Knowledge and Clinical Judgment

A nursing supervisor is determining bed placement for four clients. which of the following clients should be placed on droplet precautions? 1- A client who has rubella 2- A client who has measles 3- A client who has hepatitis A 4- A client who has Rocky Mountain spotted fever

1- A client who has rubella

A nurse is planning to obtain blood pressure on four clients. on which of the following clients should the nurse perform an electronic blood pressure measurement? 1- A client who is recovering from a cardiac catheterization 2- A client who is in stage 4 of Parkinson's disease 3- A client who has anorexia and hypotension 4- A client who has a temperature of 39.1 C (102.4 F) and is shivering

1- A client who is recovering from a cardiac catheterization

A nurse is caring for a client who has terminal pancreatic cancer. the client is competent and has requested no resuscitative measures be taken in the event of respiratory or cardiac arrest. which of the following is necessary to legally change the client's code status to do-not-resuscitate (DNR)? 1- A written prescription from the provider 2- Signed documentation from the client 3- Family support of the decision 4- Admission to hospice for palliative care

1- A written prescription from the provider

A nurse is caring for a client who is postoperative following a wedge resection of a lung and has a chest tube with a water seal chest tube drainage system. the client reports a burning pain in his chest. which of the following actions by the nurse is appropriate? 1- Assist the client to side-lying position 2- Remove 10 mL of water from the suction control chamber 3- Apply a padded clamp on the tubing for 1-2 minutes 4- Move the drainage system above the level of the client's heart

1- Assist the client to side-lying position

A nurse is reinforcing teaching about diet for dumping syndrome to a client who is postoperative following a gastrectomy. which of the following food selections by the client indicates the teaching was effective? 1- Toast with peanut butter 2- Apple juice 3- Yogurt with fresh fruit 4- Beef broth

1- Toast with peanut butter

A nurse is caring for a client with bipolar disorder and is taking lithium. which serum level indicates the client's dosage is appropriate for maintenance therapy? 1- 0.25mEq/L 2- 0.75mEq/L 3- 1.5mEq/L 4- 2.25mEq/L

2- 0.75mEq/L

A nurse is collecting data on a client who is diagnosed with schizophrenia and is taking clozapine. Which of the following findings indicates the client is experiencing an adverse effect of the medication? 1- weight loss 2- WBC 2,800/mm3 3- Heart rate 64/min 4- Insomnia

2- WBC 2,800/mm3

A nurse is caring for a toddler who has acute otitis media and is prescribed benzocaine ear drops for pain relief. which of the following actions by the nurse is appropriate when administering them? 1- Place the child on the affected side for several minutes upon completion of instillation 2- Warm refrigerated drops to room temperature prior to instillation 3- Pull the pinna of the ear upward and back during instillation 4- Massage the area posterior to the ear after instillation

2- Warm refrigerated drops to room temperature prior to instillation

Pt weighs 132 lb and has been prescribed gentamicin 5mg/kg/day by IV in three equal doses. Available is 40mg/mL that is to be added to 50mL 0.9% sodium chloride. How many mL should the nurse add to the solution per dose?

2.5mL/dose

A nurse is caring for a client who is pregnant with a single fetus and has a BMI of 23. how much weight should she gain during pregnancy? 1- 10-15 lb 2- 15-20 lb 3- 25-35 lb 4- 35-45 lb

3- 25-35 lb

A nurse is collecting data on a newborn who was delivered 30 minutes ago at the gestational age of 37 weeks. which of the following findings requires further intervention? 1- Vesicular rash 2- Respiratory rate 54/min 3- Abdominal distention 4- Heart rate 142/min

3- Abdominal distention

A nurse is caring for a client who is scheduled for a lumbar puncture. the nurse should teach the client that what is a post-procedure complication? 1- Hypothermia 2- Polyuria 3- Headache 4- Seizures

3- Headache

A nurse is caring for a school-age client who was diagnosed with sickle cell anemia and has been admitted for a vaso-occlusive crisis. what has the highest priority? 1- Hematocrit 32% 2- WBC 16/mm3 3- Slurred Speech 4- Yellowed sclera

3- Slurred Speech

A nurse is caring for a client who has a new colostomy. the client is being discharged and plans to live with her daughter. what response is appropriate when the daughter states she doesn't know how she is going to care for her mother's colostomy? 1- "It's quite simple. I'll make sure that her colostomy bag is clean before she leaves and you'll have no problems." 2- " Is the colostomy care the only reason you mother is going to be living with you?" 3- "A home health nurse will be stopping by tomorrow. If you have any questions, you can ask her." 4- " What part of you mother's care concerns you?"

4- " What part of you mother's care concerns you?"

A nurse is reinforcing teaching about a new prescription for cromolyn sodium (Intal) metered-dose inhaler (MDI) to a child who has asthma. which statement indicates the child needs further teaching? 1- "I will be sure to use my nebulizer four times per day." 2- "I can't use my cromolyn nebulizer for a sudden asthma attack." 3- "It will be several weeks before I notice an improvement in my asthma." 4- "I will use my cromolyn nebulizer before using my albuterol inhaler."

4- "I will use my cromolyn nebulizer before using my albuterol inhaler."

A school nurse has requested the school board to remove a piece of playground equipment due to a documented increase in injuries that can be linked back to it. the nurse's actions are an example of what? 1- Deontology 2- Morality 3- Principlism 4- Advocacy

4- Advocacy

A nurse is providing education to the parent of an infant who is newly diagnosed with biliary atresia. the nurse should teach the parent that which of the following is a clinical manifestation associated with the illness? 1-Rapid weight gain 2- Tar-colored stools 3- Lethargy 4- Dark urine

4- Dark urine

A nurse is assigned to care for four clients. the client with which tube is at an increased risk for hypokalemia? 1- Nephrostomy tube to drainage bag 2- Indwelling catheter to gravity 3- Chest tube to water seal 4- NG tube to suction

4- NG tube to suction

A nurse is caring for a client who is experiencing night sweats and hemoptysis and is suspected to have active pulmonary tuberculosis. which of the following tests is used to confirm this diagnosis? 1- Tuberculin Test 2- Chest x-ray 3- Enzyme-linked immunoassay (ELISA) test 4- Sputum culture for acid-fast bacillus

4- Sputum culture for acid-fast bacillus