Nursing Concepts Advanced Test

A nurse is reinforcing teaching with a client who is prescribed buspirone (BuSpar). Which of the following statements by the client indicates an understanding of the teaching? A. "I will only be on this medication 4 to 6 months because it can lead to physical dependence." B. "I can have 1 to 2 alcoholic beverages each week." C. "I will need to stop taking Xanax two weeks before I can begin taking this medication." D. "I can have 6 to 8 ounces of grapefruit juice each day."

"I can have 1-2 alcoholic beverages a week." Rationale: Buspirone is an anxiolytic medications used to treat anxiety, but is different from benzodiazepines because of the fact that it is not a CNS depressant. Because of this, it does not interfere with CNS depressants, such as benodiazepines, alcohol, or barbiturates, and it is acceptable to have 1-2 alcoholic beverages each week.

A nurse working in a provider's office is reinforcing teaching with a client who is 36 weeks of gestation and has experienced a premature rupture of membranes. Which of the following statements by the client indicates a need for additional teaching? A. "I will have my husband wear a condom during intercourse." B. "I will check my temperature every 4 hours." C. "I will wipe from front to back after bowel movements." D. "I will notify my doctor if my baby moves fewer than 4 times in the 2 hours following each meal."

"I will have my husband wear a condom during intercourse." NO SEX with PROM

A nurse is reinforcing teaching about client consent to treatment with a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates a need for further teaching? A. "It is necessary to have written consent for invasive procedures." B. "Implied consent is appropriate for some aspects of nursing care." C."It is the responsibility of the provider to obtain express consent." D. "Informed consent should be obtained separately for each surgical procedure."

"It is the responsibility of the provider to obtain express consent." Nurses frequently obtain express consent by witnessing a client sign a consent form after ensuring the client has received and understands necessary information regarding the procedure.

A nurse working in a hospice facility is talking to a client's son who is distressed because his mother cries frequently and says she wants to die. Which of the following responses by the nurse is appropriate? A. "I know this must be difficult, but your mother will calm down soon." ​B. "Let's discuss some strategies you can use when this happens again." C. "Individuals near death are ready to let go toward the end." D. "Have you determined why she is crying and saying she is ready to die?"

"Let's discuss some strategies you can use when this happens again."

A nurse is caring for a school-age child who is newly diagnosed with type 1 diabetes mellitus. Which of the following actions by the nurse is appropriate to prepare the child for administration of insulin? A. Provide a toy doctor's kit to play with. B. Keep all syringes and needles out of sight until needed. C. Use an approach that is firm but direct. D. Allow the child to manipulate the medical equipment.

Allow the child to manipulate the medical equipment Rationale: Allowing the child to manipulate the equipment facilitates mastery and gives the child a sense of accomplishment. This action is appropriate when preparing a school-age child for a procedure.

A nurse is caring for a client who has a urinary tract infection and is prescribed ciprofloxacin (Cipro). The client exhibits urticaria and angioedema following administration of the medication. Which of the following is the first action the nurse should take? A. Administer epinephrine (Adrenaline). B. Elevate the lower extremities. C. Determine respiratory status. D. Apply oxygen via non-rebreather mask.

Determine respiratory status Rationale: The client is experiencing angioedema, indicating the possibility of an anaphylactic reaction, which is life-threatening therefore, the nurse should first determine the clients respiratory status.

A nurse is caring for a client who is diabetic and is being discharged home following an above-the-knee amputation. Which of the following health care professionals should be involved in the client's interdisciplinary team meeting? (Select all that apply.) A. Dietician B. Physical therapist C. Hospice nurse D. Social worker E. Respiratory therapist

Dietitian Physical therapist Social Work

A nurse is caring for a client who was admitted for acute alcohol delirium withdrawal 2 days ago. Which of the following findings is associated with this diagnosis? A. Increased appetite B. Elevated temperature C. Bradycardia D. Drowsiness

Elevated temperature

A nurse is caring for a client who has an acid-base imbalance. For which of the following manifestations is metabolic alkalosis a possible complication? A. Hyperkalemia B. Severe diarrhea C. Atelectasis D. Excessive vomiting

Excessive vomiting

A nurse working in a provider's office is reinforcing teaching with a client who is 14 weeks of gestation. The nurse should instruct the client to immediately notify the provider if she experiences which of the following? A. Facial edema B. Urinary frequency C. Acid indigestion D. Breast leakage

Facial edema Rationale: Facial edema is an indication of pregnancy-induced hypertension and should be reported immediately to the provider

A nurse is caring for a neonate who was delivered at 30 weeks of gestation after his mother received two injections of betamethasone (Celestone). Because of the administration of betamethasone to the client's mother, the nurse should monitor the neonate for which of the following effects? A. Tachycardia B. Sternal retractions C. Hypoglycemia D. Hypothermia

Hypoglycemia

A nurse is caring for a client who had a cerebrovascular accident 2 days ago. Which of the following is the first sign of increased intracranial pressure (ICP)? A. Pupil dilation B. Ataxia C. Lethargy D. Bradycardia

Lethargy

A nurse at a long-term care facility is participating in a quality improvement project to reduce the occurrence of pressure ulcers. Which of the following audits should be conducted to determine the impact of a new skincare regimen on the incidence of pressure ulcers among clients who are immobile? A. Prospective audit B. Outcome audit C. Process audit D. Structure audit

Outcome audit

*A nurse is caring for a child who has leukemia and is prescribed a transfusion of platelets. Which of the following should the client experience as a result of the transfusion? A. Reduced bleeding time B. Decreased plasma globulins C. Improved activity tolerance D. Increased immune functioning*

Reduced bleeding time Rationale: Platelets are responsible for triggering the process of blood clotting. Clients who have leukemia are prone to bleeding because of low platelet counts and should therefore. experience a reduced bleeding time as a result of a transfusion of platelets.

A nurse has assigned four tasks to an assistive personnel (AP). Which of the following should the nurse instruct the AP to perform first? A. Take an ABG specimen to the laboratory. B. Transport a client to the radiology department for an x-ray. C. Obtain a clean catch urine sample from a newly admitted client. D. Pass fresh water to clients.

Take an ABG specimen to laboratory

A charge nurse on the pediatric unit is making assignments for a nurse who has floated from the labor and delivery unit. Which of the following clients is appropriate for the charge nurse to assign? A. A preschooler with a hip spica cast who is being discharged today B. An infant scheduled for a surgical repair of a ventricular septal defect tomorrow C. A toddler with a fractured femur who has been in Bryant's traction for 5 days D. An adolescent who is 2 days postoperative following an appendectomy

an adolescent who is 2 days post operative following an appendectomy Rationale: The care of an adolescent who is 2 days postoperative following an appendectomy requires postoperative care including education, infection prevention, and medications that require fundamental nursing skills and knowledge; therefore it is appropriate to assign this client to the nurse who has floated from the labor and delivery unit

A nurse is reinforcing teaching with the caregiver of a client who has aphasia. The nurse should include which of the following communication strategies in the teaching? A. Cue the client by providing picture cards that portray common needs. B. Increase the volume of the voice when speaking to the client. C. Encourage the client to limit hand gestures when communicating. D. Vary the use of phrases and terminology in discussions.

cue client by providing cards that portray common needs

A nurse is caring for an adult client who has attempted suicide. The client tells the nurse he is calling his family to come pick him up. Which of the following actions by the nurse is appropriate when the client insists on leaving the facility against medical advice? A. Assign a security guard to stay at the client's door. B. Request a prescription from the provider for soft restraints. C. Discuss the risks associated with leaving with the client. D. Remove the telephone from the client's room.

discuss risks associated with leaving

A nurse is caring for a client who is receiving parenteral nutrition through a nontunneled central venous catheter and reports hearing a gurgling sound on the side of the catheter. The nurse suspects the catheter has migrated to the jugular vein. Which of the following actions should the nurse take first? A. Notify the provider. B. Obtain a chest x-ray. C. Flush the catheter. D. Stop the infusion.

stop the infusion

A nurse is caring for a child who is 24 hr postoperative following a supratentorial craniotomy. The nurse should maintain the child in which of the following positions? A. Prone with head of the bed flat B. Dorsal recumbent with head of the bed elevated to 15° C. Supine with head of the bed elevated to 30° D. Side-lying with head of the bed elevated to 45°.

supine with head of the bed (HOB) elevated to 30 degrees