Week 3 Practice Questions

C (situational crisis results from a specific event in life of a person who then is overwhelmed by the event. Alcoholism would be chronic)

A 40-year-old executive who was unexpectedly laid off from work 2 days earlier complains of fatigue and an inability to cope. The client admits drinking excessively over the previous 48 hours. This behavior is an example of: a) alcoholism. b) a manic episode. c) situational crisis. d) depression.

D

A nurse working in the emergency department receives arterial blood gas results on four clients. Which laboratory result requires immediate nursing intervention? a) pH 7.33, PaCO2 58 mm Hg, and PaO2 64 mm Hg b) pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg c) pH 7.48, PaCO2 35 mm Hg, and PaO2 65 mm Hg d) pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg

A, B, D, E (A relieves itching)

A parent asks the nurse how to care for a child with chickenpox. What should the nurse include in the plan of care? Select all that apply. a) Encourage oatmeal baths. b) Keep finger nails short. c) Use over-the-counter aspirin for fever. d) Do not return to school until all lesions have crusted over. e) Avoid overheating.

B (then C)

A parent brings a 3-month-old infant to the clinic, reporting that the infant has a cold, is having trouble breathing, and "just does not seem to be acting right." Which action should the nurse take first? a) Weigh the infant. b) Assess the infant's oxygen saturation. c) Check the infant's heart rate. d) Obtain more information from the father.

B (never do D)

A physician orders mannitol I.V. stat for a client who develops increased intracranial pressure after a head injury. While preparing to administer mannitol, the nurse notices crystals in the solution. What should the nurse do? a) Administer the solution as is. b) Warm the solution in hot water to dissolve the crystals. c) Send the crystallized solution back to the pharmacy. d) Add a filter to the infusion set and administer the solution.

B (Shows culturally competent care)

A woman gave birth to a term neonate a short time ago and has requests that a "special bracelet" be placed on the baby's wrist. What should the nurse do? a) Tell the mother that the bracelet is not recommended for cleanliness reasons. b) Apply the bracelet on the neonate's wrist as the mother requests. c) Place the bracelet on the neonate, limiting its use to when the neonate is with the mother. d) Recommend that the mother wait until she is discharged to apply the bracelet.

D

After instructing a primigravid client about desired weight gain during pregnancy, the nurse determines that the teaching has been successful when the client states which statement? a) "A total weight gain of approximately 20 lb (9 kg) is recommended." b) "A weight gain of 6.6 lb (3 kg) in the second and third trimesters is considered normal." c) "A weight gain of about 12 lb (5.5 kg) every trimester is recommended." d) "Although it varies, a gain of 25 to 35 lb (11.4 to 14.5 kg) is about average."

B, D, E

During a health history the nurse learns that a pediatric client seldom eats foods high in iron. Which physical assessment findings would suggest that the child has developed iron-deficiency anemia? Select all that apply. a) yellowed sclera b) systolic murmur c) decreased heart rate d) swollen tongue e) pale skin

D (4th stage is placental delivery. Priority is concern for bleeding/clots)

During the fourth stage of labor, a nurse notes that the client's fundus is boggy and located above the umbilicus. What is the nurse's priority intervention? a) Notify the healthcare provider. b) Insert a straight catheter to empty the bladder. c) Assess the amount of lochia on the client's pad. d) Massage the client's fundus.

A Fluvastatin in antilipid, Dimenhydrinate is antiemetic, Disulfiram = alcohol deterrent)

The client who is 28 weeks gestation is at the obstetric (OB) clinic reviewing lab work. The human immunodeficiency virus (HIV) test is positive, and treatment is indicated. Which medication should the nurse expect to administer that will help to prevent transmission of the virus to the fetus? a) zidovudine b) disulfiram c) dimenhydrinate d) fluvastatin

B, D (Others require nursing judgment)

The nurse is caring for a group of clients on a medical-surgical nursing unit. Which task(s) could the nurse delegate to unlicensed assistive personnel (UAP)? Select all that apply. a) Administer oxygen via nasal cannula to a client with a saturation of 89%. b) Obtain intake and outputs on a client experiencing heart failure. c) Administer acetaminophen to a client with a pain level of "5" out of "10." d) Obtain vital signs for a client admitted yesterday. e) Assess pedal pulses on a client who just returned from a cardiac angiogram.

A

To which unlicensed assistive personnel should the nurse assign a male orthodox Muslim client who needs complete morning care? a) Joe, who has one client requiring complete morning care b) Jim, who has five clients requiring partial morning care c) Jill, who has four clients requiring partial morning care d) Judy, who has two other clients requiring complete morning care

B ("The client would be positioned on the right side. Gravity will help mobilize secretions from the affected (left) lung, thereby allowing for improved blood flow and oxygenation. Elevating the head of the bed does not facilitate drainage removal.")

A 2-year-old is being treated for pneumonia. They have a productive cough and crackles in the LL. The nurse concludes that which position is most beneficial to maximize oxygenation? a) left-side lying b) right-side lying c) semi-Fowler d) supine with the head of the bed elevated 30°

D

A 6-month-old on the pediatric floor has a respiratory rate of 68, mild intercostal retractions, and an oxygen saturation of 89%. The infant has not been feeding well for the last 24 hours and is restless. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the health care provider (HCP) with the recommendation for which treatment? a) prescribing a chest CT scan. b) providing sedation. c) transferring the child to pediatric intensive care. d) starting oxygen.

A (Ramadan)

A Muslim client is scheduled to be discharged in 2 days, but insists on fasting until after dark. The nurse anticipates which explanation from the client? a) "My religion requires me to fast all day until sunset." b) "I must fast to prepare for meditation tomorrow." c) "Today is the Sabbath and I cannot eat or drink." d) "My weekly Shabbat demands I completely fast."

C

A client diagnosed with bulimia tells the nurse she only eats excessively when upset with her best friend, and then she vomits to avoid gaining a lot of weight. What should the nurse do next? a) Schedule daily family therapy sessions. b) Work with the client to limit her purging. c) Enroll the client in a coping skills group. d) Obtain a PRN prescription for lorazepam to reduce binge eating urges.

D (keep the affected leg abducted at all times! pillow reminds pt not to cross legs)

A client undergoes hip-pinning surgery to treat an intertrochanteric fracture of the right hip. The nurse should include which intervention in the postoperative care plan? a) turning the client from side to side every 2 hours b) maintaining the client in semi-Fowler's position c) performing passive range-of-motion (ROM) exercises on the client's legs once each shift d) keeping a pillow between the client's legs at all times

D

A client who takes neuroleptic medication for treatment of chronic schizophrenia is admitted to the psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, and diaphoresis. Which life-threatening reaction do these findings suggest? a) akathisia b) tardive dyskinesia c) dystonia d) neuroleptic malignant syndrome

B (priority is to save their life)

A client who was recently discharged from the psychiatric unit telephones the unit to speak to the nurse. The client states that she took her children to the neighbors' house and has turned on the gas to kill herself. Which action should the nurse take next? a) Refer the caller to a 24-hour suicide hotline. b) Tell the caller that another nurse will telephone the police. c) Ask the caller whether she telephoned her health care provider (HCP). d) Instruct the caller to telephone her family for help.

C (indicates cardiac decompensation)

A client with cardiac disease gives birth. Afterward, the nurse assesses the client for signs and symptoms of cardiac decompensation. During the postpartum period, which assessment finding indicates a need for further investigation? a) diuresis b) uterine pain c) tachycardia d) weight loss

B

A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may a) increase the amount of scarring. b) dislodge the autografts. c) increase edema in the arms. d) decrease circulation to the fingers.

C

A client with human papillomavirus (HPV) infection is being treated by a colposcopy. The client asks the nurse if this procedure is really necessary. The nurse can tell the client that if the HPV infection is not treated which health problem is likely to occur? a) pelvic inflammatory disease b) rectal cancer c) cervical cancer d) infertility

C (will have most pain in morning and after exercise) (A is wrong because should do in intervals with rest, rather than all at once)

A client with osteoarthritis tells the nurse they are concerned that the disease will prevent them from doing their chores. Which suggestion should the nurse offer? a) "Do all your chores in the evening, when pain and stiffness are least pronounced." b) "Do all your chores after performing morning exercises to loosen up." c) "Pace yourself and rest frequently, especially after activities." d) "Do all your chores in the morning, when pain and stiffness are least pronounced."

B (consumes maternal calories = increased maternal met = lowers BS) (All others are false)

A diabetic postpartum client plans to breastfeed. The nurse determines that the client's understanding of breastfeeding instructions is sufficient when the client makes which statement? a) "Breast milk from diabetic mothers contains few antibodies." b) "Breastfeeding will assist in lowering maternal blood glucose." c) "Breastfeeding is not recommended for diabetic mothers." d) "Insulin will be transferred to the baby through breast milk."

C (b/c gets "special messages" - Ideas of reference = misinterpret content on TV as containing messages for her)

A female client with paranoid schizophrenia has been hearing negative voices and "getting special messages from various sources." Which intervention is most appropriate for the client's symptoms? a) Ask her to make simple decisions. b) Be matter-of-fact with her. c) Monitor her reactions to television programs. d) Reinforce appropriate dress and hygiene.

D

A laboring client on oxytocin is becoming more vocal and is voicing increased pain with the uterine contractions. The nurse performs a fetal and maternal assessment and finds that the uterus is not relaxing between contractions. Based on the assessment findings which of the following would be the best action for the nurse? a) Increase the oxytocin until uterine contractions exceed 80 seconds duration. b) Continue the oxytocin until uterine contractions are more frequent than every 2-3 minutes. c) Administer pain medicine for reports of increasing discomfort. d) Discontinue the oxytocin if the uterus does not relax between uterine contractions.

D (hyperthyroidism = low TSH and high thyroid levels) (Hashimotos = hypothyroidism = high TSH and low thyroid levels)

A middle-aged female client complains of anxiety, insomnia, weight loss, the inability to concentrate, and eyes feeling "gritty." Thyroid function tests reveal the following: thyroid-stimulating hormone (TSH) 0.02 U/ml, thyroxine 20 g/dl, and triiodothyronine 253 ng/dl. A 6-hour radioactive iodine uptake test showed a diffuse uptake of 85%. Based on these assessment findings, the nurse should suspect: a) thyroiditis. b) multinodular goiter. c) Hashimoto's thyroiditis. d) Graves' disease.

A

A multigravid client at term is admitted to the hospital for a trial labor and possible vaginal birth. She has a history of previous cesarean birth because of fetal distress. When the client is 4 cm dilated, she receives nalbuphine intravenously. While monitoring the fetal heart rate, the nurse observes minimal variability and a rate of 120 bpm. The nurse should explain to the client that the decreased variability is most likely caused by which factor? a) effects of analgesic medication b) fetal malposition c) small-for-gestational-age fetus d) maternal fatigue

B (A would require exposing the neonate, which could further lower the temp)

A nurse is assessing a full-term neonate and discovers a heart rate of 100 beats/minute and an axillary temperature of 97.3°F (36.3°C). What action should the nurse take? a) Perform a thorough physical assessment including checking rectal temperature. b) Place a cap on the neonate's head, and offer the neonate to the mother for skin-to-skin contact. c) Place the neonate in an incubator, and notify the healthcare provider of the neonate's temperature. d) Encourage the mother to breastfeed the infant as soon as possible.

C

A nurse is caring for a severely depressed client who is barely functioning. The priority nursing goal for this client would be to: a) assess for level of depression and continue antidepressant medication. b) assess for the client's hygiene needs and ensure that these needs are met. c) assess for and maintain adequate nutrition and hydration. d) involve the family in the client's care as much as possible.

D, E (antigens - triggers)

A nurse is preparing to teach a client recovering from an anaphylaxis reaction about the prevention and management of reactions. What should the nurse include in the teaching? Select all that apply. a) monitor daily weight b) take vital signs every day c) administer emergency medications until symptoms are severe d) how to administer emergency medications e) antigens that should be avoided

B

An elderly Jewish client received a lunch tray that consists of a cheeseburger, French fries, and an apple. The client tells the nurse to remove the tray. What is the nurse's understanding of why the client wants the tray removed? a) Jewish clients do not eat fresh fruit. b) Clients of the Jewish faith do not allow the mixture of dairy and meat. c) Meat is only permitted for the evening meal. d) The client's family should be included in meal preparation and decisions.

C (these are temporary SE when start lithium)

Assessment of a client taking lithium reveals dry mouth, nausea, thirst, and mild hand tremor. Based on an analysis of these findings, which should the nurse do next? a) Withhold the lithium, and obtain a STAT lithium level. b) Continue the lithium, and immediately notify the health care provider (HCP) about the assessment findings. c) Continue the lithium, and reassure the client that these temporary side effects will subside. d) Withhold the lithium, and monitor the client for signs and symptoms of increasing toxicity.

C

At the beginning of a shift, the team leader notices that all of the I.V. antibiotics for a client are still in the medication room. What is the team leader's first action? a) Ask the client if medication was received during the previous shift. b) Return the medications to the pharmacy to reduce hospital expenses. c) Ask the nurse assigned to this client about the medications. d) Notify the unit's nurse manager.

C

During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she has been experiencing breast engorgement. To relieve engorgement, the nurse teaches the client to use which intervention before nursing her baby? a) Apply an ice cube to the nipples. b) Rub the nipples gently with lanolin cream. c) Express a small amount of breast milk. d) Offer the neonate a small amount of formula.

A (before age 2 = needed for continued neural growth. After age 2 is okay)

The mother of a newborn is concerned about the number of persons with heart disease in her family. She asks the nurse when she should start her baby on a low-fat, low-cholesterol diet to lower the risk of heart disease. At what age does the nurse should tell the client to start modifying her child's diet? a) age 2 years b) birth c) age 5 years d) age 10 years

A (ankle edema indicates FVO given heart condition)

The nurse is admitting an older adult to the hospital. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first? a) Assess respiratory status. b) Insert a Foley catheter. c) Draw blood for laboratory studies. d) Weigh the client.

A, C, D (remember late decels indicate placental insufficiency)

The nurse is caring for a client in labor and notes late decelerations on the external fetal monitoring strip. Which actions will the nurse include in the client's plan of care? Select all that apply. a) Contact the healthcare provider. b) Discontinue the external fetal heart monitor. c) Administer oxygen to the client. d) Change the client's position. Increase the oxytocin infusion.

A (increases contractility = increased oxygenation via blood flow)

The nurse is caring for a client in the intensive care unit. Which drug is most commonly used to treat cardiogenic shock? a) dopamine b) metoprolol c) enalapril d) furosemide

C

The nurse is caring for a client who has experienced severe multiple trauma. The client's arterial blood gases reveal low arterial oxygen levels that are not responsive to high concentrations of oxygen. This finding is an indicator of the development of which of the following conditions? a) Hospital-acquired pneumonia. b) Hypovolemic shock. c) Acute respiratory distress syndrome (ARDS). d) Asthma.

D

The nurse should ensure that which item is placed when the client is to receive intravascular therapy for more than 6 days? a) short peripheral catheter b) central venous access in the femoral vein c) intravenous catheter insertion device d) peripherally inserted central catheter (PICC)

C (A would be RN)

The registered nurse (RN) is supervising for the evening shift at a long-term care facility. The RN is working with 3 certified nursing assistants (CNA) and a licensed practical/vocational nurse (LPN/VN). Which aspect of care is most appropriately delegated to the LPN/VN? a) Assessing a client's oxygenation status b) Assisting a client to ambulate in the hall c) Administering a client's tube feeding d) Reminding a client to use the bathroom every 4 hours

A (eye med for gluacoma)

What should a nurse do when administering pilocarpine? a) Apply pressure on the inner canthus to prevent systemic absorption. b) Apply pressure on the outer canthus to prevent adverse reactions. c) Administer at bedtime to prevent night blindness. d) Flush the client's eye with normal saline solution to prevent burning.

C (would do C then if that does not work A)

When performing a heel stick on a newborn, the nurse is unable to obtain an adequate sample. What should the nurse do? a) Perform venipuncture instead. b) Place a cold compress on the heel. c) Attempt the heel stick in a new location. d) Call the health care provider.

C (indicates inadequate nutrition)

When planning care for a group of clients, the nurse should identify which client as having the greatest risk for the development of pressure ulcers? a) a client who ambulates 4 times a day b) a client with an indwelling urinary catheter c) a client who has a decreased serum albumin level d) a client with an elevated white blood cell count

A

Which characteristic would make the nurse suspect that a client with changes in cognition has delirium? a) disturbances in cognition and consciousness that fluctuate during the day b) failure to identify objects despite intact sensory functions c) significant impairment in social or occupational functioning over time d) memory impairment to the degree of being called amnesia

D (elevated. Likely to cause + d-dimer as well) (normal INR = 1.1 or below)

Which laboratory test result does the nurse anticipate for a client diagnosed with a bite from a pit viper? a) negative D-dimer b) serum creatinine 1 mg mg/dL (90 μmol/L) c) serum potassium 3.8 mmol/L (3.8 mEq/L) d) INR (international normalized ratio) of 2.3

A

Which nursing approach is most helpful to a client with Parkinson disease who is experiencing a freezing of gait with difficulty initiating movement? a) Tell the client to march in place. b) Have the client remain still. c) Pull the client forward to initiate walking. d) Instruct the client to use a wheelchair.

C (alleviates urge to push)

While the nurse is caring for a multigravid client at 39 weeks' gestation in active labor whose cervix is dilated to 7 cm and completely effaced at +1 station, the client says, "I need to push!" What should the nurse do next? a) Tell her to push when she has the urge. b) Tell her to focus on an object in the room to relax. c) Have her pant quickly during the contraction. d) Turn the client to her left side.