Hurst Review Questions (7)

A client who has recurrent episodes of allergic rhinitis asks the nurse what could be done to decrease symptoms. What instruction should the nurse provide to this client? Select all that apply 1. Remove pets from interior of home. 2. Treat a stuffy nose with warm salt water. 3. Remove carpeting. 4. Stay inside when pollen count is at its lowest. 5. Wash bed linens in hot water.

1. Remove pets from interior of home. 2. Treat a stuffy nose with warm salt water. 3. Remove carpeting. 5. Wash bed linens in hot water.

The nurse is preparing to hang an IV bag of Heparin after receiving a prescription from a client's primary healthcare provider: Heparin IV to infuse at 1000 U/h. What flow rate should the nurse set the IV infusion pump rate at? Round to the nearest whole number. Heparin 25,000 units (100usp units/mL) added to 0.45% NS 250mL

10 25000 / 250 NS = 1,000 units 250,000 / 25,000 = 10

A client calls the prenatal clinic at 37 weeks gestation to report expelling large amounts of fluid. What instruction by the nurse is most appropriate at this time? 1. Lie on left side and take slow, deep breaths. 2. Call an ambulance and go to emergency room. 3. Come to the clinic for assessment and evaluation. 4. Go directly to the hospital emergency room.

3. Come to the clinic for assessment and evaluation.

The nurse is caring for a client who has been intubated and placed on a ventilator. The nurse hears the ventilator alarm and enters the client's room to find the high pressure alarm sounding. The client is very agitated with a respiratory rate of 40; arterial line BP 98/44; oxygen saturation 82%; cardiac monitor sinus tachycardia at 138. What action should the nurse take first? 1. Turn off alarm, then check ventilator settings. 2. Increase FiO2 setting to 100%. 3. Hyperventilate client, then suction ET tube. 4. Auscultate lung sounds.

4. Auscultate lung sounds.

Which assigned postpartum client should the nurse identify as being at highest risk for hemorrhage? 1. C-section delivery 2. Vaginal delivery of twins 3. Vaginal delivery of premature baby 4. Precipitous delivery of gravida 5

1. C-section delivery

All of the beds in a 10 bed Labor, Delivery, Recovery, Postpartum Unit (LDRP) are full when one of the nurses assigned that day calls in sick. A nurse from the Med surg unit is transferred to the LDRP unit. Which client should the charge nurse assign to this nurse? 1. Client at 32 weeks gestation on oral terbutaline with 4 contractions/hour. 2. One hour postpartum client with a continuous trickle of vaginal bleeding. 3. 2 hours postpartum client reporting intense perineal pain. 4. Client at 36 weeks gestation with a blood pressure of 148/92.

1. Client at 32 weeks gestation on oral terbutaline with 4 contractions/hour.

A client is admitted to the Labor & Delivery Unit with severe preeclampsia. Which nursing intervention does the nurse include in the plan of care for this client? Select all that apply 1. Monitor for headache. 2. Place client in left recumbent position. 3. Insert indwelling urinary catheter. 4. Administer propranolol for BP > 100 diastolic. 5. Initiate external fetal heart monitoring.

1. Monitor for headache. 2. Place client in left recumbent position. 3. Insert indwelling urinary catheter. 5. Initiate external fetal heart monitoring.

What is the primary electrolyte that the nurse should be aware to monitor for in a client who is receiving an insulin infusion? 1. Sodium 2. Potassium 3. Calcium 4. Phosphorus

2. Potassium

The nurse is preparing to give a client's prescribed furosemide dose. How many mL will the nurse give to the client? Answer to the first decimal place. Answer with numbers and decimal only. Prescription: Furosemide 25 mg by mouth daily Furosemide 10mg/mL

2.5

The nurse identifies that additional teaching about skin care is needed when an 80 year old client makes what statement? 1. "I shower 3 - 4 times per week." 2. "I apply moisturizers at least daily." 3. "I bathe in the tub at least 6 times per week." 4. "I drink 64 ounces (1.89 L) of liquid per day."

3. "I bathe in the tub at least 6 times per week."

A client buzzes the nurses' station to report chest pain. The nurse looks at the client's cardiac rhythm strip, then hurries into the client's room to find the client unresponsive and without a pulse. What initial action should the nurse take? Exhibit - Ventricular Tachycardia demonstrated on EKG 1. Administer Epinephrine 1mg IV push. 2. Begin cardiopulmonary resuscitation (CPR) for 2 minutes. 3. Defibrillate at 120 joules. 4. Insert supraglottic airway device.

3. Defibrillate at 120 joules

A client diagnosed with an embolic stroke has been admitted to the medical unit. Which nursing assessment would the nurse include to identify an early sign of increased intracranial pressure (ICP)? 1. Bradypnea 2. Bradycardia 3. Restlessness 4. Elevated systolic pressure

3. Restlessness

At what age does the nurse expect to see a child build a tower of 9 blocks? 1. One 2. Two 3. Three 4. Four

3. Three

Which client should the nurse recognize as being at greatest risk for the development of cancer? 1. Smoker for 30 plus years 2. Body builder taking steroids and using tanning salons 3. Newborn with multiple birth defects 4. Older individual with acquired immunodeficiency syndrome

4. Older individual with acquired immunodeficiency syndrome

A newly hired nurse has been instructed by the preceptor nurse on burn dressing techniques. The nurse knows teaching has been effective when the new nurse performs wound care in what order? a. Clean burn and place sterile dressing. b. Set up sterile field and open packages. c. Wash hands and apply sterile gloves. d. Medicate client with pain medication. e. Remove the old dressing and discard. f. Wash hands and apply clean gloves.

d. Medicate client with pain medication. f. Wash hands and apply clean gloves. b. Set up sterile field and open packages. e. Remove the old dressing and discard. c. Wash hands and apply sterile gloves. a. Clean burn and place sterile dressing.

A client who is Chinese comes to the clinic for a follow-up appointment following cardiac bypass surgery. The client's father accompanies the client into the examination room. What is the most appropriate action by the nurse? 1. Ask the client's father if he has any questions regarding his son's condition. 2. Ask the client's father to leave the examination room due to confidentiality. 3. Perform needed assessments and care without interacting with the father. 4. Inform the father of the assessment findings and plan of care.

1. Ask the client's father if he has any questions regarding his son's condition.

A client who has been taking phenytoin for several years arrives to the clinic for follow-up care. During the nurse's history and physical of the client, which findings indicate a possible side effect to the phenytoin? Select all that apply 1. Skin rash 2. Reports fatigue 3. Dyspnea on exertion 4. Pale conjunctiva 5. Heart rate 60/min

1. Skin rash 2. Reports fatigue 3. Dyspnea on exertion 4. Pale conjunctiva

A client at 34 weeks gestation with pregnancy induced hypertension (PIH) reports "heartburn." Which action by the nurse has priority? 1. Administer an antacid per standing orders. 2. Check client's blood pressure. 3. Call the primary healthcare provider immediately. 4. Assure client this is a normal discomfort of pregnancy.

3. Call the primary healthcare provider immediately.

A nurse is caring for a client who was brought into the ED with a gunshot wound to the chest. There is an occlusive dressing in place and the client is receiving high flow oxygen. The nurse notes a deviated trachea, asymmetrical chest wall movement and decreased breath sounds bilaterally. What action should the nurse take first? 1. Elevate the head of the bed. 2. Initiate CPR. 3. Remove the occlusive dressing. 4. Notify the primary healthcare provider.

3. Remove the occlusive dressing.

The nurse is caring for a client with body dysmorphic disorder. The client tells the nurse, "My ugly ears make everyone sick!" Which defense mechanism is this client utilizing? Select all that apply 1. Sublimation 2. Somatization 3. Symbolism 4. Projection 5. Conversion

3. Symbolism 4. Projection

A client newly diagnosed with insulin dependent diabetes mellitus is started on insulin aspart protamine suspension/insulin aspart solution mixture. The nurse would teach the client that the insulin should start to lower the blood sugar within how many minutes? 1. 15 2. 30 3. 45 4. 90

1. 15

An alert elderly client has been admitted to the hospital and placed on bedrest following a fall at home. During evening medication rounds, the nurse notes the client has become disoriented to time and place. The nurse is aware a new onset of confusion could be the result of what factors? Select all that apply 1. Admission to the hospital. 2. Amount of physical pain. 3. Current bed confinement. 4. Advanced age. 5. Response to analgesic.

1. Admission to the hospital. 2. Amount of physical pain. 3. Current bed confinement. 5. Response to analgesic.

What signs/symptoms would the nurse expect to find in a client diagnosed with late stage rheumatoid arthritis? Select all that apply 1. Effusion to knees. 2. Weight loss of 1 kg in 2 weeks. 3. Swan neck deformity. 4. Peripheral neuropathy. 5. Subcutaneous nodules on elbows.

1. Effusion to knees. 3. Swan neck deformity. 4. Peripheral neuropathy. 5. Subcutaneous nodules on elbows.

The nurse is monitoring the infection risk in a client that is to begin chemotherapy. Which activity should alert the nurse that the client is at a higher risk for infection? Select all that apply 1. Enjoys getting manicures and pedicures every two weeks. 2. Loves to go with the children to the local water park. 3. Relaxes in hot tubs when traveling. 4. Selects steamed vegetables as part of routine dietary intake. 5. Prefers to go barefooted when at home. 6. Keeps cats in the home and cleans the litter boxes once a week.

1. Enjoys getting manicures and pedicures every two weeks. 2. Loves to go with the children to the local water park. 3. Relaxes in hot tubs when traveling. 5. Prefers to go barefooted when at home. 6. Keeps cats in the home and cleans the litter boxes once a week.

The homecare nurse is instructing a client with chronic obstructive pulmonary disease (COPD) about the importance of a nutritious diet to avoid weight loss. The nurse knows that teaching has been effective when the client selects which foods for a breakfast menu? Select all that apply 1. Scrambled eggs 2. Cheese omelet 3. Sliced banana 4. Orange juice 5. Whole milk 6. Dry toast

1. Scrambled eggs 2. Cheese omelet 3. Sliced banana 4. Orange juice

The client diagnosed with a hemorrhagic stroke has been admitted to the intensive care unit. Which nursing intervention would the nurse initiated to minimize the factors that contribute to increased intracranial cerebral pressure (ICP)? Select all that apply 1. Increase the flexion of the hips 2. Maintain a calming environment 3. Administer stool softener as prescribed 4. Instruct family to not wake the client if sleeping 5. Turn and place pillows behind the client every hour

2. Maintain a calming environment 3. Administer stool softener as prescribed 4. Instruct family to not wake the client if sleeping

A newly admitted client informs the unit nurse the current identification band has the correct name but an incorrect birthdate. The best action by the nurse at this time is what? 1. Report the error to the HCP immediately. 2. Call family to verify the correct birthdate. 3. Tell client not to worry since name is correct. 4. Call Admissions office and request new band.

4. Call admissions office and request new band.

A client has arrived at the emergency room reporting tingling to both lower legs over the past 24 hours. The only significant health history is a cold for the past week. During the nursing assessment, the client indicates that both thighs are feeling numb. What priority action should the nurse initiate immediately? 1. Assess bilateral pedal pulses. 2. Initiate a Code Blue. 3. Roll client onto left side. 4. Prepare for intubation.

4. Prepare for intubation.

A client with nausea, vomiting, and diarrhea for the past three days has been prescribed one liter of normal saline with 40 mEq (40 mmol/L) of potassium chloride to infuse at 250 mL per hour. Which assessment would the nurse report to the primary healthcare provider prior to initiating the infusion? 1. Blood pressure of 106/54 2. Apical pulse of 112 per minute 3. Tenting of the skin over the sternum 4. Urinary output of 148 mL for the past 6 hours

4. Urinary output of 148 mL for the past 6 hours

The school nurse suspects that a 5 year old has been physically abused. What would be the best way for the nurse to establish trust with this child? 1. Using play therapy. 2. Asking the mother to come to the school. 3. Hugging the child. 4. Conducting an in-depth interview with the child.

1. Using play therapy.

What should the nurse teach the client following a right knee arthroscopy? Select all that apply 1. Apply ice to right knee continuously for the first 24 hours. 2. Elevate the right knee when sitting. 3. Notify the primary healthcare provider of tingling in the right leg. 4. Gradually start an exercise program to prevent scarring. 5. Place a plastic bag over wound when showering.

2. Elevate the right knee when sitting. 3. Notify the primary healthcare provider of tingling in the right leg. 4. Gradually start an exercise program to prevent scarring. 5. Place a plastic bag over wound when showering.

A child with acute lymphocytic leukemia (ALL) is receiving chemotherapy through a single lumen Groshong catheter. During the infusion, the child reports nausea and has vomited. The primary healthcare provider has prescribed ondansetron IV. What action should the nurse take? 1. Ask primary healthcare provider for an oral antiemetic. 2. Give ondansetron IVPB with the chemotherapy. 3. Wait until chemotherapy is complete to infuse ondansetron. 4. Stop chemotherapy temporarily and flush line to give ondansetron.

4. Stop chemotherapy temporarily and flush line to give ondansetron.

A premature HIV+ infant has been admitted to the Pediatric Unit with a new diagnosis of cytomegalovirus (CMV). The charge nurse is aware the most appropriate staff to assign to this client is what individual? 1. A new nurse orienting to the unit. 2. A pediatric nurse six months pregnant. 3. An LPN with an exacerbation of eczema. 4. An experienced UAP with no health issues.

1. A new nurse orienting to the unit.

The nurse suspects a client admitted with myasthenia gravis is going into a cholinergic crisis. Which signs and symptoms would validate the nurse's suspicions? Select all that apply 1. Abdominal cramping 2. Lethargy 3. Salivation 4. Hypertension 5. Lacrimation 6. Miosis

1. Abdominal cramping 2. Lethargy 3. Salivation 5. Lacrimation 6. Miosis

The unlicensed assistive personnel (UAP) reports to the nurse that a client who received morphine sulfate 4 mg IVP 30 minutes ago has a respiratory rate of 10 breaths/ minute. What is the nurse's priority intervention? 1. Administer naloxone 0.4 mg IVP. 2. Notify the primary healthcare provider of respiratory status. 3. Deliver breaths at 20 breaths/ minute via a bag-valve mask. 4. Instruct the UAP to ambulate the client.

1. Administer naloxone 0.4 mg IVP.

Prior to shift report, the charge nurse is making assignments for the nurses on the shift. Which client can be assigned to the LPN? Select all that apply 1. Client with arthralgia who is receiving regularly scheduled pain medications and has warm compresses prescribed. 2. Client who is a diabetic experiencing diabetic neuropathy. 3. Client who requires teaching about the use of a patient-controlled analgesia (PCA) pump. 4. Client who received blunt abdominal trauma in a motor vehicle accident who is reporting a worsening of the abdominal pain. 5. Client with ureterolithiasis who requires frequent PRN pain medication.

1. Client with arthralgia who is receiving regularly scheduled pain medications and has warm compresses prescribed. 2. Client who is a diabetic experiencing diabetic neuropathy. 5. Client with ureterolithiasis who requires frequent PRN pain medication.

Which finding by the nurse would need to be reported to the primary healthcare provider immediately when caring for an infant who was born with a myelomeningocele? Select all that apply 1. High pitched cry 2. Eyes fixed downward 3. Increasing head circumference 4. Decrease in a feeding by 30 mL 5. Projectile vomiting

1. High pitched cry 2. Eyes fixed downward 3. Increasing head circumference 5. Projectile vomiting

During a yearly checkup, an adult client asks the Healthcare Provider to examine a mole which has recently become bothersome. The HCP is concerned about the appearance of the mole and refers the client to a specialist. The nurse is asked to assemble the documents to be sent with the client. The nurse knows what documents are important to send to the specialist? Select all that apply 1. The most recent history and physical findings. 2. History of childhood diseases and vaccinations. 3. List of all current medications and allergies. 4. X-ray results of last year's broken clavicle. 5. Insurance info with consent for release. 6. Current diagnoses and treatments.

1. The most recent history and physical findings. 3. List of all current medications and allergies. 5. Insurance info with consent for release.

An occupational health nurse is planning to teach a group of manufacturing workers how to prevent back injuries. What teaching points should the nurse plan to include? Select all that apply 1. Wear comfortable, low-heeled shoes. 2. When sitting, keep knees slightly lower than the hips. 3. Avoid movements that require spinal flexion with straight legs. 4. Squarely face the direction of anticipated movement. 5. Pivot to turn while holding an object.

1. Wear comfortable, low-heeled shoes. 3. Avoid movements that require spinal flexion with straight legs. 4. Squarely face the direction of anticipated movement. 5. Pivot to turn while holding an object.

A client diagnosed with new onset atrial fibrillation has been prescribed dabigatran. What should the nurse teach this client? Select all that apply 1. Place medication in a weekly pill organizer so that medication is not forgotten. 2. Do not take with clopidogrel. 3. Dabigatran decreases the risk of stroke associated with atrial fibrillation. 4. Take this medication with food. 5. aPTT and INR levels will be drawn monthly.

2. Do not take with clopidogrel. 3. Dabigatran decreases the risk of stroke associated with atrial fibrillation. 4. Take this medication with food.

The nurse is caring for a client following a total thyroidectomy. What findings would alert the nurse to potential complications? Select all that apply 1. Neck dressing intact, clean and dry 2. Increased blood pressure and pulse 3. High-pitched, harsh respirations 4. Vocal quality weak and clear 5. Left-sided cheek twitching

2. Increased blood pressure and pulse 3. High-pitched, harsh respirations 5. Left-sided cheek twitching

Which tasks can the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply 1. Reporting lab results to the client 2. Measuring intake and output 3. Discontinuing an IV 4. Discussing client condition with the client's spouse 5. Performing oral hygiene for an older client

2. Measuring intake and output 5. Performing oral hygiene for an older client

While preparing to administer intravenous of chemotherapy the nurse accidently pulls the tubing apart, spilling the solution onto the floor. After clamping the tubing, what is the nurse's immediate action? 1. Use disposable towels to clean up the liquid. 2. Obtain spill kit specific to this type of solution. 3. Complete an incident report for supervisor. 4. Call housekeeping to help clean up the floor.

2. Obtain spill kit specific to this type of solution.

A client is admitted to the LDR from the emergency department at 34 weeks gestation with profuse, painless, bright red vaginal bleeding. The priority action by the nurse is to prepare for which procedure? 1. Sterile vaginal exam 2. Ultrasound exam 3. Amniocentesis 4. Contraction stress test

2. Ultrasound exam

A client is being cared for on the orthopedic unit following a football game injury which resulted in a fracture of the left tibia and fibula. An open reduction of the fracture has been performed and a leg cast was applied. The client is receiving Morphine via a Patient Controlled Analgesia (PCA) pump at 2 mg/hr. The client begins reporting an increase in the pain level (9/10) that is not being relieved by the current Morphine dosing, and is experiencing a sensation that "pins are sticking" in the left foot. What action by the nurse is needed? Select all that apply 1. Increase the PCA dosing of Morphine. 2. Elevate the foot of the bed. 3. Perform neurovascular checks. 4. Apply ice around sides of cast. 5. Prepare for possible bivalving of the cast. 6. Notify primary healthcare provider.

3. Perform neurovascular checks. 5. Prepare for possible bivalving of the cast. 6. Notify primary healthcare provider.

The head nurse on a busy surgical unit is evaluating several fresh post-operative clients. Which observation should the nurse report immediately to the primary healthcare provider? 1. A post transurethral resection client with cherry colored urine 2. A post mastectomy client drains 40 mL of bloody drainage within 3 hours of the surgery 3. A post ileostomy client with a beefy red stoma and mucus drainage 4. A post thyroidectomy client reporting tingling in toes and fingers

4. A post thyroidectomy client reporting tingling in toes and fingers

The nurse is caring for a client who is wheezing and struggling to breathe. Which inhaled medications might be indicated at this time? Select all that apply 1. Fluticasone 2. Salmeterol 3. Theophylline 4. Albuterol 5. Levalbuterol

4. Albuterol 5. Levalbuterol

Calculator A nurse is providing care to a post-operative parathyroidectomy client. Which occurrence takes highest priority? 1. Psychoses 2. Renal calculi 3. Positive Trousseau's sign 4. Laryngospasm

4. Laryngospasm

An elderly client with a recent diagnosis of atrial fibrillation (AF) caused by valvular heart disease, tells the nurse, "My daughter has AF and she only has to take one dabigatran pill a day. I have to take warfarin daily and have my blood checked every month. Why do I have to do all of this?" What education would the nurse provide to the client? 1. Your daughter's atrial fibrillation must not be caused by a heart valve problem so she can take a medication that does not require routine clotting studies. 2. Each primary healthcare provider may treat this dysrhythmia differently based on what the provider is used to prescribing. 3. When your daughter gets older, her primary healthcare provider will switch her to warfarin for the treatment of atrial fibrillation. 4. Your atrial fibrillation is caused by a heart valve problem which is treated best by warfarin, but clotting studies have to be done routinely.

4. Your atrial fibrillation is caused by a heart valve problem which is treated best by warfarin, but clotting studies have to be done routinely.

A client is suspected of having a pheochromocytoma. The nurse is explaining the process of a VMA (Vanillylmandelic acid) urine test to be complete at home. What statement made by the client indicates the need for further teaching? Select all that apply 1. "I need to keep the urine in the fridge during the 24 hours." 2. "I will have to stay well-hydrated to get enough urine to test." 3. "It does not matter what I eat or drink during this process." 4. "I need to throw away my first voiding when I start this test." 5. "I should void at the end of the 24 hours and keep that urine."

1. "I need to keep the urine in the fridge during the 24 hours." 2. "I will have to stay well-hydrated to get enough urine to test." 3. "It does not matter what I eat or drink during this process."

What signs and symptoms would a nurse assess for in a client who is receiving hospice care and is close to death? Select all that apply 1. Cool extremities 2. Mottling 3. Cheyne-Stokes respirations 4. Loss of appetite 5. Increased blood pressure

1. Cool extremities 2. Mottling 3. Cheyne-Stokes respirations 4. Loss of appetite

A client admitted with somnolence has a history of chronic bronchitis and heart failure. Vital signs on admit are T 101.8ºF (38.8ºC), HR 106, R 26/shallow, BP 90/58. ABGs are pH 7.2, PCO2 75, HCO3 26. The nurse determines that this client has which acid/base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

1. Respiratory acidosis

The nurse is working with a group of elderly clients to promote better nutrition. Prior to developing the health promotion plan, the nurse assesses individual members of the group. Which assessment findings are expected as the nurse works with this group? Select all that apply 1. Some clients may have dental issues, making chewing difficult. 2. There may be a decreased appetite in clients. 3. Caloric and nutritional needs may vary somewhat depending on activity levels. 4. Access to fresh foods is adequate. 5. The desire and interest in cooking is increased.

1. Some clients may have dental issues, making chewing difficult. 2. There may be a decreased appetite in clients. 3. Caloric and nutritional needs may vary somewhat depending on activity levels.

A client wishing to stop smoking receives a prescription for bupropion from the healthcare provider. What educational points should the nurse include regarding this medication? Select all that apply 1. This medication can cause a false positive drug screening test. 2. Alcohol intake should be limited to two drinks per day. 3. Nicotine gum may be prescribed in addition to bupropion. 4. An increased interest in sexual activity occurs while taking this medication. 5. Smoking can continue for 1 week after starting this medication.

1. This medication can cause a false positive drug screening test. 3. Nicotine gum may be prescribed in addition to bupropion. 5. Smoking can continue for 1 week after starting this medication.

The nurse is caring for a client due for a dose of fluphenazine 10 mg. The drug is available as an elixir: 5 mg / 5 mL. How many mL will the nurse give to the client? ______mL. Round answer to the nearest whole number.

10

The nurse is teaching a newly diagnosed diabetic client about self-injection of insulin. Which statement made by the client indicates to the nurse that teaching has been effective? Select all that apply 1. "The abdominal site is best because it is closest to the pancreas." 2. "I can reach my thigh the best, so I will use different areas of the same thigh." 3. "By rotating the sites within one area, my chances of having tissue changes are less." 4. "If I change injection sites from the thigh to the arm, the rate of absorption will be different." 5. "I should inject at least 1-2 inches away from the last injection site."

2. "I can reach my thigh the best, so I will use different areas of the same thigh." 3. "By rotating the sites within one area, my chances of having tissue changes are less." 4. "If I change injection sites from the thigh to the arm, the rate of absorption will be different." 5. "I should inject at least 1-2 inches away from the last injection site."

The nurse is updating the client's plan of care 24 hours after admission. What data would indicate to the nurse that the client is improving? History: While in the emergency department, 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. Treatment included: Bedrest with bathroom privileges. Continuous cardiac monitoring remaining in NSR 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 - NSR Select all that apply 1. Troponin T - 0.10 ng/mL 2. Coughing up moderate amount of clear to white sputum 3. Urinary output past 8 hours - 225 mL 4. BP - 100/64, Respirations - 18/min, Temperature - 99.2° F (37.3° C) 5. Current Telemetry ECG

2. Coughing up moderate amount of clear to white sputum 4. BP - 100/64, Respirations - 18/min, Temperature - 99.2° F (37.3° C) 5. Current Telemetry ECG

A client admitted for debridement of a leg wound has been diagnosed with vancomycin-resistant enterococci (VRE). What is the nurse's priority action? 1. Place with another client in contact isolation for methicillin-resistant staphylococcus aureus (MRSA). 2. Move the client to a private room with contact precautions. 3. Alert staff to use masks, goggles and gown to provide care. 4. Notify family members to gown and glove before entering room.

2. Move the client to a private room with contact precautions.

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 family of a client recently placed on antipsychotic medications for the treatment of schizophrenia calls the nursing hot line and reports that the client's temperature is 105.1ºF (40.6ºC), and that the client's muscles are stiff. What should the nurse tell the family? 1. Continue to monitor for signs and symptoms of infection. 2. Transport the client to the emergency room. 3. The signs and symptoms will subside within a day or so. 4. They should call the primary healthcare provider tomorrow.

2. Transport the client to the emergency room.

Which prevention measure should the nurse include when instructing a client on avoidance of otitis externa? 1. Gently cleaning the ear canal with a cotton tipped applicator daily. 2. Use of astringent drops after bathing. 3. Taking preventative antibiotics prior to swimming in lakes or ponds 4. Routine use of nasal saline to clear the sinuses and eustachian tubes.

2. Use of astringent drops after bathing.

A female client receiving chemotherapy for breast cancer reports vomiting, stomatitis, and a 10 pound 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? 1. Eating three meals daily. 2. Weight gain of two pounds. 3. No further mouth pain. 4. Improved skin turgor.

2. Weight gain of two pounds.

The nurse is caring for a client admitted with heart failure associated with an acute MI. At which time point did the nurse begin to intervene incorrectly? 1110: IV D5W started with 20-gauge catheter to left hand at 20 ml/hr via infusion pump. Client reports chest pain at 8/10. BP - 180/102, HR - 108, RR - 30. 1115: Nitroglycerin 25 mg added to glass bottle of D5W 250 mL and connected to lowest left hand IV site with primary tubing and attached to infusion pump at 3 mL/hr. Client reports chest pain at 9/10. BP - 182/100, HR - 110, RR - 28. 1120: Client reports chest pain at 8/10. BP - 168/90, HR - 108, RR - 26. Nitroglycerin infusion increased to 6 mL/hr via infusion pump. 1125: Client reports chest pain at 7/10. BP - 154/94, HR - 100, RR - 24. Nitroglycerin infusion increased to 12 mL/hr via infusion pump. 1130: Client reports chest pain at 2/10. BP - 130/80, HR - 86, RR - 24. Nitroglycerin infusion increased to 15 mL/hr via infusion pump. 1. 1115 2. 1120 3. 1125 4. 1130

3. 1125 The nurse failed to follow protocol for Nitro infusion. The nurse increased the IV rate by 6mL/h (going from 10-20mcg/min)

A charge nurse is caring for clients when a new admit arrives on the unit. What action by the charge nurse is most appropriate? 1. Instruct the unlicensed assistive personnel (UAP) to complete emptying the catheter bag, and assess the new admission. 2. Send the UAP to take VS on the new admit and begin the history until she can get there. 3. Assign a nurse on the floor to initiate the assessment process. 4. Ask the unit secretary to make the client and family comfortable until she can complete her present task.

3. Assign a nurse on the floor to initiate the assessment process.

A 70 year-old client reports not sleeping well at night, having trouble staying asleep, and awakening about 4:00 a.m. What should the nurse teach the client about sleep patterns in the elderly? 1. Don't worry about a few hours of lost sleep. 2. Elders need as much sleep as younger adults. 3. Caffeine and some medications may interfere with sleep. 4. Elders sleep more than younger adults.

3. Caffeine and some medications may interfere with sleep.

Which signs and symptoms will the nurse include when teaching a client about indicators of recurrent nephrotic syndrome? Select all that apply 1. Dysuria 2. Hematuria 3. Foamy urine 4. Periorbital edema 5. Weight loss

3. Foamy urine 4. Periorbital edema

A client is seen at the clinic two weeks after starting amitriptyline. The client reports improved sleep patterns and appetite, but no change in feelings of sadness or depression. What comment by the nurse is most appropriate? 1. "Would you like me to ask the doctor to increase your dose?" 2. "You might need to be changed to a different medication." 3. "Tell me what type of situations make you feel depressed." 4. "Some medications take a little longer to improve moods."

4. "Some medications take a little longer to improve moods."

A client is scheduled for a colonoscopy with biopsy of a large tumor that is completely blocking the large intestine in the morning. Which preoperative prescription should the nurse question? 1. Administer tap water enemas until clear at 6 AM. 2. Nothing by mouth (NPO). 3. IV of D5 ½ NS at 75 mL/hour with a 20 gauge catheter. 4. Give magnesium citrate 296 mL at 3 PM today.

4. Give magnesium citrate 296 mL at 3 PM today.

A postpartum client who is 2 hours post vaginal delivery remains on a oxytocin infusion for bleeding. Upon examination, the nurse determines that the client's fundus is boggy and soft. What is the priority nursing intervention? 1. Ambulate in the room 2. Perform crede' exercises 3. Reassess the fundus in 30 minutes. 4. Massage the fundus.

4. Massage the fundus

In what order should the home health nurse see assigned clients? Place in priority order. a. Client diagnosed with multiple sclerosis who called the office to say life is not worth living anymore. b. Client diagnosed with rheumatoid arthritis who requires an occupational consult. c. Client diagnosed with acquired immune deficiency syndrome (AIDS) dementia, whose family is requesting hospice information. d. Client diagnosed with systemic lupus erythematosus discharged home from the hospital this AM with a prescription for home healthcare.

a. Client diagnosed with multiple sclerosis who called the office to say life is not worth living anymore. d. Client diagnosed with systemic lupus erythematosus discharged home from the hospital this AM with a prescription for home healthcare. c. Client diagnosed with acquired immune deficiency syndrome (AIDS) dementia, whose family is requesting hospice information. b. Client diagnosed with rheumatoid arthritis who requires an occupational consult.

An elderly, bed-bound client receiving G-tube feeding at home is transported to the emergency department after onset of behavioral changes and hallucinations. Which nursing action is priority while diagnostic testing is underway? 1. Initiate seizure precautions 2. Discontinue G-tube feeding 3. Administer oxygen 4. Obtain blood work for troponin level

1. Initiate seizure precautions

The nurse on a large surgical unit needs to evaluate several clients returning from procedures. Which client should the nurse assess first? 1. Lumbar puncture reporting a headache. 2. Cystogram reporting burning on urination. 3. Thoracentesis reporting shortness of breath. 4. Cardiac catherization with a decreased pedal pulse below insertion site.

3. Thoracentesis reporting shortness of breath.

After shift report, which client should the nurse see first? 1. Eight year old that is in skeletal traction. 2. Six year old who is 5 hours postop appendectomy. 3. Unattended two year old admitted for a sleep study. 4. Four year old cerebral palsy child with a tracheostomy admitted for urinary tract infection (UTI).

3. Unattended two year old admitted for a sleep study.

The nurse plans to teach a client how to manage the use of a behind the ear hearing aid. What teaching strategies should the nurse include? Select all that apply 1. Hairspray should not be used while wearing the hearing aid. 2. A whistling sound when the hearing aid is inserted indicates proper placement. 3. Submerse hearing aid in cool water daily to clean. 4. Illustrate where damage commonly occurs on a hearing aid. 5. Batteries last 6 months with daily wearing of 10-12 hours.

1. Hairspray should not be used while wearing the hearing aid. 4. Illustrate where damage commonly occurs on a hearing aid.

The nurse tries to notify the primary healthcare provider (PHP) that the dosage of newly prescribed medication is higher than recommended. The PHP cannot be located and the medication is scheduled to be administered in 30 minutes. Which intervention should the nurse implement next? 1. Inform the charge nurse. 2. Administer the medication as prescribed. 3. Document the prescribed medication dosage in the nursing notes. 4. Administer the recommended dosage until the PHP is contacted.

1. Inform the charge nurse.

A nurse is planning to conduct parenting classes for first time parents in an attempt to decrease child abuse in the community. What type of prevention is the nurse utilizing? 1. Primary prevention 2. Secondary prevention 3. Tertiary prevention 4. Case management

1. Primary prevention

A hiker that was lost in the mountains for 3 days experienced exposure to below freezing temperatures. Upon arrival to the emergency department (ED), the nursing assessment reveals hard, mottled, bluish-white toes bilaterally, and the client reports being unable to feel the toes. Which actions should the nurse initially take? Select all that apply 1. Remove any wet or constricting clothing. 2. Initiate a controlled and rapid rewarming process with warm water. 3. Wrap each toe individually with sterile gauze. 4. Encourage the client to walk. 5. Apply a heating pad to the feet. 6. Massage the frozen digits.

1. Remove any wet or constricting clothing. 2. Initiate a controlled and rapid rewarming process with warm water. 3. Wrap each toe individually with sterile gauze.

Which prescription by the emergency room primary healthcare provider for a client who fell from a ladder should the nurse question? 1. Record intake and output hourly. 2. Prepare the client for lumbar puncture. 3. Perform neurologic checks every 10 minutes. 4. Schedule a brain computed tomography (CT) scan.

2. Prepare the client for lumbar puncture.

The nurse is assigned to bathe a client diagnosed with dementia. Which nursing intervention should the nurse implement? 1. Increase the volume of the television. 2. Finish the bath as soon as possible. 3. Clean the face and hair at the end of the bath. 4. Delegate another nurse to distract the client.

3. Clean the face and hair at the end of the bath.

During day shift, staff 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 blood pressure lower than normal. What action by the nurse takes priority? 1. Call primary healthcare provider stat. 2. Notify family that client is confused. 3. Have staff collect a urine specimen. 4. Apply oxygen at 2/L via nasal cannula.

3. Have staff collect a urine specimen.

After the unexpected death of a Jewish teenager, the coroner tells the family that an autopsy has been requested. The teen's mother starts crying hysterically and refuses to allow the autopsy. After calming the mother, what should the nurse do next? 1. Explain that the coroner does not need the family's permission to perform the autopsy. 2. Ask the primary healthcare provider for a sedative for the mother. 3. Notify the coroner that the family is Jewish. 4. Call the rabbi of the family's synagogue to discuss the nature of the autopsy.

3. Notify the coroner that the family is Jewish.

The nurse is caring for a client in the Emergency Department (ED) who reports a migraine headache unrelieved by over the counter medications. This is the 4th visit to the ED for this problem in 6 weeks. What is the priority nursing intervention? 1. Refer the client to their primary healthcare provider in the morning. 2. Make the client an appointment with the chronic pain clinic. 3. Rate the client's pain using the pain scale used in the ED. 4. Perform a visual acuity test.

3. Rate the client's pain using the pain scale used in the ED.

A 17 year old adolescent and girlfriend are being treated in the emergency room for moderate injuries following a motorcycle accident. The adolescent is unconscious and will need surgery but family cannot be located to give consent. What does the nurse know is true about informed consent? 1. Informed consent can be provided by the girlfriend. 2. Consent is not necessary in this particular situation. 3. Surgery must be delayed until the family is located. 4. Surgery cannot be done while client is unconscious.

3. Surgery must be delayed until the family is located.

Which comment made by a new nurse regarding calcium gluconate 1000 mg (10 mL) IV indicates to the charge nurse that further education is needed? 1. "Infusion rate should be 5 mL/minute." 2. "Calcium gluconate will counteract the effects of the client's hyperkalemia." 3. "I will monitor for hypophosphatemia after administering this medication." 4. "This medication is given to reverse the effects of hypermagnesemia."

1. "Infusion rate should be 5 mL/minute."

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? Select all that apply 1. First you will remove clothing and dispose of it in hazardous material containment area. 2. You will be placed in a warm shower for decontamination. 3. You will spend a minute or so using soap over the entire body before rinsing. 4. You will spend approximately 15 minutes in the shower. 5. You will apply soap from head to toe and then rinse for a few minutes.

1. First you will remove clothing and dispose of it in hazardous material containment area. 2. You will be placed in a warm shower for decontamination. 3. You will spend a minute or so using soap over the entire body before rinsing. 5. You will apply soap from head to toe and then rinse for a few minutes.

A pregnant client who had been on a magnesium drip for severe pregnancy induced hypertension (PIH) has had an emergency cesarean section at 35 weeks. The nursery nurse should anticipate what findings in the newborn related to the magnesium therapy? Select all that apply 1. Hypotension 2. Hypoglycemia 3. Hyperreflexia 4. Flaccid muscle tone 5. Respiratory depression

1. Hypotension 4. Flaccid muscle tone 5. Respiratory depression

The homecare nurse is instructing the family of a client recently diagnosed with Parkinson's disease about potential neurologic changes. During the discussion, what signs should the nurse include? Select all that apply 1. Unsteady gait 2. Muscle rigidity 3. Hyperactive reflexes 4. Bradykinesia (slowed movements) 5. Expressive aphasia

1. Unsteady gait 2. Muscle rigidity 4. Bradykinesia (slowed movements)

A client is undergoing outpatient psychiatric treatment for somatization disorder. Prior to the beginning of group therapy, the client tells the nurse, "I keep having headaches that are killing me! This has never happened to me before." What is the nurse's best response to this client? 1. You need to sit down, because we need to start the group session now. 2. I will notify the primary healthcare provider about your headaches, after the group session. 3. I guess we can discuss your pain now. Group therapy will have to start later. 4. Your headaches are not real, so ignore them. Go on into therapy so we can start.

2. I will notify the primary healthcare provider about your headaches, after the group session.

An elderly client with congestive heart failure (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? Select all that apply 1. Use an earlobe for placement of the probe. 2. Place on the upper arm, utilizing an automatic cuff. 3. Remove any fingernail polish before attaching probe. 4. Place fingers in warm water before checking sat level. 5. Don't use fingers on same arm as an automatic cuff.

1. Use an earlobe for placement of the probe. 3. Remove any fingernail polish before attaching probe. 4. Place fingers in warm water before checking sat level. 5. Don't use fingers on same arm as an automatic cuff.

After applying oxygen using bi-nasal prongs to a client who is having chest pain, the nurse should implement which intervention? 1. Have the client take slow deep breaths in through the mouth and out through the nose. 2. Post signs on the client's door and in the client's room indicating that oxygen is in use . 3. Apply Vaseline petroleum to both nares and 2 x 2 gauze around the oxygen tubing at the client's ears. 4. Encourage the client to hyperextend the neck, take a few deep breaths and cough.

2. Post signs on the client's door and in the client's room indicating that oxygen is in use .

The nurse is assessing a client with advanced cirrhosis and notes an abdominal girth increase of 5 inches (12.7 cm) since yesterday. What is the best position for the nurse to place this client? 1. Supine 2. Semi Fowler 3. Trendelenburg 4. Lateral, left side

2. Semi Fowler

The nurse is irrigating an acid chemical burn on a client's arm. Which would indicate to the nurse that irrigation can be stopped? 1. Client's pain rating has decreased from 6 to 2 on a 0 to 10 pain scale. 2. The pH value of the runoff solution is 7.0. 3. Client reports a burning sensation in the affected arm. 4. Capillary refill is less than 2 seconds in the affected arm.

2. The pH value of the runoff solution is 7.0.

The nurse's assessment of a client post-op abdominoplasty reveals tachycardia, restlessness and shallow slow breaths. The client was medicated with morphine 2 mg IVP one hour ago. The primary healthcare provider prescribes arterial blood gases (ABG). Which ABG report is consistent with this clinical picture? 1. pH 7.30, PaCO2 40, HCO3 29 2. pH 7.33, PaCO2 48, HCO3 25 3. pH 7.47, PaCO2 35, HCO3 29 4. pH 7.50, PaCO2 33, HCO3 22

2. pH 7.33, PaCO2 48, HCO3 25

The primary healthcare provider prescribed phenytoin for a client with grand mal seizures. What intervention would the nurse plan for the client's care? 1. Offer the client frequent high calorie snacks. 2. Check the apical pulse before each dose. 3. Perform or assist with oral hygiene every shift. 4. Give the medication 30 minutes prior to meal.

3. Perform or assist with oral hygiene every shift.

A client is admitted to the hospital reporting chills, fatigue and left lower leg pain for nearly a week. During initial assessment, the nurse notes wide-spread swelling and redness of left ankle in addition to a fever of 103.5° F (39.72° C). Which admission order should the nurse implement first? 1. Perform sterile wound care to lower leg. 2. Start I.V. for administration of antibiotics. 3. Place client on bedrest with left leg elevated. 4. Draw blood for serial cultures and lab work.

3. Place client on bedrest with left leg elevated.

Dietary teaching has been initiated for a client newly diagnosed with acute diverticulitis. The nurse knows that further instruction is necessary when the client makes what statement? 1. "I must include a lot of fluid in my daily routine." 2. "I need to take my antibiotics at the same time daily." 3. "Rest and mild exercise are important for my recovery." 4. "Decreasing fiber in my diet can help prevent recurrences."

4. "Decreasing fiber in my diet can help prevent recurrences."

A nurse has arrived late to work twice in the last week. What should be the nurse manager's first action? 1. Confront the nurse with the consequences of tardiness. 2. Ask the nurse to consent to a drug screening test. 3. Document the tardiness in the nurse's record. 4. Ask the nurse the reason for being tardy.

4. Ask the nurse the reason for being tardy.

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? 1. Apply warm compresses to the throat. 2. Encourage gargling to reduce discomfort. 3. Position the child supine. 4. Monitor for frequent clearing of the throat

4. Monitor for frequent clearing of the throat

A 35 year old client asks a clinic nurse how to find out if the client is overweight or obese. The client weighs 135 pounds and is 5 feet 2 inches tall. What should the nurse educate the client about? 1. Calculating body mass index 2. Measuring abdominal circumference 3. Determining lean body mass 4. Finding the nearest hydrostatic testing location

1. Calculating body mass index

The nurse instructs a client taking isoniazid for the treatment of tuberculosis (TB) regarding appropriate food choices. Which food choices indicate to the nurse that teaching has been successful? 1. Salad with bleu cheese dressing. 2. Smothered liver with onions. 3. Smoked salmon with crackers. 4. Pear salad with lettuce.

4. Pear salad with lettuce.