RN question trainer test 1 review
which symptoms suggest to the nurse that a client has developed an Addisonian crises? 1-bilateral arm pain and vision changes 2-confusion and rapid, weak pulse 3-dark pigmentation of the skin and headache 4-joint pain and anorexia
2
The nurse leads a parenting class for a group of expectant clients. how many extra calories a day does the nurse advise consuming while breastfeeding? 1-200 2-300 3-400 4-500
4
a 6-month-old is brought to the clinic for a well-baby checkup. During the exam, the nurse expects to observe which assessment finding? (Select all that apply) 1-a pincer grasp 2-sitting with support 3-tripling of a birth weight 4-presence of the posterior fontanelle 5-bearing weight when held in standing position 6-rolling from back to abdomen
2, 5, 6
The nurse discusses growth and development with the parents of a preschooler. Which type of play does the nurse identify as characteristic of this age group? 1-solitary play 2-parallel play 3-associative play 4-aggressive play
3
Which client information does the nurse recognize as being the most pertinent to the diagnoses of cholecystitis? 1-flatulence 2-N/V 3-right upper abdominal pain 4-dyspepsia
3 -dyspepsia can be from other GI problems other than cholecystitis
The nurse provides care for a newborn diagnosed with fetal alcohol spectrum disorder; the nurse expects to see which physical characteristics? 1-large for gestational age, craniofacial deformities, and hydrocephalus 2-small head circumference, low birth weight, and undeveloped cheek bones 3-large head circumference, low birth weight, and excessive rooting and sucking behaviors 4-normal head circumference, low birth weight, and respiratory distress syndrome
2
in the process of normal adjustment to a terminal illness, the nurse knows that client's initial denial and isolation will give way to a second stage. the second stage of grief is characterized by which behavior 1-acceptance 2-bargaining 3-anger 4-depression
3
The nurse provides care for a client diagnosed with hepatitis. It has been determined that the infection was transmitted through contaminated food. based on how the infection was transmitted, the client is likely experiencing which type of hepatitis? 1-hep D 2-hep C 3-hep B 4-hep A
4
The nurse prepares a teaching plan regarding colostomy irrigation. the nurse includes which information? 1-the colostomy needs irrigation at the same time every day and 1hr after a meal 2-irrigate the colostomy after meals to increase peristalsis 3-insert the catheter about 10 inches into the stoma 4-the solution should be at least 100F to increase dilation and flow
1
The nurse provides care for a client after a hernia repair in the PACU. since the client has vomited twice, the nurse places the client in which position? 1-side lying 2-prone 3-supine 4-trendelenburg
1
The nurse notes that a client diagnosed with Parkinson disease takes benztropine. the nurse recalls which adverse effect is expected? (Select all that apply) 1-urinary retention 2-diarrhea 3-constipation 4-blurred vision 5-tinnitus 6-dry mouth 7-drowsiness
1,3,4,6
a 6-month-old is brought to the clinic for a well-baby checkup. During the exam the nurse expects to observe which assessment finding? (Select all that apply) 1-a pincer grasp 2-sitting with support 3-tripling of the birth weight 4-presence of the posterior fontanelle 5-bearing weight when held in standing position 6-rolling from back to abdomen
2,5,6
Which action is the best way for the nurse to assess the fluid balance of an older adult client? 1-assess the client's blood pressure 2-check the client's skin turgor 3-determine if the client is thirsty 4-weigh the client daily at the same time
4
the nurse notes that a client had a polyethylene glycol-electrolyte and a soapsuds enema with previous evening for a colon resection. the client passed a medium amount of soft brown stool. which conclusion by the nurse is the most accurate? 1-the bowel preparation is incomplete 2-the client ate something after midnight 3-this is an expected finding before this type of surgery 4-the client passed the last stool in the colon
1
the nurse provides care for a client diagnosed with ataxia. which action is most important 1-supervise ambulation 2-measure I&O 3-consult an orthopedic surgeon 4-elevate the foot of the bed
1 -ataxia results from damage to the part of the brain that controls muscle coordination.
a client evaluated for infertility is prescribed clomiphene citrate 50mg daily for 5 days. the client asks the nurse how the medication works. which response by the nurse is best? 1-it induces ovulation by changing hormonal effects on the ovary 2-it changes the uterine lining to be more conductive to implantation 3-it alters the vaginal pH to increase sperm motility 4-it produces multiple pregnancies for those who desire twins
1 -clomiphene citrate induces ovulation by altering estrogen and stimulating follicular growth to produce a mature ovum
A middle age client diagnosed with a paranoid disorder reports a family member is trying to steal the client's property. the nurse suspects which symptoms are being demonstrated? 1-delusions of persecution 2-command hallucinations 3-delusions of reference 4-grandiose delusions
1 -delusions of persecution is a strongly held belief not validated by reality, such as mistreating, conspiring against, or planning to harm someone
A school age child has early stages of nephrotic syndrome. the nurse discusses which protein adjustments with the parents? 1-moderate-protein, low sodium intake 2-low protein, high fat intake 3-high protein, high potassium intake 4-limited protein, high sodium intake
1 -low sodium to control edema
a client comes to the outpatient psychiatric clinic for treatment of a fear of heights. the nurse knows that phobias involve which behaviors? 1-projection and displacement 2-sublimation and internalization 3-rationalization and intellectualization 4-reaction formation and symbolization
1 -projection is blaming an external object and displacement involves ventilation of an intense feeling
a client develops an infection and receives ceftriaxone sodium IV every day. it is most important for the nurse to monitor which change? 1-bloody, loose stools 2-hemoglobin and hematocrit 3-skinfold surfaces 4-urine characteristics
1 -this med can cause pseudomembranous colitis which presents as diarrhea containing pus or blood
The nurse provides care for an older adult client receiving chemotherapy for gastric cancer. the nurse recalls which helps prevent infection? (Select all that apply) 1-hand hygiene 2-limit immunizations 3-preventative antibiotics 4-standard precautions 5-private room
1,4,5
the nurse prepares discharge teaching for a client newly diagnosed with hypothyroidism. which client statement indicates that teaching was successful? 1-I may not be able to tolerate hot weather 2-I should change positions slowly 3-I will lose weight much easier now 4-I may notice frequent diarrhea
2
the nurse provides care for a client diagnosed with a pneumothorax. The client has a chest tube connected to a three-chamber water seal drainage system with 20 cm suction. The nurse determines the lung has re-expanded by which observation? 1-there is no drainage in the collection chamber for 3hrs 2-the fluid in the water seal chamber does not fluctuate with respirations 3-there is continuous bubbling in the water seal chamber 4-there is gentle bubbling in the suction control chamber
2
the nurse provides care for an infant scheduled for a barium swallow in the morning. Before the procedure, it is most important for the nurse to take which action? 1-offer the infant only clear liquids 2-make the infant NPO for 3hrs 3-feed the regular infant formula 4-maintain NPO status for 6hrs
2
the nurse provides care for the prenatal client at 8wks gestation with a positive venereal disease research lab test. the client is in the tertiary stage. which information is most important to include in the teaching plan? 1-avoid any over the counter medications 2-return for the two additional injections of medication 3-refrain from sexual activity for 6 months after the third dose of medication 4-confidentiality of sexual partners is maintained
2
the health care provider prescribes mannitol IV for a client with a closed head injury. which response does the nurse recognize as the desired outcome of this medication? 1-a BP increase to 150/90 2-urinary output increase to 175ml/hr 3-a decrease in level of activity 4-absence of fine tremors of the fingers
2 -mannitol is an osmotic diuretic that increases urinary output to decrease intracranial pressure
The PACU nurse provides care for a client diagnosed with type 2 diabetes following surgical debridement of a leg wound. which client statement indicates that additional teaching is needed? 1-I may need insulin temporarily due to the stress of surgery 2-I will need to monitor my wound for signs of infection 3- I will need insulin for the rest of my life since surgery 4-I will need to keep my leg bandage clean and dry
3
The nurse prepares an older adult for an intravenous pyelogram. The client asks the nurse to explain why the procedure is performed. the nurse's response is based on which explanation? 1-the health care provider can directly observe the kidney pelvis area 2-an IVP assesses the glomerular filtration rate and the presence of kidney stones 3-the health care provider can examine the urinary tract by x-ray 4-an IVP determines if the medication injected into the urinary system shows on the exam
3
The nurse provides care for a client the day after a kidney transplant. When the client's adult child visits, the nurse provides which instruction? 1-there are no specific actions needed 2-a double mask and gloves will keep you safe 3-wash hands before entering the room 4-wear a gown, mask, and gloves
3
The nurse strokes the sole of a newborn's foot and observes for dorsiflexion of the great toe. Then the nurse holds the infant upright and allows the bottom of the foot to touch the examining surface, and observes the knee and hip flexion. Which two reflexes does the nurse assess? 1-plantar and stepping reflexes 2-trunkal incurvation and Babinski reflexes 3-babinski and stepping reflexes 4-palmer and plantar reflexes
3
a client, gravida 2 para 1, is admitted with hypertension at 32 weeks' gestation. The client reports the wedding band tight. the nurse assesses for which additional indications of pre-eclampsia? 1-general edema and visual disturbances 2-epigastric pain and headache 3-proteinuria and retinal vascular constriction 4-polyuria and hypertonic reflexes
3
The nurse provides care for a client receiving a blood transfusion. After 30 min, the nurse assesses the client. which symptom indicates a severe allergic reaction? 1-bounding peripheral pulses 2-chills 3-respiratory wheezing 4-lower back discomfort
3 -a severe reaction includes anxiety, abdominal pain, dyspnea, respiratory wheezing, bronchospasm and hypotension leading to shock and possible death
A school age client diagnosed with achondroplasia is seen in the clinic. Which clinical manifestation is the nurse most likely to observe? 1-strong muscle tone. 2-delayed intelligence 3-short stature 4-coarse, dry skin
3 -achondroplasia is a genetic disorder. it's primary feature is dwarfism
The nurse reviews discharge instructions for a client recently prescribed oral hydrocortisone as a replacement for cortisol. The nurse recognizes the teaching was successful when the client makes which statement about the action of this medication? 1-this medication helps my body respond to flight or fight 2-it helps my body absorb the calcium supplements 3-it manages how my body uses proteins and fat for storage 4-it makes sure my bones and muscles function well
3 -cortisol converts proteins and fats into energy sources
The parents of a child diagnosed with hemophilia asked the nurse to explain the cause of the disease. Which response by the nurse is best? 1-the father transmits the gene to the son 2-both parents carry a recessive trait 3-the mother transmits the gene to her son 4-there is a 50% chance that the mother will pass the trait to each daughter
3 -hemophilia is a sex-linked disorder on the x chromosome. since the males have only one x chromosome, it will be visible in that male if that chromosome has the trait.
A postoperative cataract client is cautioned about not making sudden movements or bending over. The nurse understands the rationale is to prevent which complication? 1-impairement of cerebral blood flow and headaches 2-decreased intracranial pressure 3-increased fluid pressure compromising the surgical site 4-displacement of the lens implant
3 -sudden changes in position, constipation, vomiting, stooping or bending over increase the intraocular pressure and damage the surgical site
A client with an endotracheal tube requires suctioning. Which statement is an accurate description of how the nurse performs the procedure? 1-inserts the suction catheter 4 inches into the tube, applies suction for 30 seconds, and then withdraws the catheter 2-hyperoxgenates, inserts the catheter into the tube suction, and wipes the catheter with an alcohol swab after removal 3-explains the procedure to the client, inserts the catheter gently while applying suction, and assesses the client's status 4-inserts the suction catheter until resistance is met, then withdraws slightly and applies suction intermittently as the catheter is removed
4
The nurse observes a client with anxiety having increased wringing of hands and purposeless pacing. Which intervention will the nurse initiate to support the client? 1-seclude the client in one area of the unit 2-accompany the client to group session 3-engage the client to discuss emotions 4-walk with the client without conversation
4
The nurse performs ROM exercises for an older adult client inactive due to injury. The nurse identifies which statement as correct? 1-passive ROM exercises increase muscle strength 2-a full ROM must be completed for an older adult 3-exercises should be completed to eh point of discomfort 4-ROM assists the older adult in carrying out ADL's
4
a client who receives IV antibiotics reports redness, pain, and burning at the site. the nurse recalls which IV complication is occurring? 1-infiltration 2-displacement 3-occlusion 4-phlebitis
4
the nurse knows which mood-altering drugs are most often associated with an increased risk for HIV infection related to IV drug use 1-benzodiazepines 2-marijuana 3-barbiturates 4-narcotics
4
the nurse provides care for a client with a new diagnosis of herpes zoster that is diffusely spread over the abdomen and back, the nurse recalls which is true about the transmission of herpes zoster? 1-standard precautions are needed until lesions completely heal 2-droplet precautions are needed for at least 3-5 days 3-contact precautions are needed until lesions are crusted over 4-airborne and contact precautions are needed until lesions are dry
4
the nurse identifies which finding as having the greatest impact on an older adult's ability to complete functional ADL's? 1-perseveration 2-aphasia 3-mneumonic disturbance 4-apraxia
4 -apraxia is loss of purposeful movement, the above three choices are speech impairments
the nurse cares for clients in a drug rehabilitation facility. Which complication of IV drug abuse is the nurse most likely to observe? 1-jaundice 2-rash 3-bruising 4-cellulitis
4 -because most drug users aren't aseptic skin popping/cellulitis occurs
The nurse cares for a client admitted with a cerebral vascular accident and facial paralysis. Which nursing care is planned to prevent complication? 1-inability to talk 2-loss of gag reflex 3-inability to open the affected eye 4-corneal abrasion
4 -cranial nerve 5 is affected and no secretions will be made to protect the eye. nursing care includes cool compresses and eye drops.
