Fundamental of Nursing 10

58. (89010). A nurse notes the client's albumin level is 2.4 grams/dL. The nurse should plan to observe the client for which of the following at this time? a) Fluid retention b) Inelastic skin turgor c) Hypoactive bowel sounds d) Dry mucous membranes

a)

28. (60010). As part of an annual physical exam, a 60-year-old man has had lab work done. Which of the following serum creatinine levels would indicate that the patient has a mild degree of renal insufficiency? a) 4.0 mg/dL. b) 3.3 mg/dL. c) 1.7 mg/dL. d) 0.8 mg/dL.

c)

100. (61011). A male client suffered numerous types of wounds when he lost control of his motorcycle and was thrown onto the pavement. The client asks the nurse which wounds will scar more. The nurse's reply will be based on knowledge that which of the following wounds would generally be least likely to scar? a) A wound that heals by primary intention b) A wound that heals by secondary intention c) A wound that becomes infected d) A wound to an extremity

a)

13. (70019). The census on the unit is 90 percent and there are no private rooms available. An elderly patient with influenza is admitted. Which of the following rooms would it be appropriate to assign this patient? a) A double room with another patient who has the same diagnosis. b) A four-bed room with three patients who have had orthopedic surgery. c) A double room with an elderly patient with a diagnosis of chickenpox. d) A double room with a patient admitted for impetigo.

a)

15. (89006). A client is being evaluated for possible appendicitis. Which of the following results of laboratory tests suggests most strongly to the nurse the presence an acute bacterial infection? a) Elevated neutrophils b) Elevated erythrocytes c) Elevated lymphocytes d) Elevated platelets

a)

16. (77009). The pediatric nurse is a guest speaker for general health teaching in a prenatal class. In discussing factors that promote positive growth and development, the nurse stresses that the most important factor is: a) Nutrition b) Social income c) Exposure to secondary smoke d) Ethnic background

a)

20. (61016). The nurse is evaluating a client using a cane. Which observation made by the nurse would indicate that the a) Client is using the cane appropriately? b) Client holds the cane with the hand on the stronger side. c) Client moves the cane and the affected leg together. d) The cane tip is made of aluminum to prevent slippage.

a)

67. (28008). A nurse is assisting in developing a plan of care for a client with immunodeficiency. The nurse formulates which priority nursing diagnosis for the client? a) Risk for infection b) Deficient knowledge c) Ineffective coping d) Disturbed body image

a)

59. (86007). An Asian American client will be undergoing a cardiac echogram in a week. While the nurse is explaining the procedure, the client repeatedly nods the head and smiles at the nurse. What conclusion about this behavior would be most appropriate for the nurse to draw? a) The client does not speak English well but may be too embarrassed to share this information b) The client understands the procedure and is just waiting for the nurse to finish c) The client may not understand but is trying to hide this fact from the nurse d) The client may be trying to indicate politeness and a sense of harmony

d)

63. (751). A nurse is preparing to assist a Jewish client with eating lunch. A kosher meal is delivered to the client. Which nursing action is appropriate when assisting the client with the meal? a) Unwrapping the eating utensils for the client b) Replacing the plastic utensils with metal utensils c) Carefully transferring the food from paper plates to glass plates d) Asking the client to unwrap the utensils and allowing the client to prepare the meal for eating

d)

69. (758). An Hispanic-American mother brings her child to the clinic for an examination. Which of the following is important when gathering data about the child? a) Avoiding eye contact b) Using body language only c) Avoiding speaking to the child d) Touching the child during the examination

d)

11. (60009). A patient with suspected HIV will receive which test(s) to verify the diagnosis? a) Home Access HIV-1 Test System. b) Enzyme-linked immunosorbent assay (ELISA) and Western blot assay. c) Indirect immunofluorescence assay (IFA). d) ELISA and DNA.

b)

21. (77015). The toddler is admitted for severe anemia, which is found to be dietary in nature. To increase iron in the diet as a means of promoting healthy growth and development, the nurse recommends to the parents that they: a) Limit milk to no more than 32 oz/day. b) Increase fat-soluble vitamins in the diet c) Include grains and legumes in the daily intake d) Limit foods that are high in protein in the daily caloric requirement

a)

23. (55014). A man who is recovering from a prostatectomy complains of pain in his left calf, The nurse observes slight ankle swelling and elicits the Homan's sign. What is the best action for the nurse to take at this time? a) Tell him to stay in bed and notify the charge nurse b) Massage his leg to relieve the pain c) Place a blanket roll under his left knee d) Encourage active ambulation

a)

32. (905). The nurse is participating in a seminar about legal and ethical practice of nursing for continuing education credit. Which statement by a nurse best describes the relationship between law and ethics for the practice of nursing? a) "The ethics of a discipline attempt to formulate and justify responses to moral dilemmas and may or may not be regulated by law." b) "Laws dictate the ethics of nursing as they reflect societal choices about the ordering of relationships in society." c) "Ethics represent the moral customs of an individual nurse; therefore, they cannot be regulated by the law." d) "Ethical practice decreases the threat of a lawsuit, which is the primary source of legal influence on nursing practice."

a)

41. (41001). A nurse on the day shift walks into a client's room and finds the client unresponsive. The client is not breathing and does not have a pulse, and the nurse immediately calls out for help. The next nursing action is which of the following? a) Open the airway. b) Give the client oxygen. c) Start chest compressions. d) Ventilate with a mouth-to-mask device.

a)

5. (85002). A client who is legally blind has been admitted to the cardiac unit. Which of the following actions by the nurse would be best to promote adjustment to the environment? a) Speak slowly and in a low-pitched voice while facing the client. b) Post a sign on the door indicating the client is blind. c) Explain unit noises and physical surroundings. d) Give clear, concise, simple instructions to the client.

a)

54. (55008). An adult has returned to the surgical floor following an abdominal cholecystectomy and an uneventful stay in the postanesthesia room. Which nursing action should be the highest priority? a) Encourage the client to take deep breaths. b) Ask the client to flex and extend her feet. c) Assist the client in performing range-of-motion exercises. d) Irrigate the client's T-tube with normal saline.

a)

61. (904). An individual has a seizure while walking down the - street. During the seizure, a nurse from a physician's office is noticed driving past without stopping to assist. The individual sues the nurse for negligence but fails to win a judgment for which of the following reasons? a) The nurse had no duty to the individual. b) The nurse did what most nurses would do in the same circumstance. c) The nurse did not cause the client's injuries d) The nurse was off-duty at that time.

a)

66. (810). A client tells the nurse about his decision to refuse external cardiac massage. Which of the following would be the appropriate initial nursing action? a) Notify the physician of the client's request. b) Discuss the client's request with the family. c) Document the client's request in the client's record. d) Conduct a client conference to share the client's request.

a)

72. (58001). A 90-year-old client expresses a wish to die at home after being told that an esophageal stricture prevents swallowing. The client refuses a feeding tube. The family fully supports this decision. Which of the following would be most appropriate for the nurse to call? a) Hospice care b) The rabbi c) An attorney d) The medical examiner's office

a)

75. (85016). The nurse, who has a heavy work assignment for the day due to high client census, sees that a client is crying. Which of the following would be the best way for the nurse to convey a willingness to be with the client for support? a) State, "Let's talk while I change your colostomy bag." b) Ask, "Would you like to talk?" from the doorway, and go in if the client says yes. c) Pull up a chair, sit down, and state, "I see something is bothering you. Do you want to talk?" d) State, "I'll be back later and we can talk about what is troubling you at the moment."

a)

80. (153019). A client who had a mitral valve replacement is having a slow recovery. The client states, "I need to get better so that I can go hunting this season. If I'm not going to get better, I would be better off dead." Which response by the nurse is therapeutic? a) "Can you tell me more about the way you feel?" b) "Try to be a bit more positive." c) "There is plenty of hunting seasons ahead of you. Let's focus on what you need to do now to get better." d) "I know what you are saying. My husband is an avid hunter."

a)

85. (756). A nurse consults with a dietitian regarding the dietary preferences of an Asian-American client. Which of the following foods would the nurse likely include in the diet plan? a) Rice b) Fruits c) Red meat d) Fried foods

a)

89. (55011). The nurse is planning care for a woman who had an abdominal hysterectomy and bilateral salpingectomy and oophorectomy. The nurse knows that because of the location of her surgery, the client is at risk for the development of: a) thrombophlebitis. b) pneumonia. c) stress ulcers. d) wound infection.

a)

90. (38005). A nurse enters the nursing lounge and discovers that a chair is on fire. The nurse activates the alarm, closes the lounge door, and obtains the fire extinguisher to extinguish the fire. The nurse pulls the pin on the fire extinguisher. The next action would be to: a) Aim at the base of the fire. b) Squeeze the handle on the extinguisher. c) Sweep the fire from side to side with the extinguisher. d) Sweep the fire from top to bottom with the extinguisher.

a)

91. (58011). A client questions the nurse about the difference between a living will and power of attorney. The nurse's best response is which of the following? a) "The living will allows the client to indicate specific medical treatments to be omitted in the event of terminal illness, while durable power of attorney legally appoints "another to make those decisions on the behalf of the client. b) "A lawyer carries out a living will, while a designated family member or friend carries out advanced directives." c) "In a living will, the client specifies medical treatments to be carried out should he or she be incapable of making decisions, while durable power of attorney allows the client to include both treatments to be carried out and treatments to be omitted in d) "The living will indicates when a client wishes life support to be discontinued, while durable power of attorney gives that power to another in the event of terminal illness."

a)

99. (153026). A nurse is caring for a client who is dying. The nurse assists to develop a plan of care understanding that which intervention is inappropriate in the care of the client? a) Provide extremely thorough answers to each question asked by the client or family. b) Suggest making referrals to other disciplines based on the client's stated needs. c) Plan to balance the client's need for assistance with that for independence. d) Offer to contact the clergy to support the client's spiritual needs.

a)

(60017). A patient with symptoms of nausea and vomiting is admitted to the emergency department. He states that before he came to the hospital, when he tried to lie down, his abdominal pain got worse and was not relieved by antacids. When questioned, he states that he had consumed a large meal and two glasses of wine. The tentative diagnosis is acute pancreatitis. The physician orders lab work. With this complaint picture and diagnosis, the nurse would expect lab results to indicate a) Decreased white blood cell count. b) Elevated serum amylase and lipase. c) No change in serum bilirubin level. d) Elevated alkaline phosphatase.

b)

1. (757). An antihypertensive medication has been prescribed for a client with hypertension. The client tells the nurse that she would like to take an herbal substance to help lower her blood pressure. The nurse should: a) Tell the client that herbal substances are not safe and should never be used. b) Advise the client to discuss the use of an herbal substance with the physician. c) Teach the client how to take her blood pressure so that it can be monitored closely. d) Tell the client that if she takes the herbal substance, she will need to have her blood pressure checked frequently.

b)

18. (70009). CDC guidelines are specific for patients with tuberculosis. The major differences in providing care for the patient with TB versus other patients requiring barrier nursing are the a) Staff must wear gowns, mask, and gloves. b) Patient should be in a private room with a special ventilation system. c) Patient may be placed in a room with other patients requiring barrier nursing protocol. d) Protocol of donning and removing isolation garb before entering or leaving the patient?s room is different.

b)

2. (86000). While examining an infant, a home health nurse notices that he is wearing a soiled piece of braided yarn around his neck. Which action by the nurse is most appropriate? a) Leave the yarn in place but wash it with a cloth and mild soap b) Ask about its significance and suggest that it be placed more safely on his body. c) Explain that the yarn offers no benefit and ask the parents to remove it. d) Remove the yarn because it is soiled and could lead to strangulation

b)

22. (85000). The nurse has explained a therapeutic diet to a client. To ensure learning occurred, the nurse should do which of the following? a) Repeat the details of the diet once or twice more. b) Listen to comments from the client. c) Ask another nurse to verify the client understands the diet. d) Refer the client to a nutritionist.

b)

24. (61009). A female client can move her right arm and leg but has hemiplegia on the left. The nurse instructs the nursing assistant to do which of the following exercises on the client's left side during care? a) Active range of motion b) Passive range of motion c) Isotonic d) Isometric

b)

38. (85006). A nurse is evaluating a client's ability to change the surgical dressing before discharge. During the demonstration, the nurse notices the client has not performed the procedure correctly. The most appropriate action of the nurse would be to do which of the following? a) Immediately change the dressing again to demonstrate correct technique. b) Praise the client for aspects of the procedure done accurately and correct the client's mistakes c) Praise the client for steps completed correctly and refer the client to home care for follow up. d) Explain kindly that the procedure was performed incorrectly and have the client repeat the procedure.

b)

44. (28010). A client with a diagnosis of tonic-clonic seizures is being admitted to the hospital, and the nurse needs to institute seizure precautions. Which items is unnecessary and could cause harm to the client if used during a seizure? a) Padded side rails b) Restraints c) Nasal cannula d) Suction catheter

b)

49. (89014). The nurse checks the prothrombin time on a client with aortic valve replacement who is receiving sodium warfarin (Coumadin). The client's level is 20 seconds; control is 13 seconds. The nurse should take which of the following actions? a) Encourage client to eat foods high in vitamin K. b) Administer the daily dose of Coumadin as ordered. c) Monitor the client closely for signs of a deep vein thrombosis d) Withhold the next scheduled dose of Coumadin and notify the prescriber

b)

53. (85014). A nurse floating to the nursing unit learns during inter-shift report that a client suffered disfiguring injuries in an accident a week ago. What is the best way for the nurse to prepare for the first encounter with this client? a) Learn about the client's support systems (family, friends, religion). b) Obtain the specifics of the disfigurement to better control first reactions by the nurse. c) Review all medications and treatment procedures prior to meeting the client. d) Have all supplies and equipment ready to be able to provide efficient care.

b)

6. (906). A female client being treated in an outpatient setting for blood clots in the leg is taking anticoagulant medication. The client reports to her neighbor, a nurse, that she has a headache. The nurse offers the individual aspirin for the headache, which she takes. The client suffers a bleeding episode secondary to interaction between the aspirin and the anticoagulant. The legal nurse consultant interprets that which of the following elements of malpractice is missing from this case? a) Breech of duty b) Duty owed c) Injury d) Causation between nurse's action and injury

b)

60. (89002). The nurse inserts a nasogastric tube, and it immediately drains 1000 mL of fluid. Which of the following electrolyte levels is of greatest concern to the nurse at this time? a) Sodium b) Potassium c) Chloride d) CO2 content

b)

62. (86004). A hospice nurse in a small Appalachian community is caring for a client at home who is an active member of his church. As death nears, the minister and several members of the congregation come together in the home for a "death watch." Which action by the nurse is most therapeutic? a) Ask the minister to have church members come in scheduled time blocks to avoid overcrowding. b) Observe the client's religious beliefs and allow the family and minister unlimited access to the client. c) Allow the family and three other visitors at a time to stay with the client, but keep everyone else in the next room d) Explain that the watch will not be a problem as long as it does not conflict with medical care.

b)

64. (153029). A pregnant client experienced a uterine rupture with subsequent fetal death. After ensuring that the client is physiologically stable, the nurse uses which approach as the best first step to support the client psychologically? a) Suggests that family members see and hold the dead infant if they wish b) Find out how the client perceived the event c) Avoids talking about the dead fetus d) Asks the client and husband about plans for future pregnancies

b)

68. (805). A nurse enters a client's room and finds the client lying on the floor. The nurse checks the client and then calls the nursing supervisor and the physician to inform them of the occurrence. The nurse completes the incident report, understanding that it allows for the analysis of adverse client events through: a) Providing clients with necessary stabilizing treatments b) A method of promoting quality care and risk management c) Determining the effectiveness of interventions in relation to outcomes d) The appropriate method of reporting to local, state, and federal agencies

b)

7. (77000). The nurse is developing plans to reduce the stress of a hospitalized, chronically ill 8-year-old child. Coping for this child will be improved if the nurse arranges for the child to: a) Be allowed 24-hour open visitation with peers. b) Receive care specifically designed for a school-aged child. c) Avoid making any decisions while hospitalized. d) Have all tutoring postponed until discharge.

b)

73. (55004). A client who is about to have surgery asks the nurse why it is necessary to be shaved in that area. The best response for the nurse to provide is that hair is removed to: a) enhance vision of the surgical field. b) reduce the chance of infection as the skin is opened. c) prevent postoperative discomfort from adhesive tape. d) prevent itching in the postoperative period.

b)

74. (38006). A nurse obtainsan order from the physician to restrain a client using a jacket restraint and instructs the nursing assistant to apply the restraint to the client. Which of the following observations, if made by the nurse, would indicate the inappropriate application of the restraint? a) A safety knot in the restraint strap b) The restraint straps are safely secured to the side rails. c) The jacket restraint strap does not tighten when force is applied against it. d) The jacket restraint is secure, and two fingers can easily slide between the restraint and the client's skin.

b)

8. (28025). One unit of packed red blood cells in infusing into a client over a 4-hour period. The unit of blood contains 250 ML. The drop factor is 15 drops (gtt) per 1 ML. The nurse determines that the flow rate should be set at how many drops per minute? a) 1.10 gtt b) 2.16 gtt c) 3.18 gtt d) 4.20 gtt

b)

81. (908). The physician orders a medication in a dose that is considered toxic. The nurse gives the medication to the client, who later suffers a cardiac arrest and dies. Which of the following consequences can the nurse expect? a) The doctor, not the nurse, can be charged with negligence because the doctor ordered the dose. b) The nurse and the doctor can dually be charged with negligence. c) Because the nurse actually gave the medication, only the nurse can be charged with negligence. d) Negligence will not be charged, as this event could happen to any reasonable person.

b)

87. (28005). An older client says to the home care nurse, "I can't believe that my wife died yesterday. I keep expecting to see her everywhere I go in this house, ready to plan our activities for the day." Which of the therapeutic nursing response? a) "Try to focus on the fact that you have three wonderful children and that you and your wife loved one another for years." b) "It must be hard to accept that she has passed-away." c) "Are you saying that she made all the social plans for you?" d) "Focus on the fact that her suffering is over and that she had a good life with you."

b)

92. (77017). The nurse discusses swimming pool safety with the parents of 4-year-old twins. Which statement identifies that more instruction is needed? a) "We remove all toys from the pool area when not in use." b) "The twins wear flotation devices when they are in the pool by themselves." c) "Our children are enrolled in swimming classes. " d) "We always tell the twins not to run by the pool. "

b)

96. (901). A nurse forgets to administer a client's diuretic and the client experiences an episode of pulmonary edema. This medication error would be considered negligence if it constituted which of the following? a) The purposeful failure to perform a health care procedure b) The unintentional failure to perform a health care procedure c) The act of substituting a different medication for the one ordered d) Failure to follow a direct order by a physician

b)

(77010). The nurse working in a sexually transmitted infection (STI) clinic of the city health department gives a tour to a group of student nurses. A student notes that the clinic population consists largely of teenagers. The nurse explains to the group that adolescents are at a greater risk for contracting STIs because of which of the following factors? a) The immune system of an adolescent is immature b) Untreated urinary tract infections will develop into an STI c) Adolescents are risk-takers and believe they are invincible d) Adolescents often lack parental supervision

c)

10. (55007). The nurse is caring for a client who has just been admitted to the postanesthesia care unit. The client vomits. The nurse knows that the primary problem that can occur as a result of vomiting in the immediate postoperative period is which of the following? a) Electrolyte imbalance b) Dehiscence c) Aspiration d) Wound contamination

c)

12. (907). The client has decided to discontinue further treatment for cancer. Although the nurse would like the client to continue treatment, the nurse recognizes the client is competent and supports the client's decision using which of the following ethical principles? a) Justice b) Fidelity c) Autonomy d) Confidentiality

c)

14. (153036). A client with Bell's palsy says, "I knew I'd had a stroke when I woke up like this!" The nurse should make which therapeutic response to the client? a) "It must be very frightening for you. Tell me more about how you plan to cope with the limitations of your illness?" b) "Everything is going to be all right. You really have no cause to worry about the stroke." c) "It must be very difficult for you. How reassured you must be to learn that Bell's palsy is a temporary condition that resolves within a few weeks." d) "Let's not discuss the consequences until you're feeling stronger and learn to live with the aftermath of Bell's palsy."

c)

17. (28007). A nurse is collecting data from a client admitted to the hospital with a diagnosis of suspected gastric ulcer and is asking the client questions about pain. Which statement if made by the client would support the diagnosis of gastric ulcer? a) "The Pain that I get is located on the right side of my chest." b) "The pain gets so bad that it wakes me up at night." c) "My pain comes shortly after I eat, maybe a half hour or so later." d) "My pain comes shortly after I eat."

c)

19. (28018). A hospitalized client with a diagnosis of schizophrenia who is experiencing delusions says to the nurse, "I know that the doctor is talking to the CIA to get rid of me. "The nurse's best response is: a) "The doctor is not talking to the CIA." b) "I don't believe this is true." c) "I don't know anything about the CIA. Do you feel afraid that people are trying to hurt you?." d) "What makes you think the doctor wants to get rid of you?"

c)

27. (86006). The nurse is checking the dietary trays that have been delivered to the nursing unit. A client of Orthodox Jewish faith has received a tray containing a chicken dinner with vegetables, tea, and a carton of 2% milk. What action by the nurse is best? a) Instruct the nursing assistant to deliver the meal tray after removing the tea b) Call the dietary department to send a tray without chicken c) Have the dietary department replace the entire meal tray d) Ask the client if lactose-free milk would be preferred

c)

3. (58012). The nurse working with a terminally ill client wishes to support the client's decisions concerning end-of life care. To do this appropriately, the nurse should do plan to which of the following? a) Be comfortable in assisting the client with euthanasia when requested to do so. b) Ask another nurse to provide care if the client has a belief system that differs from the nurse's belief system. c) Respect the client's wishes about death to the extent possible by law. d) Encourage the client to request a do-not-resuscitate order because the client has been diagnosed with a terminal illness.

c)

30. (38000). A mother calls a neighborhood nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. The nurse would direct the mother to immediately: a) Induce vomiting. b) Call an ambulance. c) Call the poison control center. d) Bring the child to the emergency department.

c)

31. (801). A nurse enters a client's room and finds the client sitting on the floor. The nurse checks the client thoroughly and then assists the client back into bed. The nurse completes an incident report and notifies the nursing supervisor and physician of the incident. Which of the following is the next nursing action regarding the incident? a) Place the incident report in the client's chart. b) Make a copy of the incident report for the physician. c) Document a complete entry in the client's record concerning the incident. d) Document in the client's record that an incident report has been completed.

c)

33. (41007). Which of the following is the most appropriate location for assessing the pulse of an infant who is less than 1 year old? a) Radial b) Carotid c) Brachial d) Popliteal

c)

36. (86010). The nurse is caring for a Native American woman who has given birth. The nurse anticipates that the couple will make which request regarding the umbilical cord? a) To have it burned b) To have the blood drained from it c) To take it home d) To inspect it

c)

39. (755). A nurse is planning to reinforce nutrition instructions to an African-American client. When developing the plan, the nurse is aware that a common dietary practice of clients with African-American heritage is to eat: a) Raw fish b) Red meat c) Fried foods d) Rice as the basis for all meals

c)

45. (38004). A nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. The next nursing action would be to: a) Call for help. b) Extinguish the fire. c) Activate the fire alarm. d) Confine the fire by closing the room door.

c)

48. (58005). The nurse anticipates that which of the following clients newly diagnosed with a terminal illness is least likely to have difficulty facing his or her mortality? a) A 71-year-old female whose grandson, sister, and best friend died over the past 6 months b) A 59-year-old male who never married, is an only child, and whose parents are both healthy c) A 70-year-old male who has planned his funeral and enjoys riding his motorcycle at high speeds in rural areas d) A 68-year-old female who is an atheist

c)

50. (38002). A nurse is caring for a client with a health care-associated infection caused by methicillin-resistant Staphylococcus aureus who is on contact precautions. The nurse prepares to provide colostomy care to the client. Which of the following protective items will be required to perform this procedure? a) Gloves and a gown b) Gloves and goggles c) Gloves, a gown, and goggles d) Gloves, a gown, and shoe protectors

c)

51. (41006). A nurse is performing cardiopulmonary resuscitation (CPR) on an infant. When performing chest compressions, the nurse understands that the compression rate is at least: a) 60 times per minute b) 80 times per minute c) 100 times per minute d) 160 times per minute

c)

52. (77001). A mother brings her l5-month-old son to the clinic. During the exam, the mother makes the following comments. Which comment merits further investigation? a) "My son cries sometimes when I leave him at his grandparents' house." b) "My son always takes his blanket with him." c) "My son is not crawling yet." d) "My son likes to eat mashed potatoes."

c)

55. (61010). A client has weakness of the lower extremities and uses crutches for mobility. The nurse concludes the client needs further information about using crutches when the client does which of the following? a) Uses the swing-to gait b) Uses axillary crutches c) Bears weight on the armpits d) Has new rubber tips on the crutches

c)

57. (28012). A nurse provides dietary instruction to a client with meniere's disease. The nurse tells the client that which food or fluid item acceptable to consume? a) Coffee b) Tea c) Sugar-free jell-O d) Cold-cut meats

c)

65. (153016). Select all of the nursing interventions to be included in a plan of care for a client with schizophrenia who is experiencing disturbed thought processes. Schedule frequent one-hour sessions with the client. Demonstrate an attitude of caring and concern. Set goals for the client. Help the client identify the difference between reality and internal thought processes. Establish a nurse-client relationship contract mutually agreed on by the nurse and client. a) All of the above b) 1 & 3 c) 2, 4 & 5 d) 2 & 5 e) 1 & 5

c)

76. (61001). A 92-year-old client is in the hospital. The client is very hard of hearing, and the nurse needs to do the admission interview when speaking with the client? Which of the following should the nurse do? a) Obtain a cotton swab to clean cerumen in the client's ear before beginning the interview. b) Speak louder in the client's better ear after determining which has better hearing. c) Lower the pitch of the voice and face the client during the interview. d) Put new batteries in the hearing aid to ensure proper functioning.

c)

78. (70015). A nurse is assigned to provide care for a patient with AIDS. Infection control guidelines specify that a gown should be worn when the nurse a) Enters the room to provide patient care. b) Administers IV medications. c) Completes a dressing change. d) Administers an IM injection.

c)

83. (60003). At the physician`s office, a patient has a random plasma glucose test. The results were 250 mg/dL. The patient asked the office nurse why the doctor told him to come back the next day to repeat the test. The best Answeris a) "The doctor always repeats this test." b) "You may have diabetes and the doctor wants to be sure." c) "This test requires that it be done at least twice for accurate results." d) "It was a little high, so the doctor wants to check the results."

c)

88. (70010). The nurse is assigned to care for two patients. One patient has just returned from surgery for an abdominal resection. The second patient is hospitalized with an acute case of tuberculosis. What special precautions should the nurse take when providing care for these two patients? a) Proper handwashing between patients and use of specific isolation garb. b) Provide care to the patient with tuberculosis before the patient with abdominal surgery. c) Strictly adhere to barrier nursing principles. d) Thorough handwashing and gloving is sufficient in this situation.

c)

9. (60019). Which group of cells is the first line of defense against bacterial infection working primarily through phagocytosis? a) Monocytes. b) Platelets. c) Neutrophils. d) Basophils.

c)

93. (85018). A client can understand only minimal English, and no interpreter is available. What alternative measures can the nurse use to enhance communication? a) Speak loudly to the client b) Use a paper and pencil to write questions and information c) Use pictures and nonverbal cues to communicate d) Speak more slowly and face the client.

c)

94. (41002). A nurse witnesses a neighbor's husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to open the airway. The nurse opens the airway in this victim with the use of which method? a) Flexed position b) Head tilt-chin lift c) Jaw thrust maneuver d) Modified head tilt-chin lift

c)

97. (86003). A nurse is caring for two clients who have had abdominal surgery. One client is of Hispanic heritage, who writhes in pain and moans when touched. The other is an Asian client, who appears calm and rarely complains of pain or discomfort. The nurse appropriately draws which conclusion from these observations? a) The Hispanic client is exaggerating his pain. b) The Asian client is not experiencing pain c) The two clients have different culturally influenced ways of coping with pain. d) The Hispanic client may be exhibiting drug-seeking behavior

c)

98. (41009). A nurse is performing cardiopulmonary resuscitation (CPR) on an adult client. The nurse understands that when performing chest compressions, one should depress the sternum: a) ¾ to 1 inch b) ½ to ¾ inch c) 1½ to 2 inches d) 2½ to 3 inches

c)

25. (58010). Which talking to adult children of a dying male client, the nurse finds them tearful, with ambivalent feelings toward the client. The client often expresses beliefs of a wasted life. The children say that their father often showed love but followed it with criticism, anger, damaging accusations, and emotional abuse. The nurse would suggest which of the following interventions that is most likely to be helpful at this time? a) Listen to relaxation tapes before visiting each other. If negative feelings arise, listen to the tapes together. b) Have a nurse present in the room at all times when a family member visits the client so that the nurse can intervene with conflict resolution if problems arise. c) Assure the client and children that the past no longer matters the only time that matters is the present and the future. Encourage the children to spend more time with their father. d) Make a videotape of each adult child telling a story of a time when their father showed love, while the client tells of a special love for each child. Plan a time for them to watch it together.

d)

26. (60008). A patient with coronary artery disease has an LDL cholesterol level of 140 mg/dL. His physician has recommended that he start on Mevacor to lower the level and slow the progression of atherosclerosis. While reinforcing discharge teaching, the nurse should emphasize a) Taking this medication with niacin to lower the LDL level. b) Notifying the physician if the patient`s gums begin to bleed. c) Reporting a rash, myalgia, or blurred vision. d) The drug causes sensitivity to the sun, hence the need for sunscreen and protective clothing.

d)

29. (41004). A nurse attempts to relieve an airway obstruction on a 3-year-old conscious child. The nurse performs this maneuver by placing the hands between: a) The groin and the abdomen b) The umbilicus and the groin c) The lower abdomen and the chest d) The umbilicus and the xiphoid process

d)

34. (61004). An of the following clients appear in the emergency room during one shift. The nurse would clarify with the physician the reason for an antibiotic order for a client with which of the following injuries? a) Cat bite to the hand of an elderly client b) Laceration from broken glass in a 6-year-old client c) Stab wound in a37-yearold client d) Closed-fractured ankle in a 40-year-old soccer player

d)

35. (89019). The white blood cell (WBC) count of a client is 18,000 cells/microliter. The nurse attributes this value to which of the following health problems of this client? a) Rheumatoid arthritis b) History of alcoholism c) Viral infection d) Wound dehiscence

d)

4. (55002). An adult is to have abdominal surgery this morning. Immediately preoperatively, the nurse must ensure that he: a) is comfortable. b) has an empty bowel. c) practices coughing. d) voids.

d)

40. (85008). While caring for an elderly female client, the nurse enhances communication by doing which of the following? a) Speaking loudly and using many gestures b) Questioning the client quickly to conserve the client's energy c) Questioning the client with family present to verify responses to questions d) Restating terms or phrases in different ways if the client does not understand

d)

43. (802). An unconscious client who is bleeding profusely is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which of the following is the best action? a) Call the nursing supervisor to initiate a court order for the surgical procedure. b) Try calling the client's spouse to obtain telephone consent before the surgical procedure. c) Ask the friend who accompanied the client to the emergency department to sign the consent form. d) Transport the client to the operating department immediately, as required by the physician, without obtaining an informed consent.

d)

46. (41003). A nurse understands that which of the following is a correct guideline for adult cardiopulmonary resuscitation (CPR) for a health care provider? a) One breath should be given for every five compressions. b) Two breaths should be given for every 15 compressions. c) Initially, two quick breaths should be given as rapidly as possible. d) Each rescue breath should be given over 1 second and should produce a visible chest rise.

d)

70. (811). A nurse is documenting information regarding a client's care into the computerized medical record. Which of the following actions by the nurse would be inappropriate? a) Change the password for entering computer files at least monthly. b) Shred the printout of the nurse's flowchart at the end of the nurse's shift. c) Use own user name and password when logging into the computer system. d) Leave the computer terminal immediately after logging in to check on the status of a client.

d)

71. (89007). The nurse is assigned to the care of a client who has been admitted with meningitis. A spinal tap has been performed. Which of the following cell types in the spinal fluid suggests that the client has become infected with viral meningitis? a) Platelets b) Neutrophils c) Red blood cells d) Lymphocytes

d)

77. (70008). A nurse is assigned to take two patients` vital signs, complete a focus assessment and provide hygienic care, administer meds, and complete a dressing change for a patient with an abdominal wound. Which task will have priority with this assignment? a) Complete a focus assessment and provide hygienic care on the first patient. b) Administer medications to the patient. c) Complete the dressing change. d) Take vital signs on the two patients.

d)

79. (153001). A client receiving therapy at a mental health clinic says to the nurse, "When I have a stressful day at work and when my boss is on my case all day, I go home and take my frustrations out on my children." The appropriate response to the client is which of the following? a) "Why do you do this? Can you think of another way to take out your frustrations?" b) "The only way to take out your frustrations is to join a health care center that provides equipment for weightlifting and boxing." c) "Is there someplace that you can go after work to relieve your frustrations before going home?" d) "Let's talk about some other ways that you can handle your frustrations."

d)

82. (58009). A year-old hospitalized client with a recent diagnosis of acquired immunodeficiency syndrome (AIDS) says to the nurse, "The food on this breakfast tray is terrible. Why can't you people do even simple things well? "What is the nurse's best response? a) "I know you are angry, but I cannot let you make me the object of your anger.. I will send up the dietitian."" b) "This is not about breakfast. Tell me what you are really angry about." c) "I understand you are angry. I'll shut the door and let you cool off." d) "I hear a lot of anger in your voice that is quite normal and healthy. Do you want a new breakfast or do you want something else."

d)

84. (70014). Gloves are an important component of infection control protocol. Which of the following situations would not require that gloves be worn? a) When the nurse is in contact with urine. b) Suctioning a patient who does not have an infectious disease. c) Changing an ostomy pouch. d) Delivering a food tray to a patient with AIDS.

d)

86. (750). A client is diagnosed with cancer and is told that surgery followed by chemotherapy will be necessary. The client states to the nurse, "I have read a lot about complementary therapies. Do you think that I should try any?" The nurse responds by making which appropriate statement? a) "You need to ask your physician about it." b) "I would try anything that I could if I had cancer." c) "No, because it will interact with the chemotherapy." d) "There are many different forms of complementary therapies. Let's talk about these therapies."

d)

95. (38008). A nurse is assisting with planning care for a client with an internal radiation implant. Which of the following is an inappropriate component for the nurse to include in the plan of care? a) Wearing gloves when emptying the client's bedpan b) Keeping all linens in the room until the implant is removed c) Wearing a lead apron when providing direct care to the client d) Placing the client in a semiprivate room at the end of the hallway

d)