3500 - LPQ's
Match the following fluids to the correct reason for administration A. Used to treat hypovolemia B. Used to treat prolonged (cellular) dehydration 1. IV 0.45% NaCl select 2. IV 0.9% Na Cl
1:B, 2:A
In order to understand how to care for adults with Alzheimer's disease, the nurse needs to recognize what signs and symptoms of the disease? (Select all that apply) A. Poor or decreased judgment. B. Declining job skills. C. Inability to be comfortable in social situations. D. Obsession with cleanliness and organization. E. Focus on abstract thoughts.
A, B, C
A student nurse asks the nursing instructor why older adults are more prone to infection than other adults. What reasons does the nursing instructor give? (Select all that apply.) A. Age-related decrease in immune function B. Decreased cough and gag reflexes C. Diminished acidity of gastric secretions D. Increased lymphocytes and antibodies E. Thinning skin that is less protective
A, B, C, E
The healthcare provider is assessing an elderly client who is disoriented to time and place. Which additional finding would support a diagnosis of delirium? (Select all that apply) A. Rambling and incoherent speech. B. Often linked to an identifiable cause. C. Attention is impaired. D. Gradual onset of symptoms. E. Frightening hallucinations
A, B, C, E
The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which of the classic signs of preeclampsia? (Select all that apply) A. Proteinuria B. Hypertension C. Low-grade fever D. Facial edema E. Increased pulse rate
A, B, D
The nurse is assessing a 3-year-old child who has characteristics of autism. Which observed behaviors are associated with autism? (Select all that apply) A. Flicks the light in the examination room on and off repetitiously B. Has a flat affect. C. Demonstrates imitation and gesturing skills. D. The mother reports the child has no interest in playing with other children. E. Able to make eye contact.
A, B, D
The nurse is reviewing lab results on several hospitalized clients. For which clients would the nurse expect to see hypomagnesemia? (Select all that apply) A. A client with a fractured arm who reports being a heavy drinker. B. A client who is currently homeless and reports eating irregularly. C. A client with diabetes who is morbidly obese. D. A client who has had diarrhea and GI absorption issues. E. A client with Stage 4 esophageal cancer who is dealing with long term nutritional issues.
A, B, D, E
The nurse provides health teaching for a client seeking gender reassignment who is receiving estrogen therapy. Which statement by the client indicates the teaching was effective? (Select all that apply) A. "I need to check my blood pressure frequently when taking this medication." B. "I will call my provider if I have any redness or swelling in my legs." C. "I will drink extra fluids because this drug will cause me to urinate a lot." D. "I know that the drug will cause my breasts to feel tender." E. "I can get frequent headaches from taking this drug."
A, B, D, E
The nurse who suspects that a patient has early signs of ectopic pregnancy should be observing her for which symptoms? A. Pelvic pain B. Abdominal pain C. Unanticipated heavy bleeding D. Vaginal spotting or light bleeding E. Missed period
A, B, D, E
The student nurse learns that effective antimicrobial therapy requires which factors to be present? (select all that apply) A. Appropriate Drug B. Proper route of administration C. Standardized peak levels D. Sufficient dose E. Sufficient length of treatment
A, B, D, E
A nurse is providing education to a patient being discharged with a MRSA infection. Which of the following statements should the nurse include in her education? (select all that apply) A. You should launder your washcloth after every use. B. You can begin working out with your basketball team tomorrow. C. You should sleep in your own bed until after the infection has cleared. D. Every day you should clean any surface that comes in contact with your skin with household disinfectant or bleach water. E. You should always wash your hands with soap and warm water before and after touching the infected area and when handling the bandages.
A, C, D, E
A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances, the event organizers must limit giving the vaccination to priority groups. What patients would be considered a priority when administering the pneumonia vaccination? (Select all that apply) A. 22-year-old patient with asthma B. Patient who had a cholecystectomy last year C. Patient with well-controlled diabetes D. Healthy 72-year-old patient E. Patient who is taking medication for hypertension
A, C, D, E
A nurse is teaching patients with gastroesophageal reflux disease (GERD) about foods to avoid. Which foods would the nurse include in the teaching? (Select all that apply) A. Chocolate B. Chicken C. Citrus fruits D. Herbal tea E. Tomato Sauce
A, C, E
A client is admitted to the hospital with signs and symptoms of type 1 diabetes mellitus. Which findings is the nurse most likely to observe in this client? (Select all that apply) A. Excessive thirst B. Weight gain C. Constipation D. Excessive hunger E. Frequent, high-volume urination
A, D, E
A couple are asking the nurse about in vitro fertilization. What explanation by the nurse is best? A. "IVF places the product of conception from your sperm and her egg into the uterus." B. "A donor embryo will be transferred into your wife's uterus." C. "Donor sperm will be used to inseminate your wife." D. "Don't worry about the technical stuff; that's what we are here for."
A.
A nurse is providing discharge teaching to a client following an abdominal hysterectomy. Which of the following information should the nurse include in the teaching? A. "You should refrain from sexual intercourse for at least 4 weeks." B. "You should expect to have burning with urination for the first week." C. "You should soak in a warm tub bath to ease incisional pain." D. "You should limit lifting to objects of 20 pounds or less."
A.
A patient arrives to the clinic for evaluation of epigastric pain. The patient describes the pain to be relieved by food intake. In addition, the patient reports awaking in the middle of the night with a gnawing pain in the stomach. Based on the patient's description this appears to be what type of peptic ulcer? A. Duodenal B. Gastric C. Esophageal D. Stress
A.
A patient is hospitalized and on multiple antibiotics. The patient develops frequent diarrhea. What action by the nurse is most important? A. Consult with the provider about obtaining stool cultures. B. Delegate frequent perianal care to unlicensed assistive personnel. C. Place the patient on NPO status until the diarrhea resolves D. Request a prescription for an anti-diarrheal medication.
A.
A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed? A. Applying suction while inserting the catheter B. Preoxygenating the client prior to suctioning C. Suctioning for a total of three times if needed D. Suctioning for only 10 to 15 seconds each time
A.
Excessive anxiety in labor heightens the woman's sensitivity to pain by increasing: A. muscle tension B. blood flow to the uterus C. the pain threshold D. rest time between contractions
A.
The multiple marker screen is used to assess the fetus for which condition? A. Down syndrome B. Diaphragmatic hernia C. Congenital cardiac abnormality D. Anencephaly
A.
The nurse learns that which is the most common cause of spontaneous abortion? A. Chromosomal abnormalities B. Infections C. Endocrine imbalances D. Immunologic factors
A.
The patient with mild fluid volume overload has been instructed by the provider to follow dietary sodium restriction. What would the nurse teach this patient about sodium restriction? A. Do not add salt to ordinary table foods. B. Restrict sodium intake to 2 gms per day. C. Restrict sodium intake to 4 gms per day. D. Do not add salt when cooking or eating.
A.
The provider has ordered Aricept (donepezil) for the client with dementia. The family asks if this medication will cure the patient. The best response by the nurse includes which of the following information? A. Donepezil is a cholinesterase inhibitor and has been known to have positive effects when used in the early stage of Alzheimer's disease. B. Donepezil is an anticholinergic and has been known to eradicate some of the symptoms associated with Alzheimer's disease. C. Donepezil should be taken on an empty stomach. D. Donepezil shortens the early stages of Alzheimer's disease.
A.
What will the nurse teach the client with type 2 diabetes regarding exercise in his orher treatment program? A. During exercise, the body will use carbohydrates for energy production, whichin turn, will decrease the need for insulin. B. With an increase in activity, the body will use more carbohydrates; thereforemore insulin will be required. C. The increase in activity results in an increase in the use of insulin; therefore the client should decrease his or her carbohydrate intake. D. Exercise will improve pancreatic circulation and stimulate the Islets of Langerhans increase the production of intrinsic insulin.
A.
You are planning care for a patient with a K of 3.2 (hypokalemia)This could be caused due to your patient having GI suction. A. True B. False
A.
The nurse is aware that which factors are related to the development of gastroesophageal reflux disease (GERD)? (Select all that apply) A. Sitting upright after meals B. Eating large meals C. Hiatal hernia D. Obesity E. Viral infections
B, C, D
A nurse prepares to admit a patient who has herpes zoster. Which actions would the nurse take? (select all that apply) A. Prepare a room for reverse isolation. B. Assess staff for a history of or vaccination for chickenpox. C. Check the admission prescriptions for analgesia. D. Choose a roommate who also is immune suppressed. E. Ensure that gloves are available in the room.
B, C, E
A client has a calcium level of 14 mg/dL (hypercalcemia). Which intervention is the priority? A. Force fluids to 2 L/day B. Place the client on a cardiac monitor C. Assessing for Chvostek's sign every 2 hours D. Administering IV calcium chloride
B.
A diabetic patient has recently been diagnosed with peripheral neuropathy. What statement made by the patient indicates to the nurse that a knowledge deficit is present? A. "I will monitor my feet for injury on a daily basis." B. "My shoes are a half size to small, but I will continue to wear them because they do not cause pain." C. I will follow up with my physician if I notice wounds on my feet." D. "I will alternate what shoes I wear each day."
B.
A mental status change in an older patient who underwent a prostatectomy three days ago is to be expected. A. True B. False
B.
A nurse is assessing a client who is eight hours postpartum and multiparous. Which of the following findings should alert the nurse that the client needs to urinate? A. Moderate lochia rubra B. Fundus deviated to the right C. Moderate swelling of the labia D. Blood pressure 130/84 mm Hg
B.
A nurse is caring for patients in the prenatal clinical who are all 35 weeks along. Which patient should the nurse see first? A. Shortness of breath when climbing stairs B. Abdominal pain C. Ankle edema in the afternoon D. Backache with prolonged standing
B.
A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention would be most appropriate? A. Elevate the client's legs B. Massage the fundus until firm C. Ask the client to turn on her left side D. Assess for vaginal laceration
B.
A patient has been placed on Contact Precautions. The patient's family is very afraid to visit for fear of being "contaminated" by the patient. What action by the nurse is best? A. Explain to them that these precautions are mandated by law. B. Inform them that the infection is the issue, not the patient. C. Reassure the family that they will not get the infection. D. Tell the family it is important that they visit the patient.
B.
A patient is wearing a venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best? A. Assess the patient's oxygen saturation and, if normal, turn off the oxygen. B. Determine if the patient can switch to a nasal cannula during the meal. C. Have the patient lift the mask off the face when taking bites of food. D. Turn the oxygen off while the patient eats the meal and then restart it.
B.
A pulmonary nurse cares for patients who have chronic obstructive pulmonary disease (COPD). Which patient would the nurse assess first? A. A 46-year-old with a 30-pack-year history of smoking B. A 52-year-old in a tripod position using accessory muscles to breathe C. A 68-year-old who has dependent edema and clubbed fingers D. A 74-year-old with a chronic cough and thick, tenacious secretions
B.
A volleyball player was just diagnosed with exercise-induced asthma. The patient asks if she will be able to continue playing on her team. What would be the best response by the nurse? A. No. It would be too dangerous to participate in extensive workouts because it could cause bronchoconstriction. B. Yes. You should use your Albuterol inhaler 30 minutes prior to practice to help prevent, or reduce, bronchospasm. C. Yes. Exercise-induced asthma will not interfere with your ability to play sports. D. No. People with asthma should not play sports because it cannot be adequately controlled.
B.
Analyze the following diagnostic findings for your patient with type 2 diabetes. Which result will need further assessment? A. BP 126/80 B. A1C 9% C. Fingerstick Blood Glucose 130mg/dL D. LDL cholesterol 100mg/dL
B.
Signs and symptoms of hypovolemia associated with GI losses include: Tachycardia, increased blood pressure, increased urine output. A. True B. False
B.
The nurse assesses a client who has an elevated prostate-specific antigen (PSA) level. The nurse anticipates that this client will probably need which diagnostic test to accurately diagnose the presence or absence of cancer? A. Abdominal x-ray B. Biopsy C. CT-scan D. Small bowel examination
B.
The nurse is providing discharge teaching to a client who has undergone gender reassignment surgery to include bilateral breast augmentation and vaginoplasty. Which of the following should be included in the follow-up instructions? A. "You will need to have a pap smear every year." B. "You will need to have prostate health screening." C. "You will not need to be concerned about sexually transmitted infections." D. "You do not need to report bleeding to your provider."
B.
The nurse recognizes signs and symptoms of delirium in an 80-year-old client who is dying from metastatic breast cancer. What does the nurse do initially for this client? A. Requests an order for an antipsychotic medication to control these symptoms. B. Collaborates with the end-of-life (EOL) care team to evaluate possible medication-induced causes. C. Discontinues all medications that have central nervous system adverse effects. D. Assures the client's family that this terminal delirium indicates that death is imminent.
B.
The nurse understands that which of the following assessment findings may be a contributing factor for the client's recent experience with erectile dysfunction? A. The client plays golf twice a week. B. The client has been receiving treatment for type 2 diabetes mellitus for seven years. C. The client has a body mass index (BMI) of 24.5. D. The client's vital signs include a blood pressure of 118/68 mmHg.
B.
The perinatal nurse is giving discharge instructions to a woman, status post dilation and curettage (D&C) secondary to a hydatidiform mole (molar pregnancy). The woman asks why she must take oral contraceptives for the next 12 months. The best response from the nurse is: A. "If you get pregnant within 1 year, the chance of a successful pregnancy is very small. Therefore, if you desire a future pregnancy, it would be better for you to use the most reliable method of contraception available." B. "The major risk to you after a molar pregnancy is a type of cancer that can be diagnosed only by measuring the same hormone that your body produces during pregnancy. If you were to get pregnant, it would make the diagnosis of this cancer more difficult." C. "If you can avoid a pregnancy for the next year, the chance of developing a second molar pregnancy is rare. Therefore, to improve your chance of a successful pregnancy, it is better not to get pregnant at this time." D. "Oral contraceptives are the only form of birth control that will prevent a recurrence of a molar pregnancy."
B.
What intervention can be taught to the parents of a 3-year-old child with pneumonia who is not hospitalized? A. Offer the child only cool liquids. B. Offer the child favorite warm liquid drinks. C. Use a warm mist humidifier. D. Report a respiratory rate less than 28 breaths/min.
B.
When caring for a patient having a hypoglycemic episode, the nurse knows which symptom requires immediate intervention? A. Hunger B. Confusion C. Headache D. Tachycardia
B.
Which maternal factor may inhibit fetal descent and require further nursing interventions? A. Decreased peristalsis B. A full bladder C. Reduction in internal uterine size D. Rupture of membranes
B.
A client arrives at a birthing center in active labor. Her membranes are still intact, and the health care provider prepares to perform an amniotomy. What is the priority nursing assessment after amniotomy? A. Dilation of the client's cervix B. Assessing number of contractions C. Assessing the fetal heartrate D. Assessing the client's blood pressure
C.
A client complains of nocturia and difficulty starting a stream of urine. A diagnosis of benign prostatic hyperplasia (BPH) is made. Which statement by the client indicates the need for additional teaching? A. "There are nonsurgical treatment options available." B. "This condition may lead to cancer of the prostate." C. 'My symptoms will go away in the first few days of taking Proscar." D. "Alpha-blockers can be used to control my symptoms."
C.
A client had a transurethral resection of the prostate (TURP) with continuous bladder irrigation one day ago. The nurse notes the urinary drainage is pink-tinged and clear. What is the nurse's BEST action? A. Notify the charge nurse as soon as possible, B. Increase the rate of bladder irrigation. C. Document the assessment in the electronic medical record. D. Prepare the client for a blood transfusion.
C.
A client who delivered a baby 36 hours ago informs the nurse that she has been passing unusually large volumes of urine very often. What explanation for this manifestation should the nurse provide? A. Bruising and swelling of the perineum B. Swelling of the tissues surrounding the meatus C. Diuresis of extra fluids retained during pregnancy D. Decreased bladder tone due to anesthesia
C.
A couple is trying to cope with an infertility problem. They want to know what they can do to preserve their emotional equilibrium. What response by the nurse is most appropriate? A. "Tell your friends and family so that they can help you." B. "Talk only to other friends who are infertile, because only they can help." C. "Get involved with a support group. I'll give you some names." D. "You might start thinking about adoption to end this roller coaster of emotion."
C.
A nurse is caring for a client who has just delivered her first newborn. The nurse anticipates hyperbilirubinemia in the newborn due to Rh incompatibility. The nurse should understand that hyperbilirubinemia occurs with Rh incompatibility for which of the following reasons? A. The client's anti-A and anti-B antibodies cross the placenta and cause the destruction of the fetal red blood cells B. The client has a history of receiving a transfusion with Rh-negative blood C. The client's blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns. D. The client's blood contains the Rh factor and the newborn's does not, and antibodies that destroy red blood cells are formed in the fetus.
C.
A nurse is caring for several older patients in the hospital that the nurse identifies as being at high risk for healthcare-associated pneumonia. To reduce this risk, what activity should the nurse delegate to the unlicensed assistive personnel (UAP)? A. Encourage between-meal snacks. B. Monitor temperature every 4 hours. C. Provide oral care every 4 hours. D. Report any new onset of cough.
C.
A nurse is instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching? A. Limit alcohol consumption B. Increase intake of iron-rich foods C. Consume foods fortified with folic acid D. Avoid foods containing aspartame
C.
A nurse is teaching a client who has iron deficiency anemia about ferrous sulfate. Which of the following instructions should the nurse include in the teaching? A. Take the ferrous sulfate at bedtime. B. Take the ferrous sulfate with an antacid. C. Take the ferrous sulfate between meals. D. Take the ferrous sulfate with yogurt.
C.
A nurse is teaching a client who is at risk for iron-deficiency anemia about optimizing her dietary intake of iron. The nurse should explain that which of the following sources of iron is easiest for the body to absorb? A. Spinach B. Cantaloupe C. Chicken D. Lentils
C.
A patient with Type 1 diabetes presents to the emergency department complaining of abdominal pain, vomiting, dehydration from excessive urination, and lethargy. The nurse discovers his finger stick blood sugar is "high" and that he is having Kussmaul's respirations. She is concerned the patient may be in diabetic ketoacidosis (DKA). Which of the following lab values would confirm the nurses' suspicion? A. Negative ketones on the urine dipstick B. Serum glucose of 1018 C. Positive ketones on the urine dipstick D. Serum bicarbonate level of 24
C.
The nurse is reviewing the health care provider's orders for a client admitted for premature rupture of membranes (PROM). Gestational age of the fetus is determined to be 37 weeks. Which order should the nurse question? A. Monitor fetal heart rate (FHR) continuously B. Monitor maternal vital signs frequently C. Perform a cervical/vaginal examination every shift D. Administer ampicillin 1 gr as an intravenous piggyback every 6 hours
C.
The nurse is working with an overweight client who has a high-stress job and smokes. This client has just received a diagnosis of type 2 diabetes and has just been started on an oral hypoglycemic agent. Which of the following goals for the client, which if met, would be most likely to lead to an improvement in insulin efficiency to the point the client would no longer require oral hypoglycemic agents? A. Comply with medication regimen 100% for 6 months. B. Quit the use of any tobacco products by the end of three months. C. Lose a pound a week until weight is in the normal range for height and exercise 30 minutes daily. D. Practice relaxation techniques for at least five minutes five times a day for at least five months."
C.
The patient with diabetes mellitus reports having difficulty cutting his toenails. The patient states the toenails are thick and ingrown. Which of the following recommendations should be provided to this patient from the nurse? A. Cut the nails straight across with a clipper after the bath. B. Make an appointment with a nail shop for a pedicure. C. Make an appointment with a podiatrist. D. Offer to file the tops of the nails to reduce thickness after cutting.
C.
What should the nurse keep in mind when planning to communicate with a child who has autism? A. Has normal verbal communication. B. Expect the child to use sign language to communicate. C. May exhibit monotone speech and echolalia. D. Understands that the child is not listening if they are not looking at the nurse.
C.
A nurse in a clinic is interviewing a client who has a possible diagnosis of endometriosis. Which of the following findings in the client's history should the nurse recognize as consistent with a diagnosis of endometriosis? A. A history of syphilis B. Abdominal bloating starting several days before menses C. An atypical Papanicolaou smear at her last clinic visit. D. Dysmenorrhea that is unresponsive to NSAIDs.
D.
A nurse is assessing a client who has malnutrition. Which of the following findings should the nurse expect? A. Increased vital capacity B. Moist skin C. Heat intolerance D. Decreased mental status
D.
A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse identify as the priority? A. Epigastric discomfort B. Dyspepsia C. Constipation D. Hematemesis
D.
A nurse is interviewing a client with type 2 diabetes mellitus. Which statement by the client indicated an understanding of the treatment for this disorder? A. "I take oral insulin instead of shots." B. "By taking these medications I am able to eat more." C. "When I become ill, I need to increase the number of pills I take." D. "The medications I'm taking help me use the insulin I already make."
D.
A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take? A. Mix the three medications together prior to administering. B. Dilute each medication with 10 mL of tap water. C. Maintain the head of bed in a flat position for 30 minutes following medication administration. D. Flush the NG feeding tube with 30 mL of water immediately following medication administration.
D.
The infant with Down syndrome is closely monitored during the first year of life for what serious condition? A. Thyroid complications B. Orthopedic malformations C. Dental malformations D. Cardiac abnormalities
D.
The nurse explains to the student that increasing the infusion rate of non-additive intravenous fluids can increase fetal oxygenation primarily by: A. maintaining normal maternal temperature. B. preventing normal maternal hypoglycemia. C. increasing the oxygen-carrying capacity of the maternal blood. D. expanding maternal blood volume.
D.
The nurse is caring for a patient who had a tracheostomy 2 days ago. The nurse was repositioning the patient when the cannula became dislodged. What should be the initial action by the nurse? A. Call the Rapid Response Team B. Reinsert a tracheostomy tube using the obturator C. Call for a respiratory therapist to reinsert the tracheostomy tube D. Manually oxygenate the patient using a bag-valve-mask and facemask
D.
The nurse is preparing to care for four assigned clients. Which client is at highest risk for hemorrhage? A. A primiparous client who delivered 4 hours ago B. A multiparous client who delivered 6 hours ago C. A primiparous client who delivered 6 hours ago and had epidural anesthesia D. A multiparous client who delivered a large baby after oxytocin (Pitocin) induction
D.
The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breastfeeding her newborn. Which client statement would indicate a need for further teaching? A. I should breastfeed at least every 2 or 3 hours B. I should change the breast pads frequently C. I should wash my hands well before breastfeeding D. I should wash my nipples daily with soap and water
D.
The nurse is teaching a client about taking sildenafil (Viagra) for erectile dysfunction. Which statement by the client indicates a need for further teaching? A. "I should have sex within an hour after taking the drug." B. "I should avoid alcohol when on the drug or it might not work well." C. "I can expect to maybe feel flushed or get a headache when I take the drug." D. "If I have chest pain during sex, I should take a nitroglycerin tablet."
D.
The nurse is teaching about feeding concerns to a mom of an infant diagnosed with Down syndrome. What should be included in the care? A. Delaying feeding solid foods until the tongue thrush has stopped. B. Modifying diet as necessary to minimize the diarrhea that often occurs. C. Providing calories appropriate to child's age. D. Using special bottles that may assist the infant with feeding.
D.
What information should the nurse teach workers at a daycare center about RSV? A. RSV can be transmitted through particles in the air. B. RSV can live on skin or paper for up to a few seconds after contact. C. RSV can survive on nonporous surfaces for about 60 minutes. D. Frequent handwashing can decrease the spread of the virus.
D.
A client has continuous bladder irrigation after surgery one day ago. The amount of irrigation fluid that has infused over the last 12 hours is 1050 mL. The amount of fluid in the urinary drainage bag 1825 mL. How much urinary output should the nurse record in the electronic medical record? A. 775 mL B. 3000 mL C. 450 mL D. 725 mL
A.
A laboring woman is lying in the supine position. The most appropriate nursing action is to: A. ask her to turn to one side. B. elevate her feet and legs. C. take her blood pressure. D. let her stay in a position of comfort.
A.
The nurse is caring for a client diagnosed with fluid volume overload. Which of the following interventions should the nurse anticipate and implement? (Select all that apply) A. Encourage the client to adjust positions once every shift. B. Assess the skin frequently throughout the shift. C. Monitor intake and output. D. Perform weekly weights. E. Encourage the client to use salt substitutes.
B, C, E
A client comes into the clinic with the complaint of vomiting and watery diarrhea for several days. They state they can't "keep anything down." What assessment data (including labs) would the nurse anticipate? (Select all that apply) A. Capillary refill less than 2 seconds B. Serum Potassium of 3.0 mEq/L C. Muscle weakness D. HR 118 E. Voiding a large amount of dilute urine
B, C, D
A hospitalized child has developed a methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse plans which interventions when caring for this child? (select all that apply) A. Airborne Isolation B. Administration of Vancomycin C. Contact Isolation D. Administration of mupirocin ointment to the nares if colonized E. Administration of cefotaxime (Cefotetan)
B, C, D
A client with newly diagnosed type 2 diabetes mellitus asks the nurse what "type 2" means in relation to diabetes. The nurse explains to the client that type 2 diabetes differs from type 1 diabetes primarily in that with type 2 diabetes: A. The client is totally dependent on an outside source of insulin. B. There are a decreased insulin secretion and cellular resistance to insulin that is produced. C. The immune system destroys the pancreatic insulin-producing cells. D. The insulin precursor that is secreted by the pancreas is not activated by the liver.
B.
The nurse should ask specific questions about gender and sexuality when caring for a transgender client diagnosed with a sprained ankle. A. True B. False
B.
The nurse is caring for a client in renal failure with serum potassium of 7.1 mEq/L. Which of the following should the nurse do first? A. Assess level of consciousness. B. Measure urine output hourly. C. Assess blood gases. D. Obtain an electrocardiogram (ECG).
D.
Quiz 5 question 10?
??
A nurse teaches a patient who has viral gastroenteritis. Which dietary instruction would the nurse include in this patient's teaching? A. "Drink plenty of fluids to prevent dehydration." B. "Increase your protein intake by drinking more milk." C. "You should only drink 1 L of fluids daily." D. "Sips of cola or tea may help to relieve your nausea."
A.
A nurse is giving a parent information about autism. Which statement made by the parent indicates understanding of the teaching? A. Autism is characterized by periods of remission and exacerbation. B. The onset of autism usually occurs before 3 years of age. C. Children with autism have imitation and gesturing skills. D. Autism can be treated effectively with medication.
B.
A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse? A. Assess elimination patterns B. Elevate the head of the client's bed 30 - 45 degrees. C. Monitor intake and output every 8 hours. D. Check residual volume every 4 to 6 hours.
B.
A home health nurse visits a client with late stage Alzheimer's disease who lives at home with a spouse. In order to meet the needs of the spouse, what is the best response by the nurse? A. Making arrangements for the patient to spend afternoons at the local senior citizen's center. B. Providing the patient with a list of daily activities to complete to help out around the house. C. Encouraging the caregiver to take rest periods and avoid fatigue. D. Finding placement for the patient in a long term care facility.
C.
A laboring woman has just had an epidural placed for pain management. Which assessment by the nurse takes priority? A. Urinary output B. Contraction pattern C. Maternal blood pressure D. Intravenous infusion rate
C.
A patient is in the family practice clinic reporting a severe "cold" that started 4 days ago. On examination, the nurse notes that the patient also has a severe headache and muscle aches. What action by the nurse is best? A. Educate the patient on oseltamivir (Tamiflu). B. Facilitate admission to the hospital. C. Instruct the patient to have a flu vaccine. D. Teach the patient to sneeze in the upper sleeve.
D.
The nurse is educating a client who is scheduled for a permanent ileostomy. What should the nurse include regarding bowel function and care? A. A collection device over the stoma will always be required. B. Stool will gradually become semi-solid and formed C. Bowel control will progressively return. D. Oral fluid intake should be limited
A.
A nurse is reviewing the care plan for a client after a urinary diversion with an ileal conduit that includes all of the nursing diagnoses listed below. Which nursing diagnosis should the nurse place as the lowest priority? A. Altered skin integrity B. Disturbed body image C. Deficient fluid volume D. Acute pain
B.
A patient has vague symptoms that indicate an acute inflammatory bowel disorder. Which signs & symptoms are most indicative of Crohn's disease (CD)? A. Lower abdominal colicky pain relieved with defecation B. Chronic diarrhea, constant abdominal pain in the right lower quadrant, and low-grade fever. C. Multiple episodes of bloody diarrhea D. Constipation, weight loss, fatigue, and constant need to have a bowel movement that is not relieved by having a bowel movement.
B.
An abortion in which the fetus dies but is retained in the uterus is called ____ abortion. A. inevitable B. missed C. incomplete D. threatened
B.
The client diagnosed with renal calculi is admitted to the medical unit. What should be the nurse's first action? A. Monitor the client's urinary output. B. Assess the client's pain. C. Increase the client's oral fluid intake. D. Use a safety gait belt when ambulating the patient.
B.
The nurse is preparing to discharge a patient with urinary diversion. The nurse anticipates the patient will require some teaching prior to going home. Which of the following points will the nurse incorporate into the plan? A. The need to change the appliance every day. B. The importance of increasing fluid intake. C. Instructing the patient to notify the physician if the stoma is deep pink and moist. D. Instructing the patient that strands of blood may appear in the urine.
B.
A client with a chronic urinary tract infection (UTI) is scheduled for a number of laboratory tests. The nurse would note that which test result best evaluates whether the kidneys are being adversely affected? A. Serum potassium 3.8 mEq/L B. Urinalysis specific gravity 1.015 C. Serum creatinine 2.0 mg/dL D. Urine culture negative
C.
A patient has been newly diagnosed with ulcerative colitis (UC). What does the nurse teach the patient about diet and lifestyle choices? A. "Drinking carbonated beverages will help with your abdominal distress." B. "It's OK to smoke cigarettes, but you should limit them to ½ pack per day." C. "Lactose-containing foods should be reduced or eliminated from your diet." D. "Raw vegetables and high-fiber foods may help to diminish your symptoms."
C.
Which is a correct statement differentiating Crohn's disease (CD) from ulcerative colitis (UC)? A. Patients with Crohn's Disease experience about 20 loose, bloody stools daily. B. Nutritional issues are common with Ulcerative Colitis. C. Patients with Ulcerative Colitis may experience hemorrhage. D. Very few complications are associated with Crohn's Disease.
C.
Which statement made by a parent indicates an understanding about treatment of streptococcal pharyngitis? A. "I guess my child will need to have his tonsils removed." B. "A couple of days of rest and some ibuprofen will take care of this." C. "I should give the penicillin three times a day for 10 days." D. "I am giving my child prednisone to decrease the swelling of the tonsils."
C.
When taking a history on a child with a possible diagnosis of cellulitis, what should be the priority nursing assessment to help establish a diagnosis? A. Any pain the child is experiencing B. Enlarged, mobile, and nontender lymph nodes C. Child's urinalysis results D. Recent infections or signs of infection
D.
When the mother's membranes rupture during active labor, the fetal heart rate should be observed for the occurrence of which periodic pattern? A. Increase in baseline variability B. Nonperiodic accelerations C. Early decelerations D. Variable decelerations
D.
A school nurse is speaking with a teenage girl. The girl asks the school nurse why she is getting frequent urinary tract infections. The nurse concludes that the nursing diagnosis for this patient is knowledge deficit based on the patient's incorrect response to which of the following questions? A. "How often do you shower?" B. "Do you have a family history of urinary problems?" C. "When was your last UTI?" D. "In what direction do you wipe after a bowel movement?"
D.
The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of placental abruption. Which complication of placental abruption should the nurse assess for? A. Soft abdomen B. Uterine tenderness C. Absence of abdominal pain D. Painless, bright red vaginal bleeding
D.
The nurse is caring for a laboring client whose contractions are lasting approximately 120 seconds. Over the last 10 minutes, she has had 6 contractions, and when the nurse palpates the client's uterus between contractions, the uterus still feels moderately contracted. What is the priority nursing action? A. Provide pain relief measures B. Prepare the client for an amniotomy C. Promote ambulation every 30 minutes D. Decrease the rate of the oxytocin (Pitocin) infusion
D.
A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Nursing care is based on the knowledge that A. bed rest and analgesics are the recommended treatment. B. she will be unable to conceive in the future. C. a D&C will be performed to remove the products of conception. D. hemorrhage is the major concern.
D.
A couple comes in for an infertility workup, having attempted to get pregnant for 2 years. The woman, 37, has always had irregular menstrual cycles but is otherwise healthy. The man has fathered two children from a previous marriage and had a vasectomy reversal 2 years ago. What is the first test that should be performed? A. Testicular biopsy B. Antisperm antibodies C. FSH level D. Semen Analysis
D.
A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered? A. Creatine kinase B. Troponin C. Total bilirubin D. Albumin
D.
A nurse is assessing a client's colostomy during a pouching change and finds that the stoma is reddish pink and moist with slight bleeding when the mucosa is rubbed. What should the nurse do? A. Leave the pouch off because due to redness of the stoma. B. Reapply the pouch, and then call the healthcare provider about the bleeding at the stoma site. C. Immediately call the healthcare provider to report bleeding at the stoma site. D. Complete the pouching change because this is a normal assessment of the stoma.
D.
