arrest.
The nurse prepares discharge instructions for a client who speaks very little English and is recovering from an emergency appendectomy. Which nursing action best helps this client understand wound care instructions? 1- Asking if the client understands the instruction. 2- Demonstrating the procedure and having the client return the demonstration. 3- Asking an interpreter to replay the instructions to the client. 4- Writing out the instructions and having a family member read them to the client.
2)when pt can repeat action taught by nurse, best ensures pt can perform wound care correctly at home.
The nurse provides cares for a client with a wound. The client's wound culture is positive for vancomycinresistant Staphylococcus aureus (VRSA). Which personal protective equipment (PPE) does the nurse don before entering the client's room? (Select all that apply.) 1- Mask. 2- Gown. 3- Gloves. 4- Face shield. 5- N-95 respirator mask.
2,3
The nurse provides care for a hospitalized client. The client's room is located close to the nurses station. The client tells the nurse, "I don't know how anyone can get any rest around here, it is so noisy." The nurse reports these concerns to the nursing supervisor. Which change to the nursing unit should the nursing supervisor implement? (Select all that apply.) 1- Encourage staff to change shoes to clogs to reduce noise. 2- Reduce the volume of phones and pagers. 3- Turn off all lights in the hallways. 4- Keep conversations quiet. 5- Close the client's room door if possible.
2,4,5
The nurse is caring for a client with a shoulder injury. Which intervention will the nurse delegate to nursing assistive personnel (NAP)? 1- Perform a complete bed bath. 2- Direct the client to the shower. 3- Provide back care as part of a partial-care bath. 4- Set the client up for a self-care bath at the bedside.
3
The nurse notes that four clients have returned from surgery within the last 24 hours. Which client is at the highest risk for developing a post-operative infection? 1- A school-age client recovering from a tonsillectomy. 2- An adolescent client who had an unruptured appendectomy. 3- An older adult client with gastric tube placement. 4- A middle-age client with a coronary artery by-pass graft.
3
The nurse prioritizes the needs of several assigned clients. Which client need will the nurse address first? 1- Comforting a client who received a cancer diagnosis. 2- Instituting precautions for a client identified at risk for falling. 3- Assessing a client with a reported blood glucose level of 60 mg/dL (3.33 mmol/L). 4- Implementing precautions for a client identified at risk for aspiration.
3
The nurse provides care for a client diagnosed with deep vein thrombosis. The client receives warfarin therapy. Which laboratory test result indicates to the nurse that treatment is successful? 1- International normalized ratio 1 to 2. 2- Partial thromboplastin time 1.5 times the control. 3- International normalized ratio 2 to 3. 4- Partial thromboplastin times 2.5 times the control.
3
The nurse provides care for a client taking warfarin for a mechanical prosthetic heart valve. The client has an international normalized ratio (INR) of 3.1. Which is the correct interpretation by the nurse of this finding? 1- The next dose of warfarin needs to be stopped. 2- The result indicates a sign of warfarin toxicity. 3- The client's treatment goal has been achieved. 4- The client may require a plasma transfusion.
3
The nurse provides care for a newly admitted client with chest pain. Which task will the nurse complete instead of delegating to nursing assistive personnel (NAP)? 1- Set up the client's meal tray. 2- Obtain a urine specimen and send it to the laboratory. 3- Remove the client's oxygen if chest pain is rated as zero. 4- Place the client on the cardiac monitor.
3
The nurse provides care to a client at risk for hypercalcemia. Which action is most appropriate for the nurse to take? 1- Encourage strict bed rest. 2- Limit dietary fiber. 3- Encourage oral fluids. 4- Hold prescribed zoledronate.
3
The nurse provides home care to a client receiving intravenous therapy and enteral nutrition. Which care objective will the nurse identify as a priority for this client? 1- Screening. 2- Counseling. 3- Education. 4- Case management.
3
The nurse uses research findings to improve client care. Which technique of care is the nurse using? 1- Nurse-sensitive indicators. 2- Care management. 3- Performance improvement. 4- Utilization review.
3
A nurse who is in Generation X, works the night shift and requests more time off than other staff nurses. Which statement best explains a characteristic of this generation? 1- Believes that there are enough other nurses to fill the staffing needs. 2- Prefers to work the day shift, but hesitates to ask for the schedule change. 3- Wants to increase leisure time to balance work time. 4- Wants to be rewarded for the time spent at work.
3) Gen X ppl have a tendency to want work-life balance. --Wouldnt be hesitant to request schedule change (2) Gen Y- wants to be rewarded for time spent at work (4)
The nurse mentors a nursing student. The student asks which organization requires all clients to be assessed for pain. Which response by the nurse is correct? 1- The National Council of State Boards of Nursing (NCSBN). 2- The American Nursing Association (ANA). 3- The Joint Commission. 4- The National League of Nursing (NLN).
3) JC developed assessment standards, including all pts be assessed for pain. --NCSBN asserts scope of nursing includes comprehensive assessment. --ANA developed standards for clinical practice, including those for assessment --NLN promotes valid, reliable guidelines & stand
The nurse develops a teaching plan to promote optimal cardiac output during pregnancy. Which information is most important for the nurse include? 1- Take frequent rest periods between activities. 2- Modify aerobic exercise as pregnancy progresses. 3- Avoid resting or sleeping in the supine position. 4- Elevate both lower extremities whenever sitting.
3) Particularly in second half of pregnancy, the weight of the pregnant uterus compresses the vena cava (which can lead to maternal hypotension syndrome) and aorta (which can lead to fetal hypoxia). It is a priority to prevent compression of these major vessels.
The nurse auscultates crackles throughout all lung fields and measures a heart rate of 132 bpm, a respiratory rate of 30, and blood pressure of 102/54 mm Hg in a client recovering from an esophagectomy. Which action will the nurse take first? 1- Place the client on continuous pulse oximetry. 2- Monitor the client for changes in blood pressure. 3- Notify the health care provider. 4- Assist the client to use the incentive spirometer.
3) demonstrating sign of early shock!!!!
The nurse provides care for clients in a headache clinic. Which client should the nurse assess first? 1- The client reporting pain and neck stiffness. 2- The client reporting abdominal pain and vomiting. 3- The client with difficulty speaking to the receptionist. 4- The client with a headache of 3 weeks' duration.
3) difficulty speaking could be sign of CVA, a migraine complication --pain & stiffness common symptoms of tension headaches. -- 3 weeks headache (is long time) but not unusual for tension headaches. --abd pain, n?v are common symptoms for migraine headaches.
The nurse uses a tape measure to ensure that a client receives the correct size of knee-high antiembolism stockings. Which measurement does the nurse use for these stockings? 1- Knee circumference. 2- Mid-thigh circumference. 3- Achilles tendon to the popliteal fold. 4- Bottom of the heel to the fold of buttocks.
3) for knee-high TEDs 2&4) measuring for thigh-high TEDs
The nurse is assisting in the care of a client with ventricular fibrillation. The "code" leader called to shock the client uses a biphasic defibrillator. The nurse sets the defibrillator at which energy level? 1- 80 to 100 Joules. 2- 100 to 110 Joules. 3- 120 to 200 Joules. 4- 300 to 360 Joules.
3) initial defibrillation for V-fib, set defibrillator @ 120-200 Joules
The nurse follows up with a client diagnosed with insomnia. The nurse seeks to determine if treatment was successful. Which response by the client best indicates treatment was successful? 1 "I am sleeping 4 hours a night." 2 "I fall asleep within 1 to 2 hours at night now." 3 "I am not napping in the day anymore." 4- "I am waking up twice a night."
3) insomniacs typically nap in daytime. Not napping indicates pt is getting through the day now.= positive response
The nurse is assessing a neonate born at 44 weeks' gestation. Which finding does the nurse document as consistent with the newborn's gestational age? 1- Slow recoil of the pinna. 2- Absence of plantar creases. 3- Cracked, peeling skin. 4- Abundant vernix.
3) post-term neonates has dry, cracked (desquamating) skin at birth. --1) In preterm neonates of less than 34 weeks gestation, the ear has little cartilage to keep it stiff. It will remain folded over or return slowly when folded longitudinally and horizontally. In a fullor post-term neonate, the ear springs back to the original position immediately. --2) Full- and post-term neonates have deep plantar creases. A preterm newborn has few creases on the foot. --4) There is little vernix on the body of a full-term neonate except small amounts in the skin creases. No vernix is on the body of a post-term newborn. A preterm neonate has a thick covering of vernix.
A client with diabetes returns from the post-anesthesia care unit (PACU) after a transurethral resection of the prostate (TURP). Which intervention will the nurse perform first? 1- Perform a bedside bladder scan. 2- Collect a specimen for urine culture. 3- Check patency of the indwelling urinary catheter. 4- Obtain a capillary blood glucose level.
3) priority is to check patency of indwelling urinary catheter
The nurse provides care for a client diagnosed with sickle cell crisis. Which sign or symptom should the nurse immediately report to the healthcare provider? 1- Cyanosis of the tongue. 2- Jaundiced skin. 3- Slurred speech. 4- Slow capillary refill.
3) slurred speech indicates possible stroke & reported immediately 1)common d/t poor profusion 2)common d/t rapid breakdown of RBCs 4)common d/t poor capillary profusion
The nurse provides care for a client who reports difficulty breathing. Which assessment finding requires immediate action by the nurse? (Select all that apply.) 1- Non-productive cough. 2- Flushed skin appearance. 3- Use of accessory muscles. 4- Oxygen saturation of 78%. 5- A heart rate of 145/minute.
3) use of accessory muscles for breathing indicates air hunger 4) Severe hypoxia (SPO2 78%) 5) Tachycardia indicates hypoxia & resp. distress status
The nurse conducts a staff development workshop about organ donations. Which statement by a staff member indicates a correct understanding of the Uniform Anatomical Gift Act? 1- "A client needs to complete an advance directive and identify a health care proxy to become an organ donor." 2- "The health care provider is the person who requests organ donation from a client's family members." 3- "The health care provider who signs the client's death certificate must supervise the removal of the client's donated organs." 4- "Family members can consent to organ donation after the client's death, even if the client had not expressed a desire to have organs donated."
4
The nurse documents care on a client who is 3 hours postoperative after a right leg amputation. Which charting entry indicates a problem with the documentation? 1- Client A/O x 4, gag reflex intact, reports nausea. 2- Client post above the knee amputation, sequential compression device to left leg, scant amount bleeding on dressing. 3- Client A/O x 4, dressing dry and intact, reports incisional pain at 5 on a 10 point scale. 4- Client post above the knee amputation, voids without difficulty, 2+ dorsalis pedis pulses bilaterally.
4
The nurse observes a nursing assistive personnel (NAP) prepare to provide mouth care to a client who is comatose. Which action made by the NAP requires the nurse to intervene? 1- The NAP applies clean gloves. 2- The NAP activates an oral suction device. 3- The NAP places a towel under the client's chin. 4- The NAP raises the head of the bed thirty degrees.
4
The nurse provides care for a client diagnosed with a stage 2 sacral pressure injury. The nurse educates the client's family members about proper positioning. Which statement by the family members indicates a need for further teaching? 1- "We will not keep our parent sitting on the bedpan for too long." 2- "We will encourage our parent to change position every few hours." 3- "We will use a draw sheet to help position our parent when in bed." 4- "We will put our parent on a rubber ring cushion when he is sitting up."
4
The nurse provides care for a client diagnosed with vitamin A deficiency. Which menu selection is most appropriate for the nurse to recommend to the client? 1- Legumes, grains, fish. 2- Tomatoes, potatoes, fruit juice. 3- Leafy vegetables, eggs, cheese. 4- Liver, sweet potato, carrots.
4 1) is best for Thiamine def. 2) is best for Vit C def. 3) if best for Vit K def.
The nurse notes that a client is prescribed alendronate. Which instruction will the nurse include when teaching about this medication? 1- "Take the medication at bedtime with a snack." 2- "Take the medication in the morning after breakfast." 3- "Lie down for 30 minutes after taking the medication." 4- "Take the medication with a full glass of water."
4) Alendronate take w/ full glass of water to prevent acid reflux. --taken on empty stomach --taken anytime of day --must remain upright 30 min. after taking to prevent esophagitis.
A client takes a statin as prescribed. Which action does the nurse implement to identify if the client is experiencing any side effects of the medication? 1- Measure height and weight. 2- Check recent cholesterol level. 3- Inquire about the consistency of stool. 4- Assess for muscle tenderness.
4) Myalgia (or muscle tenderness) may indicate development of rhabdomyolysis, AE to statin
The nurse applies the prescribed medication to an adult client diagnosed with scabies. Which body area should the nurse avoid when applying the scabicide? 1- Knees and elbows. 2- Fingers and hands. 3- Groin and axillae. 4- Face and scalp.
4) scabicide is applied from neck down
The nurse provides care for a client with the following arterial blood gas (ABG) results: pH 7.29, pCO231 mmHg, and HCO3 19 mEq/L. Which electrolyte alteration does the nurse monitor for based on this client data? 1- Hypocalcemia. 2- Hypernatremia. 3- Hypomagnesemia. 4- Hyperkalemia.
4)potassium levels are often high in metabolic acidosis 1- seen w/alkalotic 2&3- not associated w/ metabolic acidosis