CAT 1 part 2

A middle-aged client, newly diagnosed with type 2 diabetes, expresses disbelief at this diagnosis. The nurse explains that the development of diabetes in middle-age is most likely related to which factor? 1.Obesity. 2.Increased sugar intake. 3.Viral infections. 4.Decreased cortisol level.

1) Obesity

A client with a history of intravenous drug abuse experiences a low-grade fever, cough, night sweats, fatigue, weight loss, and a productive cough with mucopurulent sputum. Which transmission-based precaution will the nurse use for this client? 1.Airborne. 2.Contact. 3.Droplet. 4.Standard.

1. Airborne.

The nurse provides care to a client who had right femoral-popliteal bypass surgery 5 hours ago. Which finding will the nurse report immediately to the health care provider? 1.Develops pallor of the right extremity. 2.Voids 180 mL of urine since surgery. 3.Has an oral temperature of 99.8°F (37.6°C). 4.Has a small amount of bright red bloody drainage on the dressing.

1.Develops pallor of the right extremity.

The health care provider prescribes a unit of packed red blood cells for a client admitted with lower gastrointestinal bleeding. Which step will the nurse take when administering the blood product? (Select all that apply.) 1.Ensure adequate infusion access is present before obtaining the blood from the blood bank. 2.Initiate the transfusion within 1 hour of removing the blood from the blood bank refrigerator. 3.Use a two-person verification process to match the unit of blood to the prescription and the client to the unit of blood. 4.Monitor the client closely during the first 15 to 30 minutes of administration. 5.Ensure the administration time does not exceed 6 hours.

1.Ensure adequate infusion access is present before obtaining the blood from the blood bank. 2.Initiate the transfusion within 1 hour of removing the blood from the blood bank refrigerator. 3.Use a two-person verification process to match the unit of blood to the prescription and the client to the unit of blood. 4.Monitor the client closely during the first 15 to 30 minutes of administration.

After receiving a unit of red blood cells, a child reports tingling in the ears, nose, fingers, and toes. Which electrolyte imbalance does the nurse suspect the client is experiencing? 1.Hypocalcemia. 2.Hypercalcemia. 3.Hyponatremia. 4.Hypernatremia.

1.Hypocalcemia.

The nurse provides care for a client diagnosed with head trauma. The client experiences a seizure. Which actions will the nurse implement? (Select all that apply.) 1.Keep the client in a side-lying position. 2.Monitor the client's ability to maintain a patent airway. 3.Arouse the client frequently to assess neurological status. 4.Provide environmental stimuli to help the client awaken. 5.Place suction equipment and an oral airway at the client's bedside.

1.Keep the client in a side-lying position. 2.Monitor the client's ability to maintain a patent airway. 5.Place suction equipment and an oral airway at the client's bedside.

The nurse provides care to a client in hypovolemic shock. Which intravenous solution will the nurse recognize as being an isotonic crystalloid solution? (Select all that apply.) 1.Normal saline. 2.Lactated ringer.3.0.5% normal saline.4.10% dextrose.5.0.45% dextrose in normal saline.

1.Normal saline. 2.Lactated ringer.3.0.5% normal saline.4.10% dextrose.5.0.45% dextrose in normal saline.

Prior to the beginning of a site survey, the charge nurse advises the nurse to deny any knowledge of a recent sentinel event if asked by the surveyor. Which action will the nurse take? 1.Notify the unit manager. 2.Notify the medical director. 3.Tell the charge nurse about being uncomfortable lying to the surveyor. 4.Tell the surveyor the nurse is not allowed to talk to them. View Explanation

1.Notify the unit manager.

The nurse assigns a client diagnosed with cancer who is receiving chemotherapy to a nursing assistive personnel (NAP). Which instruction is most important for the nurse to include? 1.Perform hand hygiene frequently. 2.Wear a mask when entering the room. 3.Monitor the roommate for signs of infection. 4.Monitor the amount of protein the client eats.

1.Perform hand hygiene frequently.

The nurse provides care to a client with an epidural catheter for pain control with fentanyl after spinal fusion surgery. Which action will the nurse include when providing post-operative care to this client? (Select all that apply.) 1.Perform peripheral neurovascular checks every 2 hours. 2.Ambulate the client around the hallway. 3.Assess for bowel and bladder distention. 4.Keep the client at nothing by mouth status. 5.Monitor client for nausea and vomiting.

1.Perform peripheral neurovascular checks every 2 hours. 3.Assess for bowel and bladder distention. 5.Monitor client for nausea and vomiting.

The nurse provides care for a client diagnosed with a seizure disorder. Which client care activity does the nurse delegate to a nursing assistive personnel (NAP)? (Select all that apply.) 1.Place respiratory equipment at the bedside. 2.Remove harmful objects from the client's reach. 3.Apply foam padding around the bed rails. 4.Time the duration of seizure activity. 5.Teach the client about antiseizure medications.

1.Place respiratory equipment at the bedside. 2.Remove harmful objects from the client's reach. 3.Apply foam padding around the bed rails.

The nurse teaches a class on suicide prevention to high school students. Which risk factor is accurate with regard to suicide in adolescent clients? (Select all that apply.) 1.Possessions that are given to friends .2.A low grade point average. 3.Statements like, "I may not be around anymore." 4.Access to a gun at home. 5.Frequent thoughts of suicide.

1.Possessions that are given to friends 3.Statements like, "I may not be around anymore." 4.Access to a gun at home. 5.Frequent thoughts of suicide.

The outpatient nurse assesses the client's use of crutches 1 week after knee surgery. Which outcome is most important? 1.The client is able to perform activities of daily living independently. 2.The client has no tingling or numbness in the upper extremities. 3.The client reports removing all the loose rugs from the kitchen and bath. 4.The client is free of deep vein thrombosis signs and has a normal bowel pattern.

1.The client is able to perform activities of daily living independently.

The client is 4 hours postoperative. The nurse increases the supplemental oxygen dose based on the pulse oximetry reading. After 15 minutes, the nurse assesses the client's response to the intervention. Which finding does the nurse report to the health care provider? 1.The client requires an increased dose of supplemental oxygen. 2.The client is drowsy with a respiratory rate of 16 breaths per minute. 3.The client has a loose, productive cough with deep inspiration. 4.The client raises the head of the bed for breathing exercises

1.The client requires an increased dose of supplemental oxygen.

The nurse provides care to a client who experienced prolonged cold exposure. For which complication does the nurse closely monitor this client? 1.Ventricular fibrillation. 2.Hypertension. 3.Metabolic alkalosis. 4.Shivering.

1.Ventricular fibrillation.

A client recovering from surgery becomes confused and anxious and is hyperventilating. When using SBAR communication, which statement does the nurse make when notifying the health care provider? 1."The client's mental status has deteriorated." 2."I am concerned about this client who has become confused and is hyperventilating." 3."The problem seems to be the respiratory status of this client."4."Please come and see this client as the condition has changed."

2."I am concerned about this client who has become confused and is hyperventilating."

The nursing instructor is explaining the difference between hand washing and surgical hand hygiene to a nursing student. Which statement by the student indicates the need for further teaching? 1."All hand jewelry should be removed for surgical hand antisepsis." 2."Surgical hand antisepsis is performed for at least 15 seconds, depending on the antibacterial agent." 3."Hands are held higher than the elbows during washing with surgical antisepsis." 4."Faucets are regulated with elbow, knee, or foot controls."

2."Surgical hand antisepsis is performed for at least 15 seconds, depending on the antibacterial agent."

The nurse prepares to interview a client who is a suspected victim of domestic violence. The client's spouse is present. Which statement made by the nurse is appropriate? 1."Things discussed in this room are confidential." 2."This part of the exam must be done in private." 3."There are many shelters and groups available to you." 4."The results of the examination can be shared as desired."

2."This part of the exam must be done in private."

A client who is pregnant asks the nurse what an elevated serum alpha-fetoprotein (AFP) level indicates. Which information does the nurse provide to the mother? 1.Gestational diabetes. 2.A neural tube defect. 3.Trisomy 21 (Down syndrome). 4.Lack of lung maturity.

2.A neural tube defect.

The nurse admits a child with fever, malaise, headache, and a vesicular rash on the scalp, face, and trunk. Which transmission-based precaution does the nurse implement for this child? 1.Contact precautions. 2.Airborne and contact precautions. 3.Airborne and droplet precautions. 4.Droplet precautions.

2.Airborne and contact precautions.

The nurse is unable to locate an older client's left popliteal pulse. Which action will the nurse take next? 1.Check for the femoral pulse. 2.Check for the pedal pulse. 3.Ask another nurse to check for the popliteal pulse. 4.Measure the blood pressure on the left thigh.

2.Check for the pedal pulse.

The nurse provides care to clients in a skilled care facility. Which client will the nurse be most concerned about for the risk of a fall? 1.Client who received the flu vaccine. 2.Client started on a benzodiazepine. 3.Client prescribed psyllium. 4.Client receiving ibuprofen for leg pain.

2.Client started on a benzodiazepine.

The nurse prepares discharge instructions for a client who speaks very little English and is recovering from an emergency appendectomy. Which nursing action best helps this client understand wound care instructions? 1.Aski5.Place suction equipment and an oral airway at the client's bedside. View Explanationng if the client understands the instruction. 2.Demonstrating the procedure and having the client return the demonstration. 3.Asking an interpreter to replay the instructions to the client. 4.Writing out the instructions and having a family member read them to the client.

2.Demonstrating the procedure and having the client return the demonstration.

The nurse evaluates laboratory values for a client experiencing diaphoresis and weight loss. Which value will the nurse immediately report to the health care professional? 1.Calcium 9.0 mg/dL (2.25 mmol/L). 2.Hemoglobin A1C 8% (0.08). 3.Magnesium 2.2 mg/dL (1.10 mmol/L). 4.Blood glucose 118 mg/dL (6.55 mmol/L).

2.Hemoglobin A1C 8% (0.08).

The nurse provides care for a child who ingested an unknown substance. The client is unconscious with a respiratory rate of 10 breaths/min, pulse oximeter reading is 88%, and the heart rate is 160 beats/min. The nurse determines which nursing diagnosis is the highest priority for this client? 1.Decreased cardiac output. 2.Ineffective breathing pattern. 3.Ineffective tissue perfusion.4.Impaired cerebral tissue perfusion.

2.Ineffective breathing pattern.

The nurse provides care for a client in the final stage of chronic kidney disease. The client's serum calcium level is 7.5 mg/dL (1.8 mmol/L) and the phosphate level is 6.0 mg/dL (1.9 mmol/L). Which priority nursing diagnosis does the nurse use to plan care for this client? 1.Activity intolerance. 2.Risk for injury. 3.Imbalanced nutrition. 4.Failure to thrive.

2.Risk for injury.

A student nurse asks what the S represents when using SBAR communication. Which response does the nurse provide to the student? 1.System. 2.Situation. 3.Status. 4.Service.

2.Situation.

The nurse provides care for a client undergoing an exercise stress test. The cardiologist is suddenly called away for an emergency. Which action should the nurse take next? 1.Continue the test, as the client was almost finished. 2.Stop the test and reschedule for another day. 3.Ask the client to stay until the doctor returns.4.Inform the client that the test is finished.

2.Stop the test and reschedule for another day.

The nurse palpates a client's neck to assess the lymph nodes. Which technique is most appropriate for the nurse to use? 1.Compress the lymph nodes between two fingers. 2.Use the pads of two fingers in a rotating motion. 3.Use the flat aspects of all four fingers in a vertical and then side-to-side motion. 4.Use the back of one hand and observe temperature variation between the left and right nodes.

2.Use the pads of two fingers in a rotating motion.

The nurse follows up with a client diagnosed with insomnia. The nurse seeks to determine if treatment was successful. Which response by the client best indicates treatment was successful? 1. "I am sleeping 4 hours a night." 2. "I fall asleep within 1 to 2 hours at night now." 3. "I am not napping in the day anymore." 4. "I am waking up twice a night."

3. "I am not napping in the day anymore."

The graduate nurse attends an orientation to the oncology unit. Which statement indicates that the graduate nurse understands the teaching? 1."Angiogenesis is only accomplished by malignant cells. "2."Everyone diagnosed with cancer will die from it." 3."Cancers metastasize through lymphatic spread to organs." 4."Cell mutations cannot be managed by the body's immune system." View Explanation

3."Cancers metastasize through lymphatic spread to organs."

The nurse attends a conference on neonatal health problems. Which statement by the nurse indicates a correct understanding of neonatal jaundice? 1."Jaundice initially appears in the extremities and gradually progresses to the head." 2."The conjunctival sacs and buccal mucosa appear yellow for the first month of life." 3."Feeding, especially breastfeeding, is important in reducing serum bilirubin." 4."Visual assessment of jaundice gives an accurate assessment of the serum bilirubin level."

3."Feeding, especially breastfeeding, is important in reducing serum bilirubin."

The nurse assesses the coping skills of a client receiving chemotherapy after a mastectomy for breast cancer. Which client statement indicates effective coping? 1."I am glad the nausea and vomiting are subsiding. "2."I do not need as much pain medication as was prescribed. "3."I made an appointment to get fitted for prosthesis. 4."I will begin the next round of chemotherapy next week."

3."I made an appointment to get fitted for prosthesis.

The nurse attends a staff development conference on transfusion reactions. Which statement by the nurse indicates the need for further teaching? 1."I will keep the intravenous line open with normal saline after I stop the transfusion." 2."I will obtain a urine specimen to determine the presence of hemoglobin." 3."I will discard the blood bag and transfusion set in a waterproof bag "4."I will notify the blood bank if a client has a transfusion reaction."

3."I will discard the blood bag and transfusion set in a waterproof bag

The nurse is teaching the client about the warning signs and symptoms of lung cancer. Which statement is appropriate for the nurse to include in the teaching? 1."There are hardly any signs and symptoms with lung cancer." 2."Early symptoms of lung cancer include constant cough and bloody sputum." 3."Symptoms of lung cancer are vague and often present late in the disease." 4."Wheezing on exhalation is usually considered a positive sign of lung cancer."

3."Symptoms of lung cancer are vague and often present late in the disease."

The supervisor observes the nurse delegate a dressing change on a client with a fever, positive blood cultures, and a blood pressure of 86/42 mm Hg to the LPN/LVN. Which action will the supervisor take next? 1.Encourage the LPN/LVN to complete the dressing change as assigned. 2.Assign another LPN/LVN who is more comfortable with dressings to complete the dressing change. 3.Discuss with the nurse that the dressing change should not be delegated to the LPN/LVN. 4.Ensure that the nurse follows up with the LPN/LVN after the dressing change is complete.

3.Discuss with the nurse that the dressing change should not be delegated to the LPN/LVN.

The parent of a school-age child diagnosed with type 1 diabetes mellitus reports that the child has been sick and has ketones in the urine. Which instruction will the nurse provide to the parent? 1.Hold the next dose of insulin. 2.Administer an additional dose of regular insulin. 3.Encourage the child to drink calorie-free liquids. 4.Seek medical attention for additional assessment and treatment.

3.Encourage the child to drink calorie-free liquids.

The nurse provides care for a client diagnosed with an exacerbation of chronic obstructive pulmonary disease (COPD) who is wheezing. This finding supports which priority nursing diagnosis when planning this client's care? 1.Decreased cardiac output. 2.Risk for anxiety. 3.Ineffective airway clearance. 4.Risk for aspiration.

3.Ineffective airway clearance.

The nurse develops a teaching plan for a client diagnosed with hypertension and type 1 diabetes. The client's health care provider prescribes propranolol. View Explanationich information does the nurse include in the teaching plan? 1.Stop the drug immediately if experiencing adverse effects. 2.Limit alcohol use to two drinks per day, as alcohol increases the drug's effect. 3.Monitor blood glucose frequently. Propranolol may mask symptoms of hypoglycemia. 4.Do not use glucagon, as it may increase the effects of propranolol.

3.Monitor blood glucose frequently. Propranolol may mask symptoms of hypoglycemia.

The nurse provides care for a client who has undergone detoxification of long-term opioid use. The nurse plans discharge teaching for the client. Which medication does the nurse include in the discharge teaching? 1.Diazepam. 2.Vareninclin. 3.Naltrexone. 4.Disulfiram.

3.Naltrexone.

The nurse uses research findings to improve client care. Which technique of care is the nurse using? 1.Nurse-sensitive indicators. 2.Care management. 3.Performance improvement. 4.Utilization review.

3.Performance improvement.

The nurse provides care for a client experiencing status epilepticus. Which action is most appropriate for the nurse to take? 1.Place a tongue blade in the client's mouth. 2.Prevent the client from flailing the arms. 3.Remove all pillows and raise the bed rails. 4.Maintain the client's head in a midline position.

3.Remove all pillows and raise the bed rails.

The nurse provides care for a client diagnosed with sickle cell crisis. Which sign or symptom should the nurse immediately report to the healthcare provider? 1.Cyanosis of the tongue. 2.Jaundiced skin. 3.Slurred speech. 4.Slow capillary refill.

3.Slurred speech.

The nurse provides care for clients in a headache clinic. Which client should the nurse assess first? 1.The client reporting pain and neck stiffness. 2.The client reporting abdominal pain and vomiting. 3.The client with difficulty speaking to the receptionist. 4.The client with a headache of 3 weeks' duration.

3.The client with difficulty speaking to the receptionist.

A client with injuries from a motor vehicle accident is unconscious from a severe head injury. The client's identity is unknown, but the client needs emergency surgery to stabilize fractures. Which action is the best for the nurse to take when obtaining informed consent for the operative procedure? 1.Ask the emergency services team to sign the informed consent. 2.Obtain an emergency court order for the surgical procedure. 3.Transport the client to the operating room for surgery. 4.Ask the police to identify the client and locate the family.

3.Transport the client to the operating room for surgery.

The nurse provides care for a client that sleeps only 5 hours a night because of work and stress. The nurse explains to the client changes that occur in the body with inadequate rest. Which body response should the nurse include in the teaching? 1. Pain tolerance increases. 2. Immune response increases. 3. Accidents decrease. 4. Healing decreases.

4. Healing decreases.

The nurse instructs a client on advance directives. Which client statement indicates to the nurse a need for further education? 1."Advance directives should be completed long before a medical crisis develops." 2."I decide who will make health care decisions for me if I chose a Health Care Proxy." 3."A living will means my family will know what life-sustaining measures I want taken." 4."A power of attorney for health care prevents my children from selling my home."

4."A power of attorney for health care prevents my children from selling my home."

A client of Asian descent receives information about a recommended surgery from the health care provider, yet refuses to sign the consent form. Which response by the nurse is best? 1."Did you understand what the health care provider said to you about the surgery?" 2."Why won't you sign the form after the health care provider recommended the surgery?" 3."I will have to call the surgeon and have your surgery cancelled until you can make a decision." 4."Are there other people that you want to talk with before making this decision?"

4."Are there other people that you want to talk with before making this decision?"

The nurse at an outpatient health center receives a call from a client who recently began taking birth control pills. The client reports severe leg pain that turned the skin red. Which is the most appropriate response by the nurse? 1."Could you have injured your leg playing sports?" 2."This is a side effect of the pill and will resolve in a week." 3."Have you ever had this problem occur before?" 4."Come to the clinic immediately to be evaluated."

4."Come to the clinic immediately to be evaluated."

The nurse conducts a staff development workshop about organ donations. Which statement by a staff member indicates a correct understanding of the Uniform Anatomical Gift Act? 1."A client needs to complete an advance directive and identify a health care proxy to become an organ donor." 2."The health care provider is the person who requests organ donation from a client's family members." 3."The health care provider who signs the client's death certificate must supervise the removal of the client's donated organs." 4."Family members can consent to organ donation after the client's death, even if the client had not expressed a desire to have organs donated."

4."Family members can consent to organ donation after the client's death, even if the client had not expressed a desire to have organs donated."

The nurse notes that a client is prescribed alendronate. Which instruction will the nurse include when teaching about this medication? 1."Take the medication at bedtime with a snack." 2."Take the medication in the morning after breakfast." 3."Lie down for 30 minutes after taking the medication." 4."Take the medication with a full glass of water." View Explanation

4."Take the medication with a full glass of water." View Explanation

The nurse provides care for four clients. Which client will benefit the most from a multidisciplinary conference? 1.A 3-month-old client with intussusception who is vomiting, has colicky abdominal pain, and is having jelly-like stools. 2.A 2-month-old client with respiratory syncytial virus (RSV), who is wheezing and has moderate subcostal retractions and copious nasal discharge. 3.A 3-day-old client with developmental dysplasia of the hip, who has unequal leg length, limited abduction of the left hip, and asymmetry of the gluteal folds. 4.A 2-day-old client with body tremors and hyperirritability, who has intermittent episodes of sneezing and whose mother abused substances while pregnant.

4.A 2-day-old client with body tremors and hyperirritability, who has intermittent episodes of sneezing and whose mother abused substances while pregnant.

The nurse prepares teaching for a school-age child diagnosed with type 1 diabetes mellitus who has gymnastics practice three times per week. Which information is most important to provide to the child and parents to prevent hypoglycemia during practice? 1.Take the prescribed insulin at noon instead of in the morning. 2.Eat twice the amount normally eaten at lunchtime. 3.Take one-half the amount of prescribed insulin on practice days. 4.Eat six graham crackers or drink a cup of juice before gymnastics practice.

4.Eat six graham crackers or drink a cup of juice before gymnastics practice.

The nurse receives a prescription to provide aspirin to a client with an emergent acute myocardial infarction. What is the best method to administer aspirin to this client? 1.Administer as a rectal suppository. 2.Administer with a glass of milk or antacid. 3.Give sublingually, times three doses. 4.Have the client chew non-enteric coated ASA.

4.Have the client chew non-enteric coated ASA.

The nurse provides care for a client experiencing a sickle cell crisis. Which nursing diagnosis is the priority for the nurse to include in the plan of care? 1.Risk for infection. 2.Risk for ineffective cerebral tissue perfusion. 3.Activity intolerance. 4.Ineffective peripheral tissue perfusion.

4.Ineffective peripheral tissue perfusion.

The nurse provides care for a client with an enteral feeding tube. The nurse discovers that the client's continuous enteral tube feeding is 100 mL behind the prescribed infusion schedule. Which action should the nurse take first? 1.Flush the tube. 2.Reposition the tube. 3.Increase the flow rate. 4.Measure residual volume.

4.Measure residual volume.

The nurse provides care for a client who had a percutaneous coronary intervention (PCI) with an angiogram 1 hour ago. Which nursing action is priority? 1.Encourage the client to increase fluid intake. 2.Monitor potassium and magnesium levels. 3.Assist the client with toileting needs. 4.Monitor the access site for signs of bleeding.

4.Monitor the access site for signs of bleeding.

A client receiving a blood transfusion experiences a febrile reaction. Once the transfusion is discontinued, which action will the nurse take next? 1.Flush the blood tubing with normal saline. 2.Place tubing and bag in a red biohazard bag and discard. 3.Keep the blood bag and tubing hung in case the health care provider wants to restart the transfusion. 4.Place the bag and tubing in a biohazard container to send back to the blood bank.

4.Place the bag and tubing in a biohazard container to send back to the blood bank.

The nurse notes that a 4-hour-old newborn has blue hands and feet. Which action does the nurse implement next? 1.Place the neonate in a warmer. 2.Swaddle the neonate in double blankets. 3.Notify the health care provider. 4.Proceed with the assessment.

4.Proceed with the assessment.

The nurse documents assessment findings in a child's electronic medical record. Which measure does the nurse take to protect the child's confidentiality? 1.Share computer log-on information with coworkers who also care for the child. 2.Log off the computer at the end of the shift. 3.Leave client information visible to staff when leaving a computer unattended. 4.Share documented findings only with those directly involved in the child's care.

4.Share documented findings only with those directly involved in the child's care.

The nurse notes that a client's peripheral intravenous catheter site is pale, swollen, and cool to the touch. Which action will the nurse take first? 1.Remove the catheter. 2.Apply an ice pack to the site. 3.Insert a new catheter. 4.Stop the infusion

4.Stop the infusion

The nurse provides education to parents regarding home safety. Which information does the nurse include to help keep a preschool child safe? 1.Use guard gates on stairs. 2.Instruct child to never swim alone. 3.Cover electrical outlets with safety plugs. 4.Teach child to avoid strangers. View Explanation

4.Teach child to avoid strangers. View Explanation

A client reports having difficulty falling asleep at night. With which statement will the nurse respond to this client? (Select all that apply.) 1."Exercising immediately before bed will reduce stress." 2."Reading or watching television in bed will help you relax." 3."Eating a heavy meal before bedtime can interfere with sleep." 4."Maintaining a regular sleep/wake schedule promotes sleep." 5."Napping during the day can interfere with sleep at night." View Explanation

5."Napping during the day can interfere with sleep at night." View Explanation