Hurst Review Questions (4)
The nurse evaluates an electrocardiogram (EKG) and notices a U-wave. The nurse suspects that this occurrence is caused by which electrolyte imbalance? 1. Hypermagnesemia 2. Hypocalcemia 3. Hypokalemia 4. Hyponatremia
3. Hypokalemia
What turning method should the nurse use to turn a client who has a spinal injury? 1. Lateral transfer 2. Slide sheet procedure 3. Logrolling 4. Mechanical lift transfer
3. Logrolling
A post-operative client has received morphine for pain. The nurse re-assesses the client 10 minutes later. Which assessment data warrants further action by the nurse? Exhibit 1. Blood pressure 94/60 2. Pulse rate 72/min 3. Pain level 3/10 4. Respiratory rate at 8/min
4. Respiratory rate at 8/min
What would be the nurse's priority for a child who has arrived at the emergency department after sustaining a severe burn? 1. Start intravenous fluids. 2. Provide pain relief. 3. Establish airway. 4. Place an indwelling catheter.
3. Establish airway.
A primipara at 36 weeks gestation is seen in the OB/GYN clinic. Which sign/symptom should the nurse immediately report to the primary healthcare provider? 1. Puffy hands and face 2. Reports indigestion 3. Pedal edema 4. Trace proteinurea
1. Puffy hands and face
The nurse is caring for a client who is scheduled to receive furosemide 40 mg IVP twice daily, as well as 20 meq (20 mmol/l) of potassium chloride twice daily. The client's lab work reveals that the potassium level is 2.4 mEq/L (2.4 mmol/L) this morning. How should the nurse proceed? 1. Notify the primary healthcare provider of the potassium level immediately. 2. Administer the medications as scheduled and notify the primary healthcare provider on rounds. 3. Give the potassium, but hold the furosemide until primary healthcare provider rounds. 4. Assess the client for muscle cramps.
1. Notify the primary healthcare provider of the potassium level immediately.
While making rounds, the nurse discovers a small fire in a client's room. What should the nurse do first? 1. Remove the client from the room immediately. 2. Leave the client's room to obtain a fire extinguisher. 3. Instruct the unlicensed assistive personnel (UAP) to pull the fire alarm. 4. Evacuate all clients from the unit.
1. Remove the client from the room immediately.
A client has a prescription for nitroglycerin gr 1/400 SL prn for angina pain. How many tablets should the nurse give the client? Use numbers and decimals only. Nitro 0.3 (1/200 gr)
0.5 1gr = 60mg 1/400 x 60/1 = 3/20 = 0.15mg 0.15 is 1/2 of 0.3 0.15/0.3 = 0.5
A client diagnosed with heart failure has been prescribed a 2 gm sodium diet. Which food choices selected by the client would indicate to the nurse that the client understands this diet? Select all that apply 1. Pork loin 2. Frozen cheese ravioli dinner 3. Instant vanilla pudding 4. Thin crust pepperoni and ham pizza 5. Fresh salad with fresh citrus juice dressing 6. Bottled tomato juice
1. Pork loin 5. Fresh salad with fresh citrus juice dressing
A client diagnosed with a deep venous thrombosis (DVT) has been prescribed warfarin. Which of the client's current medications would the nurse notify the primary healthcare provider related to the prescribed warfarin? Select all that apply 1. Metformin 2. Aspirin 3. Ginkgo 4. Amlodipine 5. Hydrochlorothiazide
2. Aspirin 3. Ginkgo
A nurse monitors the heart rates of four children on a pediatric unit. Which client requires additional assessment by the nurse? 1. One year old child who has a heart rate of 150 bpm and is crying 2. Two year old child who has a heart rate of 165 bpm and is being rocked 3. Five year old child who has a heart rate of 100 bpm and is playing quietly 4. Thirteen year old adolescent who has a heart rate of 90 and is watching television
2. Two year old child who has a heart rate of 165 bpm and is being rocked
The nurse is caring for a client admitted with an episode of bleeding esophogeal varices. What should the nurse monitor for after administering propranolol to this client? Select all that apply 1. Increased systolic BP 2. Hypokalemia 3. Bradycardia 4. Wheezing 5. Decreased hematemesis
3. Bradycardia 4. Wheezing 5. Decreased hematemesis
The nurse is preparing to administer scheduled medications for a client. Which medication would require clarification prior to administration? Scheduled medications to administer: Digoxin 0.125 IV push every morning Sacubitril/valsartan 24/26 mg by mouth twice a day Bumetanide 0.5 mg by mouth twice a day Potassium chloride 20 mEq by mouth three times a day 1. Digoxin 2. Sacubitril/valsartan 3. Bumetanide 4. Potassium chloride
3. Bumetanide
A housekeeper has been called to the medical-surgical unit to complete several tasks. Which tasks by the housekeeper has priority? 1. Replace the full sharps container in the medication room. 2. Clean room of discharged client who was isolated with MRSA. 3. Wipe up spilled coffee in the family waiting room. 4. Repair a malfunctioning curtain around a client's bed.
3. Wipe up spilled coffee in the family waiting room.
Which room assignment would be most therapeutic for the nurse to make for a client with bipolar disorder in manic phase who is hyperactive and has difficulty sleeping? 1. A private bedroom. 2. A semi private room with a roommate who has a similar problem. 3. Either a private or a semi private room. 4. Direct admission to the seclusion room until his activity level becomes more subdued.
1. A private room
What signs/symptoms would the nurse expect to find in a client diagnosed with acute pyelonephritis? Select all that apply 1. Chills 2. Fishy smelling urine 3. Polyuria 4. Dysuria 5. Headache
1. Chills 2. Fishy smelling urine 4. Dysuria
An adolescent has been admitted for evaluation of excessive weight loss over several months. When assessing the client, what data gathered by the nurse would be most important to support a diagnosis of anorexia nervosa? Select all that apply 1. Dehydration 2. Poor appetite 3. Amenorrhea 4. Tachycardia 5. Muscle loss 6. Constipation
1. Dehydration 3. Amenorrhea 5. Muscle loss 6. Constipation
A client receiving treatment for hypertension is scheduled to receive hydrochlorothiazide 25 mg orally. Based on the label on the bottle, how many tablets should the nurse administer?
0.5 25/50 = 0.5
The nurse is preparing to make initial shift rounds. Which primipara client should the nurse see first? 1. 39 weeks with a board like abdomen and scant dark red bleeding. 2. 38 weeks gestation with blood streaked vaginal discharge 3. 40 weeks gestation reporting urinary frequency 4. 36 weeks gestation with pitting pedal edema
1. 39 weeks with a board like abdomen and scant dark red bleeding.
The nurse manager of a long-term care facility notes an increase in pressure ulcers over the last six months. What new protocol developed by the nurse manager is most likely to decrease the occurrence of decubiti? 1. Bedfast clients must be repositioned every two hours. 2. All clients should have egg crate mattress on the bed. 3. Clients bathed in bed need lotion applied to all joints. 4. Provide back massage daily to all clients on bed rest.
1. Bedfast clients must be repositioned every two hours.
The nurse is caring for a Puerto Rican client. The client has several injuries from a car accident and is experiencing pain. Which behavior is likely to be noted? 1. Loud crying with pain. 2. Enduring the pain in order to bring honor. 3. Quiet and stoic responses to pain. 4. Refusing pain medication because it is God's will.
1. Loud crying with pain.
At orientation for a new nurse, the charge nurse on the neuro unit reviews tests requiring informed consent which may be ordered for clients. The charge nurse knows the review was successful if the new nurse indicates a signed consent is required for what test(s)? Select all that apply 1. Computerized tomography 2. Cerebral spinal fluid analysis 3. Magnetic resonance imaging 4. Electroencephalogram 5. Cerebral angiogram
2. Cerebral spinal fluid analysis 5. Cerebral angiogram
A nurse educator has completed an educational program on interpreting arterial blood gases (ABGs). The educator recognizes that education has been successful when a nurse selects which set of ABGs as metabolic acidosis? 1. pH - 7.32, PaCO2 - 48, HCO3 - 23 2. pH - 7.29, PaCO2 - 42, HCO3 - 19 3. pH - 7.5, PaCO2 - 30, HCO3 - 22 4. pH - 7.35, PaCO2 - 35, HCO3 - 26
2. pH - 7.29, PaCO2 - 42, HCO3 - 19
The nurse is monitoring the IV medications that a client is receiving by an IV infusion pump. How many micrograms per min of dopamine should the nurse determine that the client is receiving? Use numbers only to answer. Height: 187 cm Weight: 75.2 kg Mix Dopamine 400 mg in 250 mL of NS to yield 1600 mcg/mL Dopamine 5mcg/kg/min
376 5mcg x 75.2 kg = 376
The nurse is removing the client's peripheral IV line prior to discharge. The nurse completes the appropriate steps in what order? Apply gauze and tape tightly. Clamp IV line closed securely. Loosen tape and tegaderm cover. 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.
A client is being evaluated for possible Rheumatoid Arthritis (RA). Which assessment finding by the nurse would be indicative of RA? Select all that apply 1. Spindle shaped fingers 2. Early morning stiffness resolves within 30 minutes. 3. Joint pain relieved by rest. 4. Presence of Bouchard's nodes 5. Ulnar drift
1. Spindle shaped fingers 5. Ulnar shift
A recently hired primary healthcare provider from India has started working at the local hospital. When receiving new phone prescriptions, the nurse is unable to understand the primary healthcare provider's thick accent. Which comment by the nurse is most likely to successfully resolve the issue? 1. "I'll have to get someone who can understand you." 2. "I can't understand you. You need to say it again." 3. "Can you please repeat that prescription again slowly? " 4. "I don't know what you are trying to say."
3. "Can you please repeat that prescription again slowly? "
Which response by the nurse is appropriate when responding to a client who reports eliminating all dairy foods from their diet because of lactose intolerance? 1. "Take calcium tablets since they can be used as a total supplement for dairy products." 2. "You can take lactose enzymes which will eliminate the effects of lactose intolerance." 3. "Valuable nutrients found in milk include calcium and protein." 4. "Consume more leafy green vegetables to maintain calcium levels."
3. "Valuable nutrients found in milk include calcium and protein."
A factory employee is brought to the emergency room on first shift with a severe hand laceration occurring at work. The employee is quite upset, indicating previous competency on the machine. When reviewing medications, the nurse notes the client has recently started alprazolam at bedtime. What vital information about this medication should the nurse provide to the client? 1. Consider getting new glasses. 2. Stand up slowly when sitting. 3. Do not operate dangerous machines. 4. Instructions for taking medication appropriately.
3. Do not operate dangerous machines.
A middle-aged client has a strong positive family history of type 2 diabetes mellitus. What should the nurse teach the client regarding the best method to prevent or delay the development of this disease? 1. Test serum glucose values monthly. 2. Avoid starches and sugars in the diet. 3. Obtain a normal body weight and exercise regularly. 4. Maintain a normal serum lipid panel.
3. Obtain a normal body weight and exercise regularly.
A client is to be discharged following treatment for hepatitis A. The nurse knows teaching was successful when the client makes what statement? 1. "I should never eat fresh salad in a restaurant." 2. "I must wait two years before traveling abroad." 3. "I will need blood work once a month for a year." 4. "I will be able to donate blood when I am well."
4. "I will be able to donate blood when I am well."
The lactation consultant is preparing to make rounds on the breastfeeding clients on the Labor, Delivery, Recovery, Postpartum (LDRP). Which client should the consultant see first? 1. The mother who is nursing her newborn every 2-3 hours for 15-20 minutes at a time. 2. The mother who stated that her newborn sucks in short bursts and has audible swallowing. 3. The mother who reported blisters on her nipples and pain whenever the newborn latches on. 4. The mother who stated that her baby was so good that she has to wake him for each feeding.
4. The mother who stated that her baby was so good that she has to wake him for each feeding.
The nurse is preparing to speak to a group of clients at the community center about influenza. Which risk factors for influenza complications would be included in the session? Select all that apply 1. Age over 65 years. 2. History of grand mal seizures 3. Diabetes 4. Renal disease 5. Clients who reside in a nursing home.
1. Age over 65 years. 3. Diabetes 4. Renal disease 5. Clients who reside in a nursing home.
A client with a history of deep vein thrombosis (DVTs) is being instructed on how to apply compression stockings prior to discharge. What statement alerts the nurse the client may be noncompliant when at home? 1. "I will follow the special diet in order to lose weight." 2. "I should walk a little every few hours after sitting." 3. "My husband can help remind me not to cross my legs." 4. "The stockings are too difficult to put on every morning."
4. "The stockings are too difficult to put on every morning."
The nurse leader is planning to change the method of client documentation on the unit. Some employees accept the change without difficulty; however, some of the employees are resistant to change and try to sabotage the plans for change. Which action should the nurse leader take to reduce resistance to change on the unit? 1. Allow staff on the unit a voice in the plan for change. 2. Discourage discussion between supporters and resisters. 3. Set an implementation date and begin the new method. 4. Announce that the plan for change is set by administration.
1. Allow staff on the unit a voice in the plan for change.
While in the emergency department, a 68 year old client being treated for flu symptoms, became symptomatic with an episode of atrial tachycardia which was successfully treated with cardioversion. After stabilization, the client was admitted to the telemetry unit with a diagnosis of the flu, and a history of angina. Primary healthcare provider prescriptions were received. What is most important for the nurse to ensure prior to administering Peramivir? Bedrest with bathroom privileges. Continuous cardiac monitoring. ½ Normal Saline at 75 mL/hour. 2 gm Low sodium diet. Peramivir 600 mg IVPB times one dose. ECG every 8 hours times three. Lab: CBC, sodium, potassium, BNP, Troponin, Creatinine clearance, Urinalysis 1. Creatinine clearance is greater than 50 mL/min. 2. Pulse greater than 70 beats/min. 3. Cardiac rhythm showing normal sinus rhythm. 4. Oral temperature less than 101° F (38.3° C)
1. Creatinine clearance is greater than 50 mL/min.
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? Select all that apply 1. Insert IV to administer conscious sedation. 2. Remove all jewelry or metal before the test. 3. Obtain urine specimen to check for pregnancy. 4. Confirm client is NPO for two hours before the test. 5. Verify client stopped anti-thyroid meds for one week.
2. Remove all jewelry or metal before the test. 3. Obtain urine specimen to check for pregnancy. 5. Verify client stopped anti-thyroid meds for one week.
Which statement made by the nurse is therapeutic when the client, who has experienced deficits from a recent cerebral vascular accident, tearfully states, "I can no longer care for myself."? 1. "Right now, I am going to help you get dressed and eat breakfast." 2. "You have to focus on the positive things in your life." 3. "It is hard not to be able to care for yourself." 4. "All you need is some physical therapy and you will be back to normal soon."
3. "It is hard not to be able to care for yourself."
A gunshot victim is brought by ambulance to the emergency room with an open pneumothorax. A bio-occlusive dressing to the chest. The nurse then notes increased dyspnea and sub-q emphysema in the client. What is the nurse's priority action? 1. Prepare client for insertion of chest tube. 2. Apply a non-rebreather with 100% oxygen. 3. Loosen one side of the bio-occlusive dressing. 4. Obtain a tracheostomy kit and call the surgeon.
3. Loosen one side of the bio-occlusive dressing.
A client who has a long leg cast is reporting unrelieved pain. What should the nurse do first? 1. Apply a cool compress. 2. Elevate and reposition the leg. 3. Assess for breakthrough bleeding on the cast. 4. Monitor extremity for paresthesia.
4. Monitor extremity for paresthesia.
A client is brought into the emergency department (ED) with nausea, vomiting and diarrhea after eating chicken at a picnic. The nurse suspects that this client has most likely contracted which infection? 1. Shigella 2. Escherichia coli 3. Clostridium Difficile 4. Salmonella
4. Salmonella
What developmental milestone does the nurse expect to see in a two month old baby? Select all that apply 1. Responds to own name. 2. Holds head up. 3. Rolls over from stomach to back. 4. Pushes down on legs when feet are on a hard surface. 5. Turns head towards sound. 6. Reaches for toy with one hand.
2. Holds head up. 5. Turns head towards sound.
A newly hired unlicensed assistive personnel (UAP) at a long-term care facility is being instructed on the proper method of feeding a stroke client with dysphagia. The nurse knows teaching was successful when the UAP makes what statement? 1. "Feeding the client in semi-fowlers position is easier." 2. "I should not allow the client to do any self-feeding." 3. "Thickened liquids are safer for the client to swallow." 4. "I am offering the client a drink after each bite to help digestion."
3. "Thickened liquids are safer for the client to swallow."
A client diagnosed with glaucoma is being instructed on self-instillation of eye drops. What statement by the client would indicate to the nurse that teaching was successful? 1. "I should look into the mirror to be sure I am getting the drops in." 2. "I will put all drops in my eyes and then close eyes for 5 minutes." 3. "I have to be sure not to touch the dropper to any part of my eye." 4. "I have to pull down the upper lid when putting the eye drops in."
3. "I have to be sure not to touch the dropper to any part of my eye."
The nurse assesses a diabetic client in the emergency department and notes a blood glucose of 400 mg/dL (22.2 mmol/L), muscle twitching, and an increased respiratory rate. What is the nurse's priority concern? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
3. Metabolic acidosis
The nurse is monitoring the healing of a full-thickness wound to a client's right thigh. The wound has a small amount of blood during the wet to dry dressing change. What action should the nurse initiate next? 1. Notify the primary healthcare provider. 2. Obtain wound culture. 3. Document the findings. 4. Remove dressing and leave open to air.
3. Document the findings.
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? 1. I should restrict my fluid intake to decrease the need to empty the drainage bag. 2. I will change my appliance daily to prevent skin excoriation from the leakage of urine. 3. I will change my drainage bag whenever it is leaking, giving special attention to my skin around the bag. 4. I will restrict going to events outside the home because leakage is common and embarrassing.
3. I will change my drainage bag whenever it is leaking, giving special attention to my skin around the bag.
The nurse is evaluating an elderly bedridden client for possible fecal impaction. What sign/symptom should the nurse report as most indicative for a fecal impaction? 1. Rigid, board-like abdomen 2. Absence of any bowel sounds 3. Diarrhea with severe cramping 4. Constipation with liquid seepage
4. Constipation with liquid seepage
The nurse is preparing to initiate postmortem care. Which postmortem care interventions would the nurse implement? 1. Identify the client by the name on the client's armband. 2. Remove tubes and indwelling lines after cleansing the body. 3. Insert the dentures after the family has viewed the body. 4. Maintain body preparation according to the client's religious beliefs.
4. Maintain body preparation according to the client's religious beliefs.
A client was prescribed a monoamine oxidase inhibitor (MAOI) for the treatment of depression. Which comment by the client indicates adequate understanding of the tyramine restrictions that apply? 1. I cannot eat avocados or smoked ham. 2. I can eat sausage for breakfast, but not bacon. 3. At least I can still have my beer. 4. I can have blue cheese on my salad but not ranch dressing.
1. I cannot eat avocados or smoked ham.
The nurse is assessing a client admitted with acute gastritis. Which client information is most significant? 1. Takes ibuprofen for arthritis pain. 2. Had an upper respiratory infection two weeks ago. 3. Has a stressful job. 4. Enjoys spicy food.
1. Takes ibuprofen for arthritis pain.
A client shares with the nurse that they are having difficulty staying asleep. Which sleep hygiene intervention would the nurse share with the client to promote falling asleep? 1. Take a cool bath. 2. Include a daytime exercise plan. 3. Take an antihistamine at bedtime. 4. Scan the news feeds on the computer.
2. Include a daytime exercise plan.
The primary healthcare provider has prescribed hydromorphone 2 mg intravenously (IV) every 4 hours as needed for pain. When should the nurse plan to administer the medication to the client? 1. Only when requested. 2. Prior to onset of intense pain. 3. With reports of acute pain lasting for at least one hour. 4. Continuously every 4 hours to keep the client pain free.
2. Prior to onset of intense pain.
A terminal client begins reminiscing about the past, expressing grief and regret over life choices. What response by the nurse would best help the client cope at this time? 1. "You can't change the past so try not to dwell on it." 2. "Would you like me to call a priest for you to talk with?" 3. "You still have time to make amends if you want." 4. "I can sit here with you while you continue to talk."
4. "I can sit here with you while you continue to talk."
During evening rounds on a medical unit, a client is discovered in cardiac arrest. After activating the code button, the nurse initiates chest compressions. A second nurse enters the room to assist. What priority task could be delegated to the second nurse? 1. Retrieve the crash cart. 2. Document the code events. 3. Notify the primary healthcare provider 4. Begin oxygenating the client.
4. Begin oxygenating the client.
A home health nurse is planning home safety education for a client and spouse. Which actions should be included to promote fire safety in the home setting? Select all that apply 1. A fire extinguisher should be kept on each level of the home. 2. Keep matches and lighters away from children by storing them in a locked cabinet. 3. Install carbon monoxide smoke alarms, and test them monthly. 4. You may leave Christmas lights lit all night as long as the tree is artificial. 5. Have a planned route of exit and a place where all family members will meet.
1. A fire extinguisher should be kept on each level of the home. 2. Keep matches and lighters away from children by storing them in a locked cabinet. 3. Install carbon monoxide smoke alarms, and test them monthly. 5. Have a planned route of exit and a place where all family members will meet.
A laboring client, with gestational hypertension, has requested an epidural for pain management. What interventions should the nurse perform to minimize the risk of hypotension? Select all that apply 1. Administer an IV bolus of Normal Saline prior to placement. 2. Place 15L of O2 via nonrebreather face mask. 3. Avoid the supine position after placement. 4. Hold nifedipine. 5. Get out of bed slowly.
1. Administer an IV bolus of Normal Saline prior to placement. 3. Avoid the supine position after placement.
The client with mania has repeatedly interrupted group session with the counselor. The client explains that they already know this information about family roles and paces around the room. What should the nurse do at this time? 1. Ask the client to take a walk with you and make another pot of coffee. 2. Ask the client to reflect on their behavior to determine if it is appropriate. 3. Ask the group to tell the client how they feel when they are interrupted. 4. Tell the client to perform jumping jacks and count out loud.
1. Ask the client to take a walk with you and make another pot of coffee.
A first time mother-to-be shares with the nurse a sense of indifference towards the impending birth of the infant. The client is concerned about "being a good mother" because of current lack of interest. What response by the nurse would be most appropriate at this time? 1. Such feelings are not unusual for first time mothers." 2. "Once you hold your new baby, you will be just fine." 3. "Would you like to discuss this problem with the doctor?" 4. "Describe the fears you have regarding your new baby."
1. Such feelings are not unusual for first time mothers."
The nurse is reviewing the Centers for Disease Control and Prevention's (CDC's) guidelines for immunization recommendations with a group of parents whose children are preparing to attend college in the fall. Which immunization recommendations should the nurse include? Select all that apply 1. Rotavirus 2. Meningococcal 3. Herpes zoster 4. Seasonal influenza 5. Human papilloma virus
2. Meningococcal 4. Seasonal influenza 5. Human papilloma virus
Which tasks would be appropriate for the RN to delegate to an unlicensed assistive personnel (UAP)? Select all that apply 1. Ask the client diagnosed with dementia memory-testing questions. 2. Monitor the urinary output hourly on the client with renal disease. 3. Demonstrate pursed lipped breathing to the client who has emphysema. 4. Give a tepid sponge bath to the client who as a fever. 5. Assess oxygen saturation on a client experiencing angina.
2. Monitor the urinary output hourly on the client with renal disease. 4. Give a tepid sponge bath to the client who as a fever.
Following escharotomy of a circumferential burn to the arm, which assessment is the best indicator when evaluating the effectiveness of this procedure? 1. Decreased pain in the extremity 2. Prompt capillary refill < 2 seconds after blanching 3. Bleeding at the site of the incision 4. Ability of the client to wiggle his/her fingers
2. Prompt capillary refill < 2 seconds after blanching
Who often performs the responsibilities of a case manager? Select all that apply 1. Physical therapist 2. Social worker 3. Dietitian nutritionist 4. Nurse 5. Unlicensed assistive personnel
2. Social worker 4. Nurse
A high school nurse is assessing multiple students reporting general flu-like symptoms. Which additional symptoms reported by a student would prompt the nurse to immediately call an ambulance? 1. Blurred vision and Trousseau's sign. 2. Vomiting and a Murphy's sign. 3. Sensitivity to light and Kernig's sign. 4. Fever and a Chvostek's sign.
3. Sensitivity to light and Kernig's sign.
The client who is scheduled for a cholecystectomy asks the nurse about her opinion on the surgeon who is going to perform the surgery. The nurse says to the client, "You should get a second opinion because your surgeon has been involved in several client lawsuits." Because the surgeon has not been involved in any client lawsuits, the nurse has initiated which tort? 1. Assault 2. Libel 3. Slander 4. Negligence
3. Slander
The nurse is passing morning medication on a busy medical-surgical unit and has been delayed in completing rounds. When re-evaluating how to distribute the remaining scheduled medications, which client would the nurse consider at greatest risk if medications are late? 1. The client with congestive heart failure receiving digoxin. 2. The client with epilepsy scheduled to receive phenytoin. 3. The client with myasthenia gravis on pyridostigmine. 4. The client with hypertension due for daily nifedipine.
3. The client with myasthenia gravis on pyridostigmine.
The nurse caring for a client who had a transurethral resection of the prostate (TURP) would increase the flow of the continuous bladder irrigation for which assessment data? 1. The drainage is continuous but slow. 2. The drainage is cloudy and dark yellow. 3. The drainage is bright red. 4. No drainage of urine or irrigation solution is noted.
3. The drainage is bright red.
Which food item would the nurse include when planning diet instructions to promote bone growth for a client with a broken tibia? 1. Lettuce 2. Apples 3. Yogurt 4. Green beans
3. Yogurt
A nurse is planning a teaching session for a group of clients diagnosed with irritable bowel syndrome. What points should the nurse include to help the clients control symptom flare-ups? Select all that apply 1. If you are constipated, try to make sure you have breakfast. 2. Avoid low fat foods. 3. If you think a certain food is a problem, try cutting it out of your diet for about 12 weeks. 4. Drinks containing caffeine are likely to contribute to symptoms. 5. Foods such as broccoli and cabbage are good sources of fiber.
1. If you are constipated, try to make sure you have breakfast. 3. If you think a certain food is a problem, try cutting it out of your diet for about 12 weeks. 4. Drinks containing caffeine are likely to contribute to symptoms.
The nurse is working with a LPN/VN and an unlicensed assistive personnel (UAP). Which client would be appropriate for the nurse to assign to the LPN/VN? Select all that apply 1. In Bucks traction requiring frequent pain medication 2. 24 hours post appendectomy 3. Diagnosed with cholelithiasis and scheduled for surgery in the AM 4. Admitted 6 hours ago in adrenal insufficiency 5. In diabetic ketoacidosis receiving IV insulin
1. In Bucks traction requiring frequent pain medication 2. 24 hours post appendectomy 3. Diagnosed with cholelithiasis and scheduled for surgery in the AM
A client with type II diabetes reports normal blood glucose levels at bedtime and high blood glucose levels in the morning for the past week. What instruction would the nurse give the client? 1. Monitor blood sugar around 2am. 2. Decrease bedtime snacking. 3. Decrease intermediate acting insulin. 4. Increase intermediate acting insulin.
1. Monitor blood sugar around 2am.
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? Select all that apply 1. Right sided mastectomy 2. Inability to abduct fingers of right hand 3. Negative Allen's test 4. Radial pulse 3+/4+ 5. Presence of A-V shunt to right forearm
1. Right sided mastectomy 3. Negative Allen's test 5. Presence of A-V shunt to right forearm
What action should the nurse take first for the 5 year old client brought to the urgent care clinic with a blistering sunburn? 1. Administer analgesics. 2. Apply cool water soaks. 3. Check immunization status for tetanus. 4. Educate family to avoid greasy lotions or butter on the burn.
2. Apply cool water soaks
A nurse is caring for a client diagnosed with the ebola virus who is experiencing vomiting and diarrhea. What personal protective equipment should be worn by the nurse while providing care to this client? Select all that apply 1. Single use impermeable gown 2. Powered Air Purifying Respirator (PAPR) or N95 respirator 3. One pair of sterile gloves 4. Single use boot covers 5. Single use apron
1. Single use impermeable gown 2. Powered Air Purifying Respirator (PAPR) or N95 respirator 4. Single use boot covers 5. Single use apron
The nurse is planning to teach a group of senior citizens about modifiable risk factors for developing a stroke. Which factors should the nurse include? Select all that apply 1. Diabetes mellitus 2. Hypertension 3. Hispanic ethnicity 4. Atrial fibrillation 5. Sleep apnea 6. Smoking
1. Diabetes mellitus 2. Hypertension 4. Atrial fibrillation 5. Sleep apnea 6. Smoking
A nurse suspects that a client admitted to the emergency department is in a hyperosmolar hyperglycemic diabetic state. What data would lead the nurse to this conclusion? Select all that apply 1. Excessive thirst 2. Fruity-smelling breath 3. Kussmaul respirations 4. Metabolic acidosis 5. Polyuria
1. Excessive thirst 5. Polyuria
A female client with a history of frequent exacerbations of asthma asks the nurse to explain to her why she is at greater risk for fractures than other women her age. What is the nurse's best response? 1. "The steroids you are taking decrease calcium in the bone by sending it to the blood." 2. "Taking steroids causes bone calcium to increase, thus causing osteoporosis." 3. "Clients who have asthma are not able to exercise enough to prevent fractures from occurring." 4. "Asthma should not put you at increased risk for fractures but you are at risk for decreased blood glucose levels."
1. "The steroids you are taking decrease calcium in the bone by sending it to the blood."
The nurse educator has provided education to newly hired emergency department nurses regarding mandatory reporting laws. Which suspected instances provided by the new nurses indicates to the nurse educator that education was effective? Select all that apply 1. Financial abuse of an elder 2. Negligence of a colleague 3. Spousal abuse denied by the victim 4. Gunshot victim 5. Client diagnosed with Gonorrhea 6. Client diagnosed with West Nile virus
1. Financial abuse of an elder 4. Gunshot victim 5. Client diagnosed with Gonorrhea 6. Client diagnosed with West Nile virus
Which assessment finding by the nurse is most indicative of fluid volume overload? 1. Client has pitting edema in lower extremities. 2. Client's blood pressure is 120/80. 3. Client's CVP measurement is 6 mmHg. 4. Weight gain of 1.5 pounds (0.68 kg) in one day.
1. Client has pitting edema in lower extremities.
An occupational health nurse works in a factory where loud equipment is used in production of the factory's product. What should the nurse emphasize to factory management persons to reduce the risk of hearing impairment? Select all that apply 1. Supply workers with earplugs when exposed to noise. 2. Replace high noise machinery with low noise machinery. 3. Limit amount of time a person spends at a noise source. 4. Operate noisy machines during shifts when fewer people are exposed. 5. Supply personal noise monitoring to identify employees at risk from hazardous level of noise. 6. Have all employees make an appointment for a hearing test.
1. Supply workers with earplugs when exposed to noise. 2. Replace high noise machinery with low noise machinery. 3. Limit amount of time a person spends at a noise source. 4. Operate noisy machines during shifts when fewer people are exposed. 5. Supply personal noise monitoring to identify employees at risk from hazardous level of noise.
The nurse receives new primary healthcare provider prescriptions on a client diagnosed with Addison's disease. What prescription should the nurse question? Select all that apply 1. Weigh QD 2. IV of Normal Saline at 125 mL/hr 3. MRI of pituitary gland 4. Fludrocortisone acetate 0.1 mg by mouth T.I.W. 5. Dehydroepiandrosterone (DHEA) 5 mg by mouth every other day
1. Weigh QD 4. Fludrocortisone acetate 0.1 mg by mouth T.I.W.
The nurse is preparing to initiate a dopamine infusion per protocol. The primary healthcare provider prescription: Dopamine 5 mcg/kg/min IV per infusion pump. At what rate should the nurse set the pump? Use numbers only. Height - 187 cm Weight - 80 kg 5mcg/80kg/15min?
15mL/h 5 x 80 = 400mcg 400mcg/min/1600mcg x 1 mL = 0.25 mL/min 0.25 x 60 = 15mL/h
A nurse asked the charge nurse on the psychiatric unit, "Why did you ask that client to explain the meaning of 'It's raining cats and dogs?'" What is the charge nurse's best response? 1. "I was attempting to get the client to admit to being afraid of cats and dogs." 2. "I am assessing the concreteness of the client's form of thought." 3. "Phrases like this one will help the client improve their abstract thinking ability." 4. "Concrete thinking is a higher form of thinking and means that the client's form of thought is improving."
2. "I am assessing the concreteness of the client's form of thought."
Which statement made by a 67 year old client who recently retired indicates to the nurse that client has developed ego integrity? 1. "I want to make my mark on the world." 2. "I am satisfied with my life so far." 3. "I wish I could go back and fix the mistakes I have made." 4. "Life is too short. I have more living to do."
2. "I am satisfied with my life so far."
A client has been admitted with a diagnosis of sepsis and two sets of blood cultures have been ordered. When the nurse explains the procedure, the client asks the purpose of drawing blood from two different veins at two different times. What is the best response by the nurse? 1. "If we don't get enough blood the first time, we can obtain more." 2. "We want to be sure to get samples of all organisms in your blood." 3. "We have to be certain none of the samples have been contaminated." 4. "It's important not to get too much blood from the arm all at once."
2. "We want to be sure to get samples of all organisms in your blood."
A client is being scheduled for a cat scan (CT) of the abdomen with contrast. When considering client safety, what should be the priority action for the nurse to implement? 1. Verify that informed consent has been provided. 2. Confirm with client the accuracy of allergies listed. 3. Force fluids following procedure. 4. Monitor output following procedure.
2. Confirm with client the accuracy of allergies listed.
The parents of a child admitted with rheumatic fever (RF) ask why the child has been placed on bedrest. The nurse explains that bedrest serves what primary purpose for the client? 1. Prevents permanent joint damage. 2. Decreases workload on the heart. 3. Helps regulate body temperature. 4. Reduces joint pain and body aches.
2. Decreases workload on the heart.
The charge nurse is observing a new nurse administer a Mantoux test. The new nurse demonstrates accurate knowledge of the procedure by completing what steps? Select all that apply 1. Administers 0.1 ml of PPD to upper outer arm. 2. Inserts needle under dermis with the bevel up. 3. Uses tuberculin syringe with 27-gauge needle. 4. Wraps site with gauze to prevent leaking. 5. Assesses the injection site after 48 hours.
2. Inserts needle under dermis with the bevel up. 3. Uses tuberculin syringe with 27-gauge needle. 5. Assesses the injection site after 48 hours.
The primary healthcare provider prescribes nafcillin 0.6 gram every 12 hours IM. Available is a vial labeled 200 mg per 1 mL. How many mL should the nurse give? Round your answer to the nearest whole number.
3 600mg/200mg = 3
The behavioral health nurse is providing crisis intervention follow-up with a client and is teaching concepts regarding crises. Which statement by the client would best indicate understanding of the teaching? 1. "I must have a type of mental illness because I was not able to cope with the stressful situation." 2. "I will usually not be able to identify a stressor that can cause a crisis in my life." 3. "This crisis has the potential to help me grow psychologically." 4. "Because this situation created a crisis for me, I can expect this crisis to recur for me."
3. "This crisis has the potential to help me grow psychologically."
The nursing supervisor is reviewing several instances in which restraints have been used. The nurse is aware the only acceptable use of restraints is what? 1. An elderly male had a chest restraint applied after crawling over bed rails several times. 2. An Alzheimer client's room door is closed to prevent wandering during shift change. 3. A confused client with a closed head injury had hand mitts applied after pulling out IV 4. A dementia client with sundowners is placed in Geri-chair with lap belt at nurse's station.
3. A confused client with a closed head injury had hand mitts applied after pulling out IV
A client who has had a stroke presents with lethargy, facial droop, and slurred speech. The client has a history of gastroesophageal reflux disease (GERD). From this history, what does the nurse recognize as an increased risk for this client? 1. Diminished colonic motility 2. Esophageal hemorrhage 3. Aspiration pneumonia 4. Stress ulcers
3. Aspiration pneumonia
A client is brought to the emergency room following a serious motor vehicle accident. Standing orders include initiating an IV line and inserting a foley catheter. What action should the nurse take first? 1. Obtain all supplies for the procedures. 2. Explain the procedure to the client. 3. Check the client's identification band. 4. Verify client has signed consent forms.
3. Check the client's identification band.
While the postpartum nurse was in report, four clients called the nurse's station for assistance. Which client should the nurse see first? 1. Client with three dime sized clots on her perineal pad. 2. Breastfeeding client who is reporting uterine cramping. 3. Client reporting blood running down legs upon standing. 4. Client who had an epidural and is now reporting a headache.
3. Client reporting blood running down legs upon standing.
A pregnant client's initial blood work shows a negative rubella titer. The nurse is aware this result indicates what important course of action? 1. Client needs to be isolated until delivery. 2. Client is immune to rubella currently. 3. Client should be given rubella vaccine after delivery. 4. Client has never been exposed to rubella.
3. Client should be given rubella vaccine after delivery.
The night nurse on a step down unit suspects another nurse may be intoxicated. What initial action should the nurse take? 1. Ask another nurse to confirm suspicions. 2. Call supervisor to report the intoxication. 3. Confront the nurse privately in person. 4. Discuss suspicions with unit nurse manager.
4. Discuss suspicions with unit nurse manager.
The client needs assistance to apply anti-embolism stockings each day in the long-term care facility. Today, as the nurse enters the room to apply the stockings, she finds that the client has been walking about the unit for 30 minutes. What should the nurse do first to lessen the risk of swelling of the lower extremities? 1. Ask the client to lie down and place the stockings on the legs. 2. Ask the client to sit on the bedside and place the stockings on the legs. 3. Tell the client that the nurse will return later to assist with the application. 4. Elevate the extremities in bed for 30 minutes before application
4. Elevate the extremities in bed for 30 minutes before application
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? 1. Examine the oral pharynx using a tongue depressor. 2. Administer a sedative so the child can be examined. 3. Have a second nurse hold the child down for the assessment. 4. Notify the primary healthcare provider immediately.
4. Notify the primary healthcare provider immediately.
The nurse is talking with a parent regarding childhood immunizations. What vaccination is recommended for children at 12 months? 1. Pertussis 2. Rotovirus 3. Tuberculosis 4. Varicella
4. Varicella
An elderly male client's wife recently died unexpectedly. During the clinic visit, the client appears tearful, lacks eye contact, and the clothing appears disheveled. What would be a priority nursing assessment for the client? 1. Adaptive and coping skills for dealing with loss 2. Intellectual capacity to make personal decisions 3. Socioeconomic status for independent living 4. Spiritual awareness for emotional comfort.
1. Adaptive and coping skills for dealing with loss
Which client is at the greatest risk for developing pancreatic cancer? 1. 70 year old obese client who smokes one pack of cigarettes a day 2. 64 year old client who had gallbladder surgery less than 5 years ago 3. 58 year old client with Chron's Disease 4. 52 year old client whose mother died from pancreatic cancer
1. 70 year old obese client who smokes one pack of cigarettes a day
Which clients can the nurse assign to the same room? Select all that apply 1. A 48 year old female one day postoperative appendectomy and a 30 year old female with nephrolithiasis. 2. A 41 year old male with nausea, vomiting, and diarrhea and a 62 year old male with neutropenia 3. A 41 year old male with Methicillin-resistant Staphylococcus aureus (MRSA) infection and a 42 year old male with Clostridium difficile 4. A 14 year old two days postoperative splenectomy and an 80 year old female with Parkinson's disease 5. A 57 year old female with chronic obstructive pulmonary disease (COPD) and an 68 year old female with asthma
1. A 48 year old female one day postoperative appendectomy and a 30 year old female with nephrolithiasis. 5. A 57 year old female with chronic obstructive pulmonary disease (COPD) and an 68 year old female with asthma
The nurse is observing a new LPN insert an indwelling foley catheter for a client. The nurse knows it is necessary to intervene when the new LPN initiates what action? 1. Applies sterile gloves prior to opening catheter kit. 2. Pours iodine solution over the sterile cotton balls. 3. Lubricates catheter by dipping into water-soluble gel. 4. Identifies client and elevates bed to waist height.
1. Applies sterile gloves prior to opening catheter kit.
A client is admitted to the hospital due to a left-sided cerebrovascular accident. Which interventions should the nurse initiate? Select all that apply 1. Apply splint nightly to affected extremities. 2. Approach client from the right side. 3. Provide full range of motion once a shift. 4. Elevate left extremities on a pillow. 5. Place pillow in the right axilla. 6. Wrap affected hand into a fist.
1. Apply splint nightly to affected extremities. 5. Place pillow in the right axilla.
Which tasks are most appropriate for the hospice nurse to delegate to an unlicensed assistive personnel (UAP)? Select all that apply 1. Bathe the client. 2. Provide spiritual support 3. Listen to the client reminisce. 4. Administer routine medications. 5. Weigh the client. 6. Take vital signs
1. Bathe the client. 3. Listen to the client reminisce. 5. Weigh the client. 6. Take vital signs
The nurse is teaching a group of parents how to promote healthy teeth in their newborn. What should the nurse include? Select all that apply 1. Clean gums with a damp washcloth after feedings. 2. Use a firm-bristled toothbrush once teeth have erupted. 3. Beginning at birth use toothpaste the size of a pea. 4. Allow only milk bottles in bed. 5. Wean from bottle by 15 months.
1. Clean gums with a damp washcloth after feedings. 5. Wean from bottle by 15 months.
What signs and symptoms will the nurse look for when caring for an infant with severe dehydration? Select all that apply 1. Dark, yellow urine 2. Lethargic 3. Bulging fontanels 4. Tachypnea 5. Decreased urine output
1. Dark, yellow urine 2. Lethargic 4. Tachypnea 5. Decreased urine output
What actions should a nurse take to provide continuity of care when discharging a client diagnosed with hemiparesis to a long-term care facility for rehabilitation? Select all that apply 1. Document current functional status assessment 2. Notify the primary healthcare provider of transfer completion. 3. Transfer essential medical record to the receiving facility. 4. Phone report to the receiving nurse. 5. Send a day's worth of medications with the client to the receiving facility.
1. Document current functional status assessment 2. Notify the primary healthcare provider of transfer completion. 3. Transfer essential medical record to the receiving facility. 4. Phone report to the receiving nurse.
In what position should the nurse place a client post intracranial surgery? 1. Head of bed elevated 30 degrees 2. Supine 3. Dorsal recumbent 4. Recovery position
1. Head of bed elevated 30 degrees
A client has been admitted with multiple severe allergies, including food and medications. The nurse knows what actions are most important to protect the client? Select all that apply 1. Assign client to a private, sterile room. 2. Place allergy alert bracelet on client. 3. Have client wear mask when in hallway. 4. Attach sign listing allergies above the bed. 5. Send list of allergies to dietary department.
2. Place allergy alert bracelet on client. 5. Send list of allergies to dietary department.
The nurse has been educating a client diagnosed with general anxiety disorder (GAD). Which statement by the client indicates the need for further education? 1. "I will avoid caffeine from now on." 2. "When I feel anxious I will increase my breathing to get more oxygen to my brain." 3. "I will go for a brisk walk when I begin to feel anxious." 4. "I will keep a diary of anxiety attacks to determine what triggers them."
2. "When I feel anxious I will increase my breathing to get more oxygen to my brain."
The following clients arrive to the emergency department (ED) at the same time. The triage nurse gives priority to which client? 1. A client with a possible fracture of the tibia 45 minutes ago. 2. A client with left hemiparesis and aphasia beginning 1 hour ago. 3. A client smelling of alcohol and reporting of severe abdominal pain. 4. A client involved in a motor vehicle accident (MVA) with a possible fractured pelvis.
2. A client with left hemiparesis and aphasia beginning 1 hour ago.
A client is to be discharged following a left modified-radical mastectomy. When reviewing ADL's to be completed at home, the nurse anticipates the client will experience the most difficulty doing what tasks? Select all that apply 1. Cooking a meal. 2. Shampooing hair. 3. Doing the laundry. 4. Vacuuming carpets. 5. Changing bed linens.
2. Shampooing hair. 3. Doing the laundry. 5. Changing bed linens.
A client prescribed oral iron medication is reporting nausea after administration. What should the nurse teach the client to decrease this symptom? 1. Take the iron with a class of milk. 2. Eat bran cereal immediately after ingesting iron. 3. Drink orange juice with the iron medication. 4. Take docusate sodium at bedtime.
3. Drink orange juice with the iron medication.
A community health nurse prepares a presentation about decreasing the risk of the spread of influenza in the community. Which information should the nurse include in the presentation? 1. The flu is spread via the influenza vaccine. 2. Use a shirtsleeve when coughing or sneezing. 3. Tissues are the most effective means to decrease the spread of the influenza. 4. Antibiotics are effective in treating influenza.
2. Use a shirtsleeve when coughing or sneezing.
A client with a history of adrenal insufficiency is placed on fludrocortisone. Which value is most important for the nurse to monitor? 1. Magnesium 2. Weight 3. Pain 4. Glucose
2. Weight
The nurse is caring for a client who has the diagnosis of schizophrenia. The nurse enters the room to administer the morning dose of the prescribed antipsychotic medication. The client is drooling and has extreme muscular rigidity. After assessing the client for adequate respiratory effort, what is the nurse's priority? 1. Elevate HOB and give the medication as prescribed. 2. Hold the medication and call the primary healthcare provider. 3. Report the behaviors to the on-coming shift. 4. Hold the medication, and check the vital signs.
2. Hold the medication and call the primary healthcare provider.
What electrolyte imbalance should the nurse monitor for when caring for a client diagnosed with chronic alcoholism? Select all that apply 1. Hypochloremia 2. Hypokalemia 3. Hypophosphatemia 4. Hypomagnesemia 5. Hypocalcemia
2. Hypokalemia 3. Hypophosphatemia 4. Hypomagnesemia 5. Hypocalcemia
A client diagnosed with human immunodeficiency virus (HIV) is to be sent home today. The nurse has initiated discharge instructions on the proper handling of blood and body fluid at home. The nurse knows the teaching is successful when the client makes what statement? 1. "As long as it's my home, I can use normal cleaning methods." 2. "I must scrub with hot, soapy water and allow it to air dry." 3. "I should clean area with a 10% mixture of bleach and water." 4. "I must sterilize with isopropyl alcohol and rinse with ammonia."
3. "I should clean area with a 10% mixture of bleach and water."
The nurse is preparing to administer a dose of sacubitril/valsartan 24/26 mg by mouth. The nurse has not administered this medication before and is using a drug reference to review information about the medication. Which client and drug reference information supports the nurse's decision to withhold the sacubitril/valsartan? Exhibit Select all that apply 1. Bilateral crackles noted to posterior lung fields. 2. Potassium- 4.8 mEq/L (4.8 mmol/L). 3. Currently taking trandolapril 2 mg by mouth daily. 4. Concomitant use or use within 36 hours of ACE inhibitors. 5. ACE inhibitors increase risk of angioedema. 6. Decreased Hematocrit.
3. Currently taking trandolapril 2 mg by mouth daily. 4. Concomitant use or use within 36 hours of ACE inhibitors. 5. ACE inhibitors increase risk of angioedema.
Which tasks should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply 1. Demonstrate post operative exercises. 2. Reposition the transcutaneous electrical nerve stimulation (TENS) unit. 3. Empty the indwelling catheter bag. 4. Assist a client with position change every 2 hours. 5. Apply anti-embolism stockings.
3. Empty the indwelling catheter bag. 4. Assist a client with position change every 2 hours. 5. Apply anti-embolism stockings.
The charge nurse on the pediatric unit has several tasks that need to be completed. What tasks can be assigned to the unlicensed assistive personnel (UAP)? Select all that apply 1. Obtain a urine sample from an infant. 2. Empty a nasogastric (NG) canister for client with ileus. 3. Feed a child with bilateral burns of hands. 4. Change an ostomy appliance on child with stoma. 5. Ambulate an adolescent two days post appendectomy.
3. Feed a child with bilateral burns of hands. 5. Ambulate an adolescent two days post appendectomy.
A parent asks the nurse why their child should be immunized against Rubella. What should the nurse tell the parent? 1. Rubella can cause a severe rash over the body, and a high fever which can lead to febrile seizures. 2. Rubella is the most common cause of meningitis and acquired deafness. 3. If a pregnant woman gets rubella from an unimmunized child during the first trimester, there is a chance the child will have a birth defect. 4. Rubella complications can include swelling of the testicles or ovaries, deafness, encephalitis or meningitis and can lead to death.
3. If a pregnant woman gets rubella from an unimmunized child during the first trimester, there is a chance the child will have a birth defect.
A 12 year old female, with a history of juvenile rheumatoid arthritis, is being admitted for re-evaluation. The child reported these symptoms for the last week: temperature of 102.9ºF/39.4ºC at 4:00 pm every day, increased pain in joints, loss of appetite, and fatigue. What would be an appropriate room assignment by the charge nurse? 1. Private room only. 2. Rooming with a 12 year old male in skeletal traction due to a fractured femur. 3. Rooming with a 10 year old female that has been admitted for sickle cell disease. 4. Rooming with a 14 month old female that has been admitted for orthopedic surgery.
3. Rooming with a 10 year old female that has been admitted for sickle cell disease.
A client newly diagnosed with Celiac disease is being instructed on a gluten-free diet. What statement by the client would indicate to the nurse that further teaching is needed? 1. "I will still have occasional abdominal discomfort." 2. "I may need to take iron or vitamin supplements." 3. "I can have eggs but no wheat toast for breakfast." 4. "I should avoid fresh apples and strawberries."
4. "I should avoid fresh apples and strawberries."
An elderly client is to be ambulated for the first time following a hip replacement. The client refuses to get out of bed, indicating an extreme fear of falling. What statement by the nurse is most therapeutic? 1. "Don't be afraid because I will not let you fall." 2. "Your doctor says you must walk twice today." 3. "I'll get another nurse to help so you won't fall." 4. "What worries you most about getting out of bed?"
4. "What worries you most about getting out of bed?"
A tour bus is involved in an accident, sending several clients to the emergency room for treatment. An unconscious client with multiple internal injuries requires immediate surgery. When itemizing the client's belongings, the nurse finds a wallet containing four thousand dollars. What is the appropriate method for the nurse to secure the money? 1. Place wallet inside client's pants and then in belongings bag. 2. Secure the money in an envelope in the E.R. narcotics drawer. 3. Sign money over to the hospital CEO until client is discharged. 4. Tally cash with 2nd nurse, document and lock in hospital safe.
4. Tally cash with 2nd nurse, document and lock in hospital safe.
The nurse, caring for a client post motor vehicle accident who sustained multiple crushing injuries, suspects that the client may be developing disseminated intravascular coagulation (DIC). Which assessment findings by the nurse suggest that the client is developing this complication? Select all that apply 1. Chest pain 2. Frothy sputum 3. Intermittent claudication 4. Subcutaneous emphysema 5. Petechiae 6. Blood oozing from chest tube insertion site
5. Petechiae 6. Blood oozing from chest tube insertion site
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? 1. Warm the room. 2. Submerge the hand in warm water. 3. Order a K pad and apply to hand. 4. Have the client exercise the fingers to increase blood flow.
1. Warm the room.
When shopping at the mall, a nurse witnesses an individual collapse in cardiac arrest. A bystander begins CPR while the nurse opens an automatic external defibrillator (AED) brought by security. What critical actions should the nurse perform before delivering a shock? Select all that apply 1. Apply defibrillator pads to bare skin. 2. Verify that synchronizer button is on. 3. Continue CPR until advised to deliver shock. 4. Stop CPR while machine analyzes the rhythm. 5. Shout "clear" prior to activating shock button. 6. Apply cream under de-fib pads to prevent burns.
1. Apply defibrillator pads to bare skin. 3. Continue CPR until advised to deliver shock. 4. Stop CPR while machine analyzes the rhythm. 5. Shout "clear" prior to activating shock button. 6. Apply cream under de-fib pads to prevent burns.
The Emergency Department triage nurse encounters a client who says that he has received exposure to a liquid hazardous chemical at work. He reports that he is only 1 of about 20 people. What should the nurse do? Select all that apply 1. Call the supervisor and inform of the possibility of contamination in the surrounding space. 2. Obtain vital signs immediately. 3. Call personnel trained in containment and decontamination immediately. 4. Direct the individual to a bed space immediately. 5. Instruct the client to remove clothing and put on disposable hospital gown.
1. Call the supervisor and inform of the possibility of contamination in the surrounding space. 3. Call personnel trained in containment and decontamination immediately.
A client presents in the emergency department with acute onset of fever, headache, stiff neck, nausea/vomiting, and mental status changes. What interventions should the nurse initiate? Select all that apply 1. Provide a quiet environment 2. Pad side rails 3. Place on droplet precautions 4. Maintain head in midline position 5. Place ice packs under axilla for fever greater than 101°F (38.3°C)
1. Provide a quiet environment 2. Pad side rails 3. Place on droplet precautions 4. Maintain head in midline position
A charge nurse is observing a new nurse for proper use of standard precautions for infection control. Which actions indicate that standard precautions are being followed? Select all that apply 1. Wearing clean gloves to convert an IV to a saline loc 2. Donning sterile gloves for a cesarean dressing change 3. Wearing a N95 respirator while caring for a child who has respiratory syncytial virus (RSV) 4. Putting on a gown to take care of a client who has toxoplasmosis 5. Performing hand hygiene after removing gloves
1. Wearing clean gloves to convert an IV to a saline loc 2. Donning sterile gloves for a cesarean dressing change 5. Performing hand hygiene after removing gloves
A traumatized soldier goes to the infirmary after being told he almost died in a gun battle. He tells the nurse, "I do not remember any of the details of this event. What is wrong with me?" What is the nurse's best response? 1. "I understand you are upset, but you will have to go back to your unit sooner or later." 2. "You are repressing this event because it was frightening and painful for you." 3. "In my professional opinion, you are trying to undo what happened in the battle." 4. "You are splitting from the bad you, so that the good you survives."
2. "You are repressing this event because it was frightening and painful for you."
A client is given an intramuscular injection of morphine following a laparoscopic cholecystectomy four hours ago. What client data would best indicate to the nurse that the medication has been effective? 1. Rates pain as 6 on 1-10 scale. 2. Heart rate is within normal limits. 3. Ambulates with assistance of one. 4. Voided 250 mL in 4 hours.
3. Ambulates with assistance of one.
The emergency department nurse is assuming care of a client with full thickness burns to both legs. Which primary healthcare provider prescription should be implemented first? 1. Administer IV morphine 2. Insert oropharyngeal airway 3. Start two large bore IVs 4. Apply silver sulfadiazine to burn area
3. Start two large bore IVs
In what order should the emergency department triage nurse send these clients to a room for treatment? Place in priority order. a. Elderly client who fell and fractured the left femoral neck. b. Client who has multiple injuries from a motor vehicle accident. c. Client reporting epigastric pain and nausea after eating. d. Female client stating she has been raped.
b. Client who has multiple injuries from a motor vehicle accident. a. Elderly client who fell and fractured the left femoral neck. d. Female client stating she has been raped. c. Client reporting epigastric pain and nausea after eating.
The nurse is caring for a client diagnosed with chronic renal failure who has been taking Epoetin alfa for 2 months. What should the nurse monitor for pertaining to Epoetin alfa during the client's clinic visit? Select all that apply 1. Hypertension 2. Halitosis 3. Hemoptysis 4. Oliguria 5. Dependent edema
1. Hypertension 3. Hemoptysis 5. Dependent edema
The nurse is observing a new nurse inserting a nasogastric (NG) tube. Which action by the student nurse needs to be corrected by the nurse? Select all that apply 1. Measures from the tip of the nose to the xiphoid process of the client. 2. Lubricates the NG tube with petroleum gel. 3. Aspirates the NG tube to test gastric contents with a pH stip. 4. Marks the tubing at measurement mark with tape and secures to nose. 5. Places tube end into a glass of water to assess for bubbling.
1. Measures from the tip of the nose to the xiphoid process of the client. 2. Lubricates the NG tube with petroleum gel. 5. Places tube end into a glass of water to assess for bubbling.
A nurse enters the operating room (OR) with artificial fingernails in place. What should the charge nurse explain to the nurse? Select all that apply 1. Pathogenic bacteria can be found on the fingertips of those who wear artificial fingernails. 2. Artificial fingernails are allowed to be worn in the OR. 3. Fungal growth can occur under the artificial fingernail, thus increasing the risk of surgical site infection to the client. 4. A more vigorous scrub is required if artificial fingernails are worn. 5. Long fingernails and artificial fingernails increase microbial load on the hands.
1. Pathogenic bacteria can be found on the fingertips of those who wear artificial fingernails. 3. Fungal growth can occur under the artificial fingernail, thus increasing the risk of surgical site infection to the client. 5. Long fingernails and artificial fingernails increase microbial load on the hands.
The nurse is developing a teaching plan covering emergency responses to smallpox. This presentation will be used with newly hired hospital employees. What information is essential for the presentation? Select all that apply 1. People may be exposed to smallpox but not get the disease. 2. People may contract the disease by handling contaminated clothing or bedding. 3. Smallpox is fatal is about 50% of cases. 4. Smallpox victims are contagious for two weeks. 5. Smallpox victims are isolated from others.
1. People may be exposed to smallpox but not get the disease. 2. People may contract the disease by handling contaminated clothing or bedding. 5. Smallpox victims are isolated from others.
Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? Select all that apply 1. Prepare a client's room for return from surgery. 2. Observe for pain relief in a client after receiving acetaminophen with codeine. 3. Assist a client with perineal care after having diarrhea. 4. Clean nares around a client's nasogasttric (NG) tube. 5. Pour a can of tube feeding into a client's percutaneous endoscopic gastrostomy (PEG).
1. Prepare a client's room for return from surgery. 3. Assist a client with perineal care after having diarrhea. 4. Clean nares around a client's nasogasttric (NG) tube.
The home health nurse is concerned about the safety of the client who lives alone in a poorly maintained home. The nurse convenes the interdisciplinary team to discuss the situation. Which action should occur first? 1. Share the assessment findings with the interdisciplinary team. 2. Suggest that the social worker visit the client in the home. 3. Ask the primary healthcare provider about possible nursing home placement. 4. Suggest a "meals on wheels" solution to nutrition.
1. Share the assessment findings with the interdisciplinary team.
Which observation of denture care by the unlicensed assistive personnel (UAP) would require the nurse to intervene? Select all that apply 1. Soaking the dentures in hot water 2. Donning gloves and using a gauze pad to grasp and remove dentures 3. Moistening the dentures prior to inserting them 4. Wrapping the dentures in tissue while the client sleeps 5. Placing a washcloth in the bathroom sink prior to cleaning.
1. Soaking the dentures in hot water 4. Wrapping the dentures in tissue while the client sleeps
A client is seen in an outpatient clinic for anxiety after losing the family home in a hurricane. What nursing interventions would be appropriate for the nurse to make? Select all that apply 1. Teach the client how to use progressive muscle relaxation. 2. Assist the client in correcting any distortion being experienced. 3. Suggest that the client might recover faster by moving away from the coastal area. 4. Refer the client to the family primary healthcare provider for a complete physical examination. 5. Allow the client time to talk about the loss.
1. Teach the client how to use progressive muscle relaxation. 2. Assist the client in correcting any distortion being experienced. 5. Allow the client time to talk about the loss.
A non-English speaking client arrives in the emergency room with a 2 inch head laceration. The nurse attempts to complete the assessment but is unable to understand information provided by client or family. The facility interpreter lives several hours away; however, a UAP is available and willing to help translate. The nurse should be most concerned about what situation? 1. The UAP is not trained to interpret medical terminology for a client. 2. The facility translator is best qualified, but waiting causes delay of treatment. 3. Obtaining consent through an unofficial interpreter is not considered legal. 4. The UAP is not providing direct care, which violates HIPAA privacy regulations.
1. The UAP is not trained to interpret medical terminology for a client.
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? 1. Flush the IV line 2. Obtain blood glucose level 3. Check written prescription 4. Restart TPN infusion
2. Obtain blood glucose level
The nurse manager is presenting a seminar on HIPAA regulations to a group of newly hired graduates. When discussing the most common cause of violating client privacy, the nurse knows teaching was successful when the graduates select what situation? 1. Failure to cover client fully during a bed bath. 2. Leaving chart open in full view when at the desk. 3. Discussing client with staff not providing direct care. 4. Healthcare provider not pulling curtain to talk to client.
3. Discussing client with staff not providing direct care.
Prior to signing a consent form for surgery, the client states, "I am not sure that I understand the possible risks for this surgery and what the alternative treatments are." What should the nurse do first? 1. Clarify any questions that the client may have and then share the client's concern with the primary healthcare provider. 2. Reinforce that it is not unusual for clients to have questions about surgery. 3. Inform the primary healthcare provider that the client has concerns about the surgery. 4. Use open ended questions to explore client's concerns.
3. Inform the primary healthcare provider that the client has concerns about the surgery.
A client with psychosis, tells another client, "You are so adorabogalishus." Which form of thought process should the nurse document this client as having? 1. Magical thinking 2. Tangentiality 3. Neologism 4. Perseveration
3. Neologism
