NU 302 Beginning Diagnostic Exam (questions I missed)

The emergency department protocol provides for administration of alteplase (tPA) for clients with confirmed acute coronary syndrome (ACS). The nurse contacts the healthcare provider to clarify the order for the client with which health history? a. atrial fibrillation and a mild stroke one month ago b. myocardial infarction one year ago with angioplasty c. hypertension, dyslipidemia, and peripheral artery disease d. no previous history of cardiovascular disease

a. atrial fibrillation and a mild stroke one month ago

A client being treated for complications of chronic obstructive pulmonary disease needs to be intubated. The client has previously discussed their wish to not be intubated with the client's partner of 5 years, whom the client has designated as healthcare power of attorney. The client's children want their parent to be intubated. A nurse caring for this client knows that a. clients commonly confer healthcare power of attorney on someone who shares their personal values and beliefs. b. the client's partner is responsible for national legislation regarding surrogate decision makers. c. the children's biological relationship with their parent supersedes the partner's wishes. d. healthcare providers must honor the children's wishes to avoid a lawsuit.

a. clients commonly confer healthcare power of attorney on someone who shares their personal values and beliefs

A postpartum mother is concerned about a noted decrease in her breast milk production. Which response by the nurse best addresses this mother's concern? a. Decrease supplemental feedings with formula. b. Suggest the mother consume a diet high in vitamin C. c. Have several alcoholic beverages for relaxation. d. Feed the infant less frequently.

a. decrease supplemental feedings with formula

The nurse teaches the client with type 1 diabetes mellitus about the importance of maintaining stable blood glucose levels. The nurse should suggest the client include which type of food to minimize the rise in blood glucose level after meals? a. dietary fiber b. dairy products c. vitamin-fortified foods d. meats

a. dietary fiber

Which amount of daily milk intake should the nurse include in the plan of care for a 15-month-old? a. ½ to 1 cup (125 to 250 mL) b. 2 to 3 cups (500 to 750 mL) c. 3 to 4 cups (750 to 1,000 mL) d. 4 to 5 cups (1,000 to 1,250 mL)

b. 2 to 3 cups (500 to 750 mL)

The nurse at a substance abuse center answers the phone. A probation officer asks if a client is in treatment. The nurse responds, "No, the client you're looking for isn't here." Which statement bestdescribes the nurse's response? a. correct, because the nurse didn't give out information about the client b. a violation of confidentiality because the nurse informed the officer that the client wasn't there c. a breach of the principle of veracity because the nurse is misleading the officer d. illegal, because the nurse is withholding information from law enforcement agents

b. a violation of confidentiality because the nurse informed the officer that the client wasn't there

The nurse is performing discharge teaching for a client who experienced a recent heart attack. The client reports feeling excited and ready to go home and "get on with life." What response by the nurse is most appropriate? a. "While I am happy you are going home, your lifestyle will have to change considerably." b. "What are your plans for when you get home and back to getting on with your life?" c. "You sound excited to be recovering from your heart attack! A positive attitude is important" d. "Do you recall the teaching done by the physiotherapist related to your heart attack?"

b. what are your plans for when you get home and back to getting on with your life?

A charge nurse is making client care assignments for the day. Which client would be mostappropriate to assign a licensed practical nurse (LPN)? a. 6-month-old infant with pneumonia on oxygen b. 1-month-old infant with bronchiolitis with a respiratory rate of 60 c. 6-year-old child 2-day post-op appendectomy with a surgical drain d. 4-year-old child with nephrotic syndrome with 4+ protein in the urine

c. 6-year-old child 2-day post-op appendectomy with a surgical drain

The nurse performs the initial assessment and reports the following findings to the health care professional: The client's contractions started 5 hours ago and are now coming every 3 minutes and lasting for 60 seconds. The cervix is 100% effaced and 5 cm dilated, the membranes are intact, and the presenting part is well applied to the cervix and is at -1 station. The nurse recognizes that the client is in which stage of labor? a. second b. latent c. active d. third

c. active

The nurse is assessing a client, who has lung cancer with spinal metastasis, for pain. The client tells the nurse that the ordered opioid medication helps, but there is still a shooting pain down the client's left leg. Identify the best pharmacologic measure to address this pain. a. a higher dose of the opioid b. an adjuvant, such as ibuprofen c. an adjuvant, such as gabapentin d. a different opioid medication

c. an adjuvant, such as gabapentin

A postpartum client gave birth 6 hours ago without anesthesia and just voided 100 ml. The nurse palpates the fundus two fingerbreadths above the umbilicus and off to the right side. What should the nurse do first? a. Administer ibuprofen. b. Reassess in 1 hour. c. Catheterize the client. d. Obtain a prescription for a fluid bolus.

c. catheterize the client

While performing an assessment of a 75-year-old client in the emergency department, a nurse notes many bruises in various stages of healing on the client's body. After documenting the locations of the bruises in the medical record, which step should the nurse take immediately? a. Notify the nursing supervisor. b. Notify the physician. c. Obtain more information from the client about the nurse's findings. d. Follow the facility's policy and procedures for reporting elder abuse.

c. obtain more information from the client about the nurse's findings

While reviewing the admission assessment of a client scheduled for colorectal surgery, the nurse discovers that the client stopped taking medications to treat emphysema 3 months ago. What would be a priority in planning collaborative care with the respiratory therapist? a. Reinforce teaching of coughing and deep breathing. b. Instruct on how to best induce a sputum specimen. c. Timely administration of breathing treatments. d. Instruct on reporting abnormal color and consistency of sputum produced.

c. timely administration of breathing treatments

A client with iron-deficiency anemia is prescribed liquid iron supplements. The nurse evaluates the client's understanding of how to take this drug. Which statement indicates the client has adequate knowledge? a. "I can use antidiarrheal drugs if I develop diarrhea." b. "I will report any black stools to the health care provider." c. "I will check my gums for any bleeding." d. "I will dilute the medication and drink it with a straw."

d. I will dilute the medication and drink it with a straw

A client recovering from a stroke is prescribed a leg brace and needs to be transferred out of bed to a chair. Which action should the nurse take first before beginning this transfer? a. Lower the head of the bed. b. Assist the client to a sitting position in bed. c. Roll the client away from the side of the transfer. d. Apply the leg splint before beginning the transfer.

d. apply the leg splint before beginning the transfer

A client with a history of chronic cystitis comes to an outpatient clinic with signs and symptoms of this disorder. To prevent cystitis from recurring, the nurse recommends maintaining an acid-ash diet to acidify the urine, thereby decreasing the rate of bacterial multiplication. On an acid-ash diet, the client must restrict which beverage? a. cranberry juice b. coffee c. prune juice d. milk

d. milk

A client with heart failure must be monitored closely after starting diuretic therapy. The best indicator for the nurse to monitor is a. fluid intake and output. b. urine specific gravity. c. vital signs. d. weight.

d. weight

The nurse is caring for a client who has a order for 1000 mL of IV fluid every 8 hours. When the nurse's shift began at 8 pm, there was 500 mL remaining in the IV fluid bag. How many mL would the nurse expect to be in the bag at midnight?

0 mL

After gathering all necessary equipment and setting up the supplies, what should be the first step in performing endotracheal (ET) or tracheal suctioning in an infant? a. Provide extra oxygen by using a ventilator or through manual bagging. b. Insert a suction catheter to the appropriate measured length. c. Insert a few drops of sterile saline solution. d. Put on clean gloves.

a. provide extra oxygen by using a ventilator or through manual bagging

An adolescent girl is being treated for anogenital warts caused by the human papillomavirus (HPV). What is the nurse's priority intervention for this client? a. Educate the client about the need to adhere to antibiotic therapy. b. Educate the client about the accompanying risk of cervical cancer. c. Assess the client's knowledge of hormonal contraceptives. d. Assess the client for signs and symptoms of systemic infection.

b. educate the client about the accompanying risk of cervical cancer

A client is diagnosed with iron deficiency anemia. When teaching the caregivers about using supplemental iron elixir, the nurse should provide which instruction? a. "Give the iron preparation with milk." b. "Give the elixir with water or juice." c. "Monitor the child for episodes of diarrhea." d. "Give the iron preparation before meals."

b. give the elixir with water or juice

A child with cystic fibrosis has been admitted to the pediatric unit. What type of diet should the nurse request for the client? a. high-fat, high-carbohydrate b. high-calorie, high-protein c. high-calorie, high-carbohydrate d. high-carbohydrate, high-protein

b. high-calorie, high-protein

Which finding should lead the nurse to decide that spinal shock was resolving in the adolescent with a spinal cord injury? a. atonic urinary bladder b. flaccid paralysis c. hyperactive reflexes d. widened pulse pressure

c. hyperactive reflexes

A client is being treated for alcoholism. After a family meeting, the client's spouse asks a nurse about ways to help the family deal with the effects of the spouse's alcoholism. The nurse should suggest that the family join which organization? a. Al-Anon b. Make Today Count c. Emotions Anonymous d. Alcoholics Anonymous

a. Al-Anon

As part of a quality improvement team, the nurse uses the plan-do-study-act method to address unit-based alarm fatigue. The team has interviewed stakeholders to identity opportunities for reducing alarms and collaborated with the equipment vendors to gather alarm data. What should the nurse do next? a. Analyze the patterns to identify which devices account for the most alarms. b. Conduct a staff training on ways to reduce wave artifact alarms. c. Prioritize which alarm parameters need visual, audio, or secondary alerts. d. Revise default alarm parameters for the unit's client population.

a. analyze the patterns to identify which devices account for the most alarms

A client returns from extracorporeal shock wave lithotripsy with ecchymosis over the left flank area. Vital signs are within normal limits, and the client appears to be in no acute distress. Which nursing action is appropriate? a. Apply a cold compress to the site. b. Notify the healthcare provider immediately. c. Place the client in the left lateral position. d. Maintain NPO status (nothing by mouth) in anticipation of surgical intervention.

a. apply a cold compress to the site

The nurse is verifying the identity of a client prior to administering medication. The client has had a stroke and has ataxia. What is the best action by the nurse? a. Ask the client to state name and birthdate. b. Give client paper and pencil with which to write name and birthdate. c. Recall the client's facial features to verify the client's identity. d. Ask two staff members to state the name of the client in the room.

a. ask the client to state name and birthdate

At which time should the nurse anticipate assisting a client to breastfeed her neonate? a. during the neonate's first period of reactivity b. in about 2 hours, after the baby has been evaluated c. in about 4 hours, after the baby has had some sleep d. after the neonate's first period of reactivity

a. during the neonate's first period of reactivity

A nurse from a surgical unit is asked to work on the pediatric unit during a staffing shortage. The surgical nurse has not worked in pediatrics for 10 years and is not familiar with the unit. The surgical nurse approaches the nurse manager and claims not to be competent to work on the pediatric unit. What should the nurse manager do? a. Find another nurse to cover the unit and send the nurse back to the surgery unit. b. Tell the nurse to buddy up with someone else and do the best that the nurse can do. c. Tell the nurse that as an RN, the nurse should be competent to work in any area. d. Give the nurse the lightest workload on the unit.

a. find another nurse to cover the unit and send the nurse back to the surgery unit

An assessment of a client on the first day after a thoracotomy shows a temperature of 100° F (37.8° C); heart rate, 96 bpm; blood pressure, 136/86 mm Hg; and shallow respirations at 30 breaths/min, with rhonchi at the bases. The client is diaphoretic, anxious, and reports of incisional pain. Which nursing action is priority? a. Medicate the client for pain as ordered. b. Help the client get out of bed. c. Give ibuprofen as ordered to reduce the fever. d. Encourage the client to cough and breathe deeply.

a. medicate the client for pain as ordered

After the physician explains the risks and benefits of a clinical trial to a client, the client agrees to participate. Later that day, the client requests clarification of the process involved in the clinical trial. As a member of the multidisciplinary team, how should the nurse respond? a. Provide the information requested. b. Encourage the client to withdraw from the trial. c. Not provide the information because it's beyond the scope of nursing practice. d. Tell the client that the information should come from the physician who first presented it to them.

a. provide the information requested

A client with severe shortness of breath comes to the emergency department. The client tells the emergency department staff that they recently traveled to China for business. Based on the client's travel history and presentation, the staff suspects severe acute respiratory syndrome (SARS). Which isolation precautions should the staff institute? a. droplet precautions b. airborne and contact precautions c. contact and droplet precautions d. contact precautions

b. airborne and contact precautions

A client admitted for alcohol detoxification is taking disulfiram. The nurse should instruct the client to avoid ingestion of which foods and/or liquids? Select all that apply. a. aged cheese b. beer c. communal wine at church d. chocolates e. cough syrup

b. beer c. communal wine at church e. cough syrup

When a client cannot read or write but is of sound mind, the nurse should read the informed consent to the client in the presence of two witnesses and do what next? a. Have the client's next-of-kin sign the informed consent. b. Have the client put an "X" on the signature line. c. Have a court appoint a guardian for the client. d. Have a hospital quality management coordinator sign for the client.

b. have the client put an "X" on the signature line

The physician orders "acyclovir, 200 mg P.O., every 4 hours while awake" for a client with herpes zoster. The nurse should inform the client that this drug may cause a. palpitations. b. dizziness. c. diarrhea. d. a metallic taste.

c. diarrhea

A client with chronic renal failure is admitted with a heart rate of 122 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, jugular vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client? a. electrolyte disturbance b. urinary retention c. excess fluid volume d. toileting self-care deficit

c. excess fluid volume

The health care provider (HCP) has prescribed insulin detemir for a client with type 2 diabetes requiring insulin. What should the nurse teach the client about this insulin? a. "You may increase the carbohydrates in your diet when using this insulin." b. "You do not need to rotate injection sites with this insulin." c. "You do not mix insulin detemir; the solution is clear." d. "You may refill the detemir insulin pen."

c. you do not mix insulin detemir; the solution is clear

A client is scheduled for cardiac catheterization the next morning. The physician ordered temazepam, 30 mg by mouth at bedtime, for sedation. Before administering the drug, the nurse should know that: a. sedatives cause predictable responses; hypnotics cause unpredictable ones. b. sedatives interact with few drugs; hypnotics interact with many. c. sedatives don't depress respirations; hypnotics do. d. sedatives reduce excitement; hypnotics induce sleep.

d. sedatives reduce excitement; hypnotics induce sleep

An overweight adolescent has been diagnosed with type 2 diabetes. What should the nurse do to increase the client's self-efficacy to manage the disease? a. Provide the client with a written daily food and exercise plan. b. Discuss eliminating junk food in the home with the parents. c. Arrange for the school nurse to weigh the child weekly. d. Utilize a peer with type 2 diabetes to role model lifestyle changes.

d. utilize a peer with type 2 diabetes to role model lifestyle changes

The client is advised by the health care provider to have mammography screening annually. Measures to improve adherence with mammography screening include: a. making sure that the individual barriers to screening are minimized. b. emphasizing that mammography screening can prevent breast cancer. c. emphasizing that mammography screening is a low-cost approach to cancer prevention. d. informing the client that she is at high risk for breast cancer and needs to follow the health care provider's recommendation.

a. making sure that the individual barriers to screening are minimized

The client is in the oliguric phase of acute renal failure. For which risk should the nurse assess the client? a. pulmonary edema b. metabolic alkalosis c. hypotension d. hypokalemia

a. pulmonary edema

A client presents to a physician's office complaining of dyspnea with exertion, weakness, and coughing up blood. Further examination reveals peripheral edema, crackles, and jugular vein distention. The nurse anticipates the physician will make which diagnosis? a. pulmonary hypertension b. chronic obstructive pulmonary disease (COPD) c. empyema d. pulmonary tuberculosis

a. pulmonary hypertension

A pregnant mother who has brought her toddler to the clinic for a check-up asks the nurse how she can keep her next baby from becoming obese. The mother plans to bottle-feed her next child. Which information should the nurse include in the teaching plan to help the mother avoid overnourishing her infant? a. recognizing clues indicating that a baby is full b. establishing a regular feeding schedule c. supplementing feedings with sterile water d. adding more water than directed when preparing formula

a. recognizing clues indicating that a baby is full

The registered nurse (RN) is teamed with a licensed practical/vocational nurse (LPN/VN) in caring for a group of cardiac clients on a pediatric unit. Which action by the LPN/VN indicates the nurse should intervene immediately? a. The LPN/VN assists a child to the bathroom 2 hours after a cardiac catheterization. b. The LPN/VN places an infant having a cyanotic episode in a knee-chest position. c. The LPN/VN checks a child's apical heart rate prior to administering digoxin. d. The LPN/VN brings breakfast to a child who is scheduled for an electrocardiogram.

a. the LPN/VN assists a child to the bathroom 2 hours after a cardiac catheterization

A client asks the nurse what factors affect how long it will take for a hip to heal following hip replacement surgery. What are the best responses by the nurse? Select all that apply. a. the age of the client b. the height of the client c. the gender of the client d. the client's comorbidities e. the client's marital status

a. the age of the client d. the client's comorbidities

A 10-year-old child is admitted with a brain tumor. Which assessment made by the nurse is mostcritical to report to the child's health care provider (HCP)? a. vomiting after lunch b. difficulty in recalling the day of the week c. blood pressure of 102/62 mm Hg d. 100 mL of concentrated urine voided at one voiding

b. difficulty in recalling the day of the week

What type of isolation precautions would the nurse request for a child diagnosed with group-A beta-hemolytic streptococcus? a. universal precautions b. droplet precautions c. contact precautions d. airborne precautions

b. droplet precautions

As she tries to decide on a birth control method, a client requests information about medroxyprogesterone. Which statement represents the nurse's best response? a. "Medroxyprogesterone needs to be administered every 12 weeks." b. "Medroxyprogesterone is effective for only 2 months at a time." c. "Medroxyprogesterone can't be given to breast-feeding women." d. "Medroxyprogesterone has a high failure rate; use a barrier form of protection also."

b. medroxyprogesterone is effective for only 2 months at a time

A client is receiving intravenous fluids and upon assessment presents with increased pulse, increased respirations, and jugular vein distension. What is the priority action by the nurse? a. Repeat the vital signs in 1 hour. b. Slow the intravenous rate and notify the physician. c. Lower the head of the bed. d. Administer oxygen and encourage the client to breathe deeply.

b. slow the intravenous rate and notify the physician

When inspecting a client's skin, a nurse finds a circumscribed elevated area filled with serous fluid. What term should the nurse use to document this finding? a. macule b. papule c. vesicle d. pustule

c. vesicle

When providing nursing care to a client of African descent, which cultural factors should the nurse consider? a. Values and beliefs are often present oriented. b. Families are usually patriarchal. c. They possess weak religious affiliations. d. Families are highly competitive.

a. values and beliefs are often present oriented

Which risk factor would most likely contribute to the development of a client's hiatal hernia? a. having a sedentary desk job b. being 5 feet, 3 inches (160 cm) tall and weighing 190 lb (86.2 kg) c. using laxatives frequently d. being 40 years old

b. being 5 feet, 3 inches (160 cm) tall and weighing 190 lbs (86.2 kg)

A client on the behavioral health unit spends several hours per day organizing and reorganizing the closet. The client repeatedly checks to see if the clothing is arranged in the proper order. What term is commonly used to describe this behavior? a. obsession b. compulsion c. exhibitionism d. transference

b. compulsion

A health care provider (HCP) prescribes a lengthy X-ray examination for a client with osteoarthritis with severe pain. Which action by the nurse would demonstrate client advocacy? a. Contact the X-ray technician to see if the lengthy session can be divided into shorter sessions. b. Contact the HCP to determine if an alternative examination could be scheduled. c. Request a prescription for acetaminophen prior to the examination. d. Request padding and careful positioning for the hard X-ray table.

a. contact the x-ray technician to see if the lengthy session can be divided into shorter sessions

A client who has been diagnosed with renal calculi reports that the pain is intermittent and less colicky. Which nursing action is most important at this time? a. Report hematuria to the health care provider (HCP). b. Strain the urine carefully. c. Administer morphine every 3 hours. d. Apply warm compresses to the flank area.

b. strain the urine carefully