HURST QBank Reduction of Risk
The nurse is removing the client's peripheral IV line prior to discharge. The nurse completes the appropriate steps in what order? - clamp IV line closed securely - loosen tape and tegaderm cover - apply gauze and tape tightly - stabilize cannula with one hand - wash hands and apply gloves
- wash hands and apply gloves - clamp IV line closed securely - stabilize cannula with one hand - loosen tape and tegaderm cover - apply gauze and tape tightly
The nurse is demonstrating ostomy care to a client with a new stoma in the sigmoid area of the colon. The nurse knows teaching is successful when the client completes care in what order? - wash stoma with warm soapy water - place stoma adhesive onto new flange - apply skin protectant and allow drying - press flange into place and attach bag - remove ostomy bag and old flange - cut center of new flange to fit stoma
- remove ostomy bag and old flange - wash stoma with warm soapy water - apply skin protectant and allow drying - cut center of new flange to fit stoma - place stoma adhesive onto new flange - press flange into place and attach bag
Which complications would the nurse assess for in the client undergoing a total hysterectomy? a. hemorrhage b. infection c. menopause d. thromboembolism e. bowel or bladder injury
a. hemorrhage b. infection d. thromboembolism e. bowel or bladder injury
A child diagnosed with AIDS is scheduled for grade school immunizations. Which immunizations are safe for the nurse to administer to the child? a. MMR (measles, mumps, rubella) b. dTaP (diphtheria, tetanus, pertussis) c. VAR (varicella) d. HIB (haemophilus influenza) e. OPV (oral polio virus)
b. dTaP (diphtheria, tetanus, pertussis) d. HIB (haemophilus influenza)
When planning post-procedure care for a client who is having a barium enema, what is the priority action of the nurse? a. cardiac monitor for potential arrhythmias b. monitoring urinary output c. encourage to drink plenty of fluids d. record the client's diet
c. encourage to drink plenty of fluids
The nurse is caring for a client following a transurethral resection of the prostate (TURP). The client has a 3 way irrigation catheter in place. Which finding would indicate the need to increase the irrigation rate? a. clots in urine b. unable to palpate bladder c. slightly pink tinged urine d. no report of bladder spasms
a. clots in urine
A client is admitted with atrial fibrillation and heart failure secondary to chronic hypertension. Current medications include: Digoxin, Captopril, Carvedilol, Furosemide, and Warfarin. Based on this profile, what lab work is essential for the nurse to monitor? a. digoxin level b. potassium level c. PT/INR d. aPTT e. CPK-MB
a. digoxin level b. potassium level c. PT/INR
Two hours post chest tube insertion, the nurse notes 100 mL of dark bloody drainage in the collection chamber of the closed drainage unit (CDU). What action should the nurse take? a. document the findings b. notify the primary healthcare provider c. decrease the amount of suction d. use a padded hemostat to clamp the chest tube
a. document the findings
An obstetrical client with new onset bright red vaginal bleeding has read that bleeding during the second half of pregnancy is usually due to either placental abruption or placenta previa. The client asks the nurse about the different signs and symptoms with placenta previa and placental abruption. What information should the nurse include? a. the classic sign of placenta previa is the onset of painless bright red vaginal bleeding in the last half of pregnancy b. the onset of bleeding is usually sudden with placental abruption and the onset of bleeding with placenta previa may start and stop abruptly and occur intermittently c. bleeding can be concealed or visible with placental abruption and is always visible with placenta previa d. uterine tone is soft and relaxed in placental abruption and firm to rigid in placenta previa e. classic manifestations of placental abruption include painful, dark red vaginal bleeding during the last half of pregnancy f. fetal distress is usually absent in placental abruption and present in placenta previa
a, b, c, e
The nurse has been trained to work in a decontamination station for hazardous exposure victims. What should the nurse tell the victim about the process? a. first you will remove clothing and dispose of it in hazardous material container b. you will be placed in a shower with tepid water for decontamination c. you will spend a minute or so using soap over the entire body before rinsing d. you will spend 30 minutes in the shower e. you will apply soap from head to toe and then rinse for a few minutes
a, b, c, e
A client has recently been diagnosed with systemic scleroderma. Which of the following client complaints would be of most concern to the homecare nurse? a. "I feel like food gets stuck in my throat when I eat." b. "I have a hard time brushing my teeth properly." c. "My fingers burn when I go outside in the winter." d. "I get short of breath whenever I exercise."
a. "I feel like food gets stuck in my throat when I eat."
A client is suspected of having a pheochromocytoma. The nurse is explaining the process of a VMA (Vanillylmandelic acid) urine test to be completed at home. What statement made by the client indicates the need for further teaching? a. "I need to keep the urine in the fridge during the 24 hours." b. "I will have to stay well-hydrated to get enough urine to test." c. "It does not matter what I eat or drink during this process." d. "I need to throw away my first voiding when I start this test." e. "I should void at the end of the 24 hours and keep that urine."
a. "I need to keep the urine in the fridge during the 24 hours." b. "I will have to stay well-hydrated to get enough urine to test." c. "It does not matter what I eat or drink during this process."
The family of an 80 year old bedfast client is providing care in the home. Which family statements indicate adequate understanding of interventions that will reduce the risk for skin breakdown? a. I will make sure that the sheets and the foam pad in the chair stay dry b. I will not encourage my parent to turn in the bed at night so they can rest c. the perineal area should be kept dry and clean d. my parent can eat 3 meals per day and drink daily supplements e. I may reposition my parent more than every 2 hours if their perception of pressure is intact
a. I will make sure that the sheets and the foam pad in the chair stay dry c. the perineal area should be kept dry and clean d. my parent can eat 3 meals per day and drink daily supplements e. I may reposition my parent more than every 2 hours if their perception of pressure is intact
A client with renal failure has returned to the unit post kidney transplant. Which postoperative interventions should the nurse provide? a. administer furosemide b. maintain fluid replacement at 150 mL per hour for 8 hours c. measure abdominal girth every 24 hours d. weigh daily e. measure urine output every 30-60 minutes
a. administer furosemide d. weigh daily e. measure urine output every 30-60 minutes
A client has been diagnosed with varicella in the clinic. What should the nurse tell the parents about home treatment of the child? a. apply calamine lotion to affected areas several times a day b. provide cool baths with baking soda c. administer aspirin for fever d. do not allow visitors who have never had varicella e. keep fingernails trimmed short
a. apply calamine lotion to affected areas several times a day b. provide cool baths with baking soda d. do not allow visitors who have never had varicella e. keep fingernails trimmed short
A client is scheduled to have a Cardiac Positron Emission Tomography (PET). What pre-procedure information should the nurse provide to the client? a. avoid caffeinated food and drinks for 24 hours prior to test b. do not eat for 4-6 hours before the test c. do not wear jewelry d. take calcium channel blocker prescription the day of the test e. wear comfortable, loose-fitting clothing
a. avoid caffeinated food and drinks for 24 hours prior to test b. do not eat for 4-6 hours before the test c. do not wear jewelry e. wear comfortable, loose-fitting clothing
A client with a history of alcoholism arrives at the clinic reporting severe abdominal pain with nausea and vomiting. What additional findings would make the nurse suspect the client may have pancreatitis? a. bruising at the umbilicus b. fever with tachycardia c. positive Trousseau sign d. pain radiating to back e. vague pain at night
a. bruising at the umbilicus b. fever with tachycardia d. pain radiating to back
The nurse is caring for a ventilator-dependent client assisted with positive expiratory end pressure (PEEP). The high-pressure alarm begins sounding. What actions should the nurse initiate? a. check to see if client is biting ET tube b. examine tubing for presence of water c. inspect for any loose connections d. reduce the amount of PEEP used e. assess client's need for suctioning
a. check to see if client is biting ET tube b. examine tubing for presence of water e. assess client's need for suctioning
Which assessment finding on a client four hours post right femoral percutaneous transluminal coronary angioplasty (PTCA) would require immediate intervention by the nurse? a. client reports chest discomfort b. legs elevated 15 degrees c. pressure dressing over puncture site intact/dry d. client reports slight tingling to right foot e. left pedal pulse 2+/4+, right pedal pulse 1+/4+
a. client reports chest discomfort b. legs elevated 15 degrees d. client reports slight tingling to right foot e. left pedal pulse 2+/4+, right pedal pulse 1+/4+
The nurse has determined that a bedridden client diagnosed with a stroke is at risk for venous thromboembolism (VTE). What interventions should the nurse initiate? a. measure the calf and thigh daily b. apply sequential compression device to legs c. position paralyzed leg with each distal joint higher than the proximal joint d. place a trochanter roll at the hip e. perform passive range of motion exercises once daily f. monitor for pain by assessing Homan's sign
a. measure the calf and thigh daily b. apply sequential compression device to legs c. position paralyzed leg with each distal joint higher than the proximal joint
A client diagnosed with renal failure has been admitted to the medical unit. An ABG analysis has been prescribed by the primary healthcare provider. Which ABG interpretation by the nurse is appropriate? pH: 7.33 PaCO2: 36 HCO3: 20 a. metabolic acidosis b. metabolic alkalosis c. respiratory acidosis d. respiratory alkalosis
a. metabolic acidosis
A client with ana cute exacerbation of systemic lupus erythematosus (SLE) is hospitalized with incapacitating fatigue and fever. A urinalysis reveals proteinuria and hematuria. The primary healthcare provider prescribes corticosteroids. During the acute phase of the client's illness, what is most important for the nurse to do? a. monitor intake and output and daily weight b. allow for frequent, uninterrupted rest periods c. institute seizure precautions d. protect client from injury that may cause bleeding
a. monitor intake and output and daily weight
A client has been admitted to the unit with acute pyelonephritis. What interventions should the nurse include in this client's plan of care? a. observe for changes in mental status b. assist client to restroom c. monitor temperature every 4 hours d. help the client get in a comfortable position to void e. instruct client to void every 30 minutes while ill
a. observe for changes in mental status b. assist client to restroom c. monitor temperature every 4 hours d. help the client get in a comfortable position to void
The nurse is caring for a burn client in the emergent phase. The client becomes extremely restless while on a ventilator. What is the priority nursing assessment? a. patency of endotracheal tube b. adventitious breath sounds c. fluid in the ventilator tubing d. ventilator settings
a. patency of endotracheal tube
A client becomes progressively cyanotic and unresponsive post central line insertion. Which action should the nurse take? a. place the client on the left side with the client's head down b. administer a thrombolytic agent c. auscultate the client's heart sounds d. have the client bear down and perform valsalva maneuver
a. place the client on the left side with the client's head down
After determining that a client diagnosed with a stroke has adequate swallowing ability, the nurse develops interventions to safely provide oral feedings to the client. What interventions should the nurse include in this plan of care? a. provide mouth care prior to feeding b. flex head forward for eating c. have dietary puree foods d. use crushed ice as a stimulant for swallowing e. offer thickened liquids to drink f. position client in semi fowler's position after feeding
a. provide mouth care prior to feeding b. flex head forward for eating d. use crushed ice as a stimulant for swallowing e. offer thickened liquids to drink
The nurse is reviewing sequential lab results on a newly admitted client with multiple health issues. Critical changes in which body system require the nurse to immediately notify the primary healthcare provider? a. renal b. endocrine c. pulmonary d. cardiovascular
a. renal
A client is admitted to the critical care unit after suffering a massive cerebral vascular accident. The client's vital signs include BP 160/110, HR 42, and Cheyne-Stokes respirations. Based on this assessment, the nurse anticipates the client to be in which acid/base imbalance? a. respiratory acidosis b. respiratory alkalosis c. metabolic acidosis d. metabolic alkalosis
a. respiratory acidosis
A client admitted to ICU has a prescription for an arterial line insertion to the right radial artery. What assessment findings by the nurse would be of concern? a. right sided mastectomy b. inability to abduct fingers of right hand c. negative Allen's test d. radial pulse 3+ e. presence of AV shunt to right forearm
a. right sided mastectomy c. negative Allen's test e. presence of AV shunt to right forearm
A client receiving chemotherapy for lung cancer reports increased fatigue. The family confirms client is sleeping most of the day and night. What priority action would the nurse take? a. discuss the risks of immobility with client and family b. check current lab values of hematocrit and hemoglobin c. suggest family seek counseling for the client's depression d. request a referral from the healthcare provider for physical therapy
b. check current lab values of hematocrit and hemoglobin
An elderly client with CHF is admitted from the ER. The nurse is attempting to obtain an oxygen saturation reading using a pulse oximeter but the probe will not record. What actions could the nurse implement in order to determine the oxygen saturation level? a. use an earlobe for placement of the probe b. place on the upper arm, utilizing an automatic cuff c. remove any fingernail polish before attaching probe d. place fingers in warm water before checking sat level e. don't use fingers on same arm as an automatic cuff
a. use an earlobe for placement of the probe c. remove any fingernail polish before attaching probe d. place fingers in warm water before checking sat level e. don't use fingers on same arm as an automatic cuff
The nurse is caring for a burn victim with a skin graft to the hand. The area is pale and mottled but has good capillary refill. What is the nurse's best action at this time? a. warm the room b. submerge the hand in warm water c. order a K pad and apply to hand d. have the client exercise the fingers to increase blood flow
a. warm the room
Which finding indicates to the nurse that a client is at risk for skin breakdown? a. weakness requiring assistance to move in bed b. daily intake of at least 85% of food offered c. occasional forgetfulness d. continent of bowel and bladder
a. weakness requiring assistance to move in bed
The nurse is preparing discharge teaching for a client diagnosed with peripheral vascular disease (PVD). Which teaching points should the nurse include about foot and leg care? a. wear soft cotton socks b. avoid hot whirlpools c. rub feet dry d. wash feet every other day e. clear pathways in house
a. wear soft cotton socks b. avoid hot whirlpools e. clear pathways in house
ABGs reflect a pH of 7.28, PaCO2 of 30, and HCO3 of 18. To which client would these ABGs most likely belong? a. weight loss of 20% in past month b. highly anxious with a panic attack c. Alzheimer's with recent overdose of acetylsalicylic acid d. post-op with gastric suction
a. weight loss of 20% in past month
The nurse is caring for a client who has a history of sleep apnea. The client is scheduled for a colon resection the following morning and asks if the sleep apnea machine should be brought to the hospital. What is the nurse's best response? a. yes, bring the sleep apnea machine b. no, do not bring the sleep apnea machine c. it is your choice d. call your primary healthcare provider
a. yes, bring the sleep apnea machine
The nurse provides education to a client who is scheduled for an upper GI series. Which statement by the client indicates an understanding of the nurse's teaching? a. "I'll have to take a strong laxative the morning of the test." b. "I'll have to drink contrast while x-rays are taken." c. "I'll have a CT scan after I'm injected with a radiopaque contrast dye." d. "I'll have an instrument passed through my nose to my stomach."
b. "I'll have to drink contrast while x-rays are taken."
A client hospitalized with a DVT is on a heparin infusion. The client asks the nurse why it is necessary to have blood drawn every 6 hours. What is the best explanation for the nurse to provide to the client? a. "The medicine might make your blood much too thin." b. "It helps us monitor and adjust the dose to work better." c. "It is required for anyone getting heparin intravenously." d. "The test results tell us whether the treatment is working."
b. "It helps us monitor and adjust the dose to work better."
A client has been admitted with a diagnosis of sepsis and 2 sets of blood cultures have been ordered. When the nurse explains the procedure, the client asks the purpose of drawing blood from 2 different veins at 2 different times. What is the best response by the nurse? a. "If we don't get enough blood the first time, we can obtain more." b. "We want to be sure to get samples of all organisms in your blood." c. "We have to be certain none of the samples have been contaminated." d. "It's important not to get too much blood from the arm all at once."
b. "We want to be sure to get samples of all organisms in your blood."
The nurse assesses a client post thyroidectomy for complications by performing which assessment? a. accucheck b. Chovostek's c. ballottement d. ice water colonic
b. Chovostek's
A client has been receiving daily heparin injections for a history of DVTs during pregnancy. Which laboratory test result should be immediately reported to the primary healthcare provider? a. PT of 13 seconds b. aPTT of 22 seconds c. INR of 1.0 d. hemoglobin of 11
b. aPTT of 22 seconds
The client arrives in the emergency department with crushing substernal chest pain radiating down the left arm. Which measure should the nurse initiate first? a. attach to a cardiac monitor b. administer oxygen at 2L nasal cannula c. start an IV line of D5W to keep open d. draw blood for troponin level
b. administer oxygen at 2L nasal cannula
The nurse is working in the term nursery. Which task should be performed first on a newborn? a. prepare the circumcision equipment for a 2 day old newborn b. assess the 5 minute APGAR of a newborn c. perform the gestational age assessment on a 30 minute old newborn d. obtain a blood sample for metabolic testing on a 24 hour old newborn
b. assess the 5 minute APGAR of a newborn
A child is being discharged home following a bone marrow transplant. When providing discharge instructions to the caregivers, what information is most important for the nurse to include? a. clean toothbrush weekly with alcohol b. avoid eating raw fruits and vegetables c. drink bottled water throughout the day d. apply heating pad to bruised areas of the skin
b. avoid eating raw fruits and vegetables
A client with a diagnosis of endocarditis and a new peripherally inserted central catheter (PICC) line has been discharged home to receive daily intravenous antibiotics for 6 more weeks. The home health nurse is making an assessment visit today. What instruction by the nurse is most important initially? a. take antibiotics before dental procedures b. brush and floss teeth at least twice daily c. report any flu like symptoms immediately d. include rest periods throughout the day
b. brush and floss teeth at least twice daily
The nurse is reviewing discharge instructions with a post-op client after bilateral mastectomy with immediate reconstruction. The nurse should instruct the client to report which symptoms related to the surgical drain to the healthcare provider? a. drainage gradually decreases b. drainage suddenly stops c. drainage changes from serosanguinous to serous d. s/s of infection e. drainage tube falls out f. drainage is bright red for more than 2 or 3 days
b. drainage suddenly stops d. s/s of infection e. drainage tube falls out f. drainage is bright red for more than 2 or 3 days
What preoperative information should the nurse provide to the client who is scheduled for an exercise stress test tomorrow morning? a. eat a light breakfast two hours before the test b. dress in loose, comfortable clothing c. take nitroglycerin dose 15 minutes prior to test d. limit drinks with caffeine to 8 oz within 12 hours
b. dress in loose, comfortable clothing
Which nursing interventions will help to prevent a contracture post-operatively in a client with a below the knee amputation? a. keep the residual limb elevated on a pillow at all times b. ensure the residual limb is positioned flat on the bed c. position the client prone several times a day d. keep head of bed elevated with knees up e. apply anti-embolism stockings to the unaffected leg
b. ensure the residual limb is positioned flat on the bed c. position the client prone several times a day
Which nursing intervention should the nurse implement when administering a medication through a NG tube? a. tilt the head forward for medication administration b. flush the tubing between administering medications c. turn the client onto their left side after medication administration d. mix the medication directly into the tube feeding
b. flush the tubing between administering medications
The obstetrical client with a history of chronic hypertension asks the clinic nurse if having hypertension will increase her risk for developing preeclampsia during pregnancy. The nurse correctly identifies which risk factors for preeclampsia? a. multiparous status b. history of hypertension c. history of diabetes or chronic renal disease d. age older than 35 e. African American ethnicity f. family history of preeclampsia (mother or sister)
b. history of hypertension c. history of diabetes or chronic renal disease d. age older than 35 e. African American ethnicity f. family history of preeclampsia (mother or sister)
A client has just had a bone marrow biopsy. What is the nurse's priority intervention post procedure? a. apply ice pack to needle site b. hold pressure on needle site for at least 5 minutes c. observe needle insertion site every 2 hours d. advise client to avoid activities that may result in trauma to the site for 48 hours
b. hold pressure on needle site for at least 5 minutes
A client is admitted with a hip fracture after falling. Based on these lab values, what is the nurse's priority nursing intervention? Na+: 147 Specific gravity: 1.030 Hct: 55% a. provide foods high in iron b. increase fluid intake c. obtain urine for culture d. measure intake and output
b. increase fluid intake
The nurse is taking care of a client that has been on TPN for 5 days. Upon entering the room, the nurse observes that the TPN has been turned off. What is the nurse's priority action? a. flush the IV line b. obtain blood glucose level c. check written prescription d. restart TPN infusion
b. obtain blood glucose level
The nurse is planning care for a client admitted with a diagnosis of new onset myasthenia gravis. Which nursing interventions should the nurse include in order to decrease the risk of aspiration? a. provide thin liquids such as water with meals b. offer small bites of food c. allow client to rest between each bite of food d. offer small meals in the morning and larger meals in the evening e. position client upright with head tilted slightly back when eating f. provide meals 30 minutes before administration of cholinesterase inhibitor medication
b. offer small bites of food c. allow client to rest between each bite of food
The nurse is observing a new LPN preparing to irrigate a client's indwelling urinary catheter. The nurse must intervene when the LPN initiates what action? a. gathers all sterile equipment for procedure b. opens bottle of sterile distilled water to flush c. allows return flow to be achieved by gravity d. uses gentle pressure when flushing catheter
b. opens bottle of sterile distilled water to flush
The nurse's assessment of a client post-op abdominoplasty reveals tachycardia, restlessness, and shallow slow breathes. The client was medicated with morphine 2 mg IVP one hour ago. The primary healthcare provider prescribes ABG. Which ABG report is consistent with this clinical picture? a. pH 7.30, PaCO2 40, HCO3 29 b. pH 7.33, PaCO2 48, HCO3 25 c. pH 7.47, PaCO2 35, HCO3 29 d. pH 7.50, PaCO2 33, HCO3 22
b. pH 7.33, PaCO2 48, HCO3 25
The nurse receives a client in the post-anesthesia care unit following application of a long leg cast due to a left fractured tibia and fibula. Which interventions should the nurse initiate? a. elevate foot of bed 30 degrees b. palpate bilateral pedal pulses c. apply ice packs to fracture site d. mark break through bleeding e. assess client's ability to move toes
b. palpate bilateral pedal pulses c. apply ice packs to fracture site d. mark break through bleeding e. assess client's ability to move toes
A client returns to the unit post scleral buckling of the right eye. Which nursing interventions should the nurse include? a. approach client from the right side b. place personal items within easy reach c. maintain patch over right eye d. administer antiemetic for reports of nausea e. assist client to turn, cough, and deep breathe every 2 hours f. place client prone for 1 hour
b. place personal items within easy reach c. maintain eye patch over right eye d. administer antiemetic for reports of nausea
After applying oxygen using bi-nasal prongs to a client who is having chest pain, the nurse should implement which intervention? a. have the client take slow deep breaths in through the mouth and out through the nose b. post signs on the client's door and in the client's room indicating that oxygen is in use c. apply Vaseline petroleum to both nares and 2x2 gauze around the oxygen tubing at the client's ears d. encourage the client to hyperextend the neck, take a few deep breaths and cough
b. post signs on the client's door and in the client's room indicating that oxygen is in use
What preferred lab value would the nurse expect to see the primary healthcare provider prescribe for a client admitted with generalized malnutrition? a. albumin b. prealbumin c. iron d. calcium
b. prealbumin
Which prescription by the emergency room primary healthcare provider for a client who fell from a ladder should the nurse question? a. record intake and output hourly b. prepare the client for lumbar puncture c. perform neurologic checks every 10 minutes d. schedule a brain CT scan
b. prepare the client for lumbar puncture
Following escharotomy of a circumferential burn to the arm, which assessment is the best indicator when evaluating the effectiveness of this procedure? a. decreased pain in the extremity b. prompt capillary refill <2 seconds after blanching c. bleeding at the site of the incision d. ability of the client to wiggle his/her fingers
b. prompt capillary refill <2 seconds after blanching
A female client has been ordered a radioactive iodine uptake test (RAIU) to evaluate for Graves Disease (hyperthyroidism). What priority actions should the nurse complete before the test? a. insert IV to administer conscious sedation b. remove all jewelry or metal before the test c. obtain urine specimen to check for pregnancy d. confirm client is NPO for 2 hours before the test e. verify client stopped anti-thyroid meds for 1 week
b. remove all jewelry or metal before the test c. obtain urine specimen to check for pregnancy e. verify client stopped anti-thyroid meds for 1 week
A client is to be discharged following a left modified-radical mastectomy. When reviewing ADLs to be completed at home, the nurse anticipates the client will experience the most difficulty doing what tasks? a. cooking a meal b. shampooing hair c. doing the laundry d. vacuuming carpets e. changing bed linens
b. shampooing hair c. doing the laundry e. changing bed linens
The nurse is irrigating an acid chemical burn on a client's arm. Which would indicate to the nurse that irrigation can be stopped? a. client's pain rating has decreased from 6 to 2 on a 0 to 10 pain scale b. the pH value of the runoff solution is 7.0 c. client reports a burning sensation in the affected arm d. capillary refill is less than 2 seconds in the affected arm
b. the pH value of the runoff solution is 7.0
A client is admitted to the LDR from the emergency department at 34 weeks gestation with profuse, painless, bright red vaginal bleeding. The nurse is to prepare for which procedure? a. sterile vaginal exam b. ultrasound exam c. amniocentesis d. contraction stress test
b. ultrasound exam
Following nasal surgery, the nurse suspects a client has developed diabetes insipidus? The nurse knows what laboratory results provide evidence of diabetes insipidus? a. white blood cells of 9,500 mm3 b. urine specific gravity of 1.004 c. serum sodium level of 149 d. hemoglobin of 20 e. glucose of 100
b. urine specific gravity of 1.004 c. serum sodium level of 149 d. hemoglobin of 20
A female client receiving chemotherapy for breast cancer reports vomiting, stomatitis, and a 10 lb weight loss over the past month. The primary healthcare provider orders an antiemetic and daily mouthwashes. When the home care nurse evaluates the client one week later, what change described by the client would best indicate improvement? a. eating 3 meals daily b. weight gain of 2 lbs c. no further mouth pain d. improved skin turgor
b. weight gain of 2 lbs
A home care nurse is assessing a client with a forearm cast recently applied for a displaced radial fracture. What client comment should the nurse consider the priority concern? a. "The cast feels tight on my arm." b. "There is an odd smell inside my cast." c. "I can't open up my fingers this morning." d. "The pain medicine is not relieving my pain."
c. "I can't open up my fingers this morning."
A client who underwent a laparoscopic cholecystectomy is being discharged from an outpatient surgical center. Which statement by the client shows the nurse that discharge teaching has been effective? a. "I will need to eat a low fat diet since I no longer have a gallbladder." b. "I can expect drainage from the incisions for a few days." c. "I may have some mild pain from the procedure." d. "I should plan to limit my activities and not return to work for several weeks."
c. "I may have some mild pain from the procedure."
A nurse has been educating a client newly diagnosed with diabetes about proper foot care. The nurse knows teaching will need to be reinforced again when the client makes what statement? a. "I should cut my toenails with nail clippers." b. "Drying both feet thoroughly is important." c. "I should never use nail polish on my toes." d. "Weekly foot inspection must include the soles of the feet." e. "I need larger shoes that don't pinch my toes."
c. "I should never use nail polish on my toes." d. "Weekly foot inspection must include the soles of the feet." e. "I need larger shoes that don't pinch my toes."
A nurse is providing discharge teaching to a client who has had a cystectomy and formation of an ileal conduit. What client statement indicates that teaching was successful? a. "I should restrict my fluid intake to decrease the need to empty the drainage bag." b. "I will change my appliance daily to prevent skin excoriation from the leakage of urine." c. "I will change my drainage bag whenever it is leaking, giving special attention to my skin around the bag." d. "I will restrict going to event outside the home because leakage is common and embarrassing."
c. "I will change my drainage bag whenever it is leaking, giving special attention to my skin around the bag."
A nurse is caring for a client on the second day after a thoracotomy reporting incisional pain. The nurse assesses the client and evaluates the vital signs. Based on the data documented in the chart, what action should the nurse take first? a. have client cough and deep breathe b. administer acetaminophen for fever c. administer the prescribed analgesic d. assist the client to ambulate
c. administer the prescribed analgesic
A pregnant client's initial blood work shows a negative rubella titer. Which nursing intervention would the nurse implement? a. place the client in isolation until delivery b. inform client that she is currently immune to rubella c. administer the rubella vaccine after delivery d. inform the client that she has never been exposed to rubella
c. administer the rubella vaccine after delivery
A client is admitted to the emergency department after sustaining burns to the chest and legs during a house fire. Which assessment should the nurse perform immediately? a. respiratory b. cardiac c. airway d. neurological
c. airway
A client was diagnosed with lethargy, facial droop, and slurred speech. From this history, what does the nurse recognize as a priority risk for this client? a. diminished colonic motility b. esophageal hemorrhage c. aspiration pneumonia d. stress ulcers
c. aspiration pneumonia
A client admitted for placement of heart stents was started on clopidogrel. The nurse knows that a daily assessment of this client should include what data? a. monitoring of intake and output b. check daily liver function tests c. assess stools for tarry appearance d. monitor daily platelet count e. assess for new ecchymosis
c. assess stools for tarry appearance d. monitor daily platelet count e. assess for new ecchymosis
A concerned caregiver is asking the nurse about activities that would be best for her child who has been diagnosed with asthma. In order to minimize the risk of exercise-induced asthma, which activity would be best for the nurse to suggest? a. track b. basketball c. baseball d. soccer
c. baseball
Following surgery, a client has an indwelling urinary catheter attached to a collection bag. The nurse empties the collection bag at 0900. At the change of shift at 1500, the collection bag contains 100 mL of urine. The system has no obstructions to urinary flow. What would be the nurse's most appropriate initial response? a. elevate the head of the client's bed b. start giving the client 8 oz of oral fluid per hour c. check circulation and take the vital signs of the client d. continue monitoring, because this is an expected finding
c. check circulation and take the vital signs of the client
The nurse is caring for a client following a transurethral resection of the prostate (TURP). The client has a 3 way irrigation catheter in place. Which observation would indicate the need to slow the irrigation? a. clots in urine b. bladder pressure c. clear urine d. bladder spasms
c. clear urine
The nurse is discharging a client post right radial percutaneous transluminal coronary angioplasty (PTCA) with stent insertion. Which instructions should the nurse give the client to reduce the risk of complications? a. do not use the wrist to lift more than 5 lbs for 24 hours b. stop taking aspirin in one week c. drink at least 8 glasses of water a day d. wear loose fitting sleeves e. do not shower or soak in a tub for one week f. take short walks around your house
c. drink at least 8 glasses of water a day d. wear loose fitting sleeves f. take short walks around your house
A client's membranes spontaneously rupture at 10 cm dilation and +2 station. The nurse notes that the fluid is colored green. Which intervention would the nurse anticipate? a. emergency cesarean delivery b. immediate high forceps delivery c. equipment for immediate suctioning of the newborn d. administration of IV oxytocin
c. equipment for immediate suctioning of the newborn
The nurse just received an ABG report that shows a borderline high PCO2 on a client who had chest surgery. What should be the priority nursing intervention? a. tell the client to breathe faster b. medicate for pain and ambulate c. have client use the incentive spirometer d. prepare to administer bicarbonate to buffer
c. have client use the incentive spirometer
The UAP notifies the nurse that an elderly client seems slightly confused and has become incontinent. Upon assessing the client, the nurse notes an increased pulse with BP lower than normal. What action by the nurse takes priority? a. call primary healthcare provider stat b. notify family that client is confused c. have staff collect a urine specimen d. apply oxygen at 2L via nasal cannula
c. have staff collect a urine specimen
The nurse is caring for a client post hysterectomy. Based on data obtained from the nurse's notes, what should be the nurse's initial response? 0900: Client received to post-anesthesia unit after hysterectomy. Easily aroused. BP 128/72, RR 18, HR 90. Skin warm and dry 1100: lethargic, VS are BP 100/68, RR 24, HR 102. Skin cool and moist a. retake the vital signs b. administer the ordered dopamine to maintain a blood pressure of 110 systolic c. increase the IV rate of the lactated ringer's solution d. raise the head of the bed to 30 degrees
c. increase the IV rate of the LR solution
A client arrives at the emergency room with active GI bleeding. What is the most important nursing action? a. treat the cause of the bleeding b. record the amount of blood loss c. initiate an intravenous access line d. prepare client for stat endoscopy
c. initiate an intravenous access line
The nurse assesses a diabetic client in the emergency department and notes a blood glucose of 400 mg/dL, muscle twitching, and an increase respiratory rate. What is the nurse's priority concern? a. respiratory acidosis b. respiratory alkalosis c. metabolic acidosis d. metabolic alkalosis
c. metabolic acidosis
The charge nurse is reviewing correct body mechanics with a group of newly hired UAPs. The nurse reinforces that muscle injuries can best be prevented by avoiding what action? a. carry objects close to body but do not touch clothing b. use the largest muscles for lifting, such as thigh muscles c. move objects with quick fast tugs to avoid muscle fatigue d. lean into objects such as a lifter and push instead of pull
c. move objects with quick fast tugs to avoid muscle fatigue
Which immediate action should a nurse take if a client's chest tube is accidentally disconnected from the disposable water-seal system? a. have client hold breath b. administer oxygen c. place the tubing coming from the client into sterile water d. raise the head of the bed
c. place the tubing coming from the client into sterile water
A client diagnosed with hypothyroidism has received dietary education from the nurse. Which snack selection chosen by the client would indicate that education has been successful? a. cup of almonds b. cheese and crackers c. popcorn d. sweet potato fries
c. popcorn
A nurse is caring for a client admitted to the hospital for a total hip replacement. In preparing the post-operative plan of care for this client, the nurse recognizes which goal as the highest priority? a. prevent complications of shock b. prevent dislocation of prosthesis c. prevent respiratory complications d. prevent skin breakdown
c. prevent respiratory complications
A client is being discharged with halo traction. What should the nurse teach the client and family about home management of this traction? a. showering is permitted once a week with assistance b. apply baby lotion under the halo vest to prevent irritation c. sleep in whatever position is found to be most comfortable d. never pull on any part of the halo traction e. clean around pins at least once daily with a new q-tip for each pin site
c. sleep in whatever position is found to be most comfortable d. never pull on any part of the halo traction e. clean around pins at least once daily with a new q-tip for each pin site
A nurse is caring for a client who has chest pain. Which statement made by the client leads the nurse to suspect angina instead of a MI? a. I became dizzy when I stood up b. I was nauseated and began vomiting c. the pain started in my chest and stopped after I sat down d. the pain was not relieved after taking 3 nitroglycerine tablets
c. the pain started in my chest and stopped after I sat down
The edrophonium (Tensilon) test has been prescribed for a client. Which statement by the client would indicate to the nurse that the client understands this test? a. "This medication will be given to me as an IM injection immediately after my muscles are tired." b. "This test will determine if I have multiple sclerosis." c. "The test is positive if my muscles do not get stronger after injection with this medication." d. "I will be asked to perform a repetitive movement to test my muscles."
d. "I will be asked to perform a repetitive movement to test my muscles."
The caregivers of a child hospitalized with cystic fibrosis have been given discharge instructions. The nurse knows that teaching has been successful when the caregivers make what statement? a. "Our child will need to have a gluten free diet." b. "The enzymes should be given at bedtime daily." c. "Salt needs to be decreased in our child's diet." d. "We need to prepare high calorie, high fat meals."
d. "We need to prepare high calorie, high fat meals."
The nurse is reviewing morning laboratory results on 4 clients. Which lab finding should the nurse report to the primary healthcare provider immediately? Client diagnosed with DVT who is receiving a heparin infusion -- aPTT: 85 Client diagnosed with possible appendicitis -- WBC: 18,000 Client diagnosed with rheumatoid arthritis -- Sed rate: 100 Client diagnosed with CHF receiving furosemide -- K+: 2.9 a. aPTT b. WBC c. sed rate d. K+
d. K+
The head nurse on a busy surgical unit is evaluating several fresh post-op clients. Which observation should the nurse report immediately to the primary healthcare provider? a. a post transurethral resection client with cherry colored urine b. a post mastectomy client drains 40 mL of bloody drainage within 3 hours of the surgery c. a post ileostomy client with a beefy red stoma and mucus drainage d. a post thyroidectomy client reporting tingling in toes and fingers
d. a post thyroidectomy client reporting tingling in toes and fingers
The nurse is caring for a post op client who is drowsy but arousable. The client will take a few deep breaths when instructed but drifts to sleep when left alone. The O2 saturation while sleeping drops to 82% on 3L of nasal oxygen. The client received a dose of oxycodone/acetaminophen 2 tabs one hour ago. What is the nurse's best action at this time? a. keep the O2 sat machine at the bedside and set the alarm to beep loudly when O2 sat drops below 83% b. give bath to arouse client and then report that oxycodone/acetaminophen 2 tabs is too much for the next dose c. let the client sleep until she has rested, then discuss abuse potential of narcotics d. call the primary healthcare provider and report client assessment findings
d. call the primary healthcare provider and report client assessment findings
An 18 year old football player is admitted to the ortho unit after a femur fracture. He is scheduled for a rod to be placed in the morning, but suddenly develops shortness of breath, a petechial rash on his chest, and BP 88/50, pulse 122, RR 21. What should the nurse do first? a. decrease rate of IV fluids b. neurovascular checks of affected leg c. elevate the head of the bed d. call the rapid response team
d. call the rapid response team
A client is admitted from the emergency department to a medical unit. What acid base imbalance do the lab values indicate? pH: 7.44 PaCO2: 30 HCO3: 20 a. metabolic acidosis b. compensated metabolic alkalosis c. respiratory acidosis d. compensated respiratory alkalosis
d. compensated respiratory alkalosis
A client returns from PACU following a mastectomy with a JP drain in place. What action by the nurse is important? a. empty drain every 8 hours b. irrigate drain with NS every shift c. drape tubing above breast incision d. measure the drainage volume
d. measure the drainage volume
The nurse is caring for a 5 year old client who is 12 hours post tonsillectomy. The client is pain free and has advanced to a soft diet. What is the priority nursing intervention? a. apply warm compresses to the throat b. encourage gargling to reduce discomfort c. position the child supine d. monitor for frequent clearing of the throat
d. monitor for frequent clearing of the throat
A client with chronic arterial occlusive disease has a bypass graft of the left femoral artery. Postoperatively, the client develops left leg pain and coolness in the left foot. What is the priority action by the nurse? a. elevate the leg b. check distal pulses c. increase the IV rate d. notify the primary healthcare provider
d. notify the primary healthcare provider
A nurse is triaging a 2 year old child in the pediatric emergency department. The nurse notes that the child will not lie down and is consistently drooling. A croaking sound is heard on inspiration. What is the priority nursing intervention? a. examine the oral pharynx using a tongue depressor b. administer a sedative so the child can be examined c. have a second nurse hold the child down for assessment d. notify the primary healthcare provider immediately
d. notify the primary healthcare provider immediately
What foods should the nurse inform the client to avoid for 3 days prior to a guaiac test? a. chicken b. carrots c. apple d. raw broccoli e. steak f. turnip greens
d. raw broccoli e. steak f. turnip greens
The nurse is preparing to teach a client about post percutaneous transluminal coronary angioplasty (PTCA) care. Which teaching points should the nurse include? a. restricting oral fluids until the gag reflex has returned b. encouraging early ambulation and deep breathing exercises c. discontinuing medicines following percutaneous intervention d. reporting any chest discomfort following percutaneous intervention e. avoid lifting more than 10 lbs until approved by healthcare provider
d. reporting any chest discomfort following percutaneous intervention e. avoid lifting more than 10 lbs until approved by healthcare provider
A client has just developed an abdominal wound evisceration post bowel resection. In what position should the nurse place the client? a. sims position b. dorsal recumbent c. right side lying in the fetal position d. supine, head of bed at 15 degrees with knees and hips bent
d. supine, head of bed at 15 degrees with knees and hips bent
An adolescent is diagnosed with a closed head injury following a motor vehicle accident. The nurse notes clear drainage from the left nostril and is aware the priority action is what? a. contact the healthcare provider b. carefully suction both nostrils c. ask client to gently blow nose d. test the drainage for glucose
d. test the drainage for glucose
The lactation consultant is preparing to make rounds on the breastfeeding clients on the Labor, Delivery, Recovery, Postpartum (LDRP) unit. Which client should the consultant see first? a. the mother who is nursing her newborn every 2-3 hours for 15-20 minutes at a time b. the mother who stated that her newborn sucks in short bursts and has audible swallowing c. the mother who reported blisters on her nipples and pain whenever the newborn latches on d. the mother who stated that her baby was so good that she has to wake him for each feeding
d. the mother who stated that her baby was so good that she has to wake him for each feeding
