Passpoint Practice Exam 1
After receiving an oral dose of codeine for an intractable cough, a client asks the nurse, "How long will it take for this drug to work?" How should the nurse respond? A. 30 minutes B. 1 hour C. 2.5 hours D. 4 hours
A. 30 minutes
The nurse observes that a client with a history of panic attacks is hyperventilating. What action should the nurse take? A. Have the client breathe into a paper bag. B. Instruct the client to put the head between the knees. C. Give the client a low concentration of oxygen by nasal cannula. D. Tell the client to take several deep, slow breaths and exhale normally.
A. Have the client breathe into a paper bag.
A new mother asks, "When will the soft spot near the front of my baby's head close?" The nurse should tell the mother the soft spot will close in about: A. 2 to 3 months. B. 6 to 8 months. C. 9 to 10 months. D. 12 to 18 months.
D. 12 to 18 months.
When caring for a multigravid client admitted to the hospital with vaginal bleeding at 38 weeks' gestation, the nurse would anticipate administering intravenously which therapeutic agent if the client develops disseminated intravascular coagulation (DIC)? A. Ringer's lactate solution B. fresh frozen platelets C. 5% dextrose solution D. warfarin
B. fresh frozen platelets
A client diagnosed with leukemia is now experiencing neutropenia. Which assessment is a priority for the nurse? A. Blood glucose B. Bowel sounds C. Heart sounds D. Breath sounds
D. Breath sounds
An older infant who has been injured in an automobile accident is to wear a splint on the injured leg. The mother reports that the infant has become mobile even while wearing the splint. What should the nurse advise the mother to do? A. Notify the health care provider (HCP) immediately to adjust the treatment plan. B. Confine the infant to one room in the apartment. C. Keep the infant in the splint at night, removing it during the day. D. Remove any unsafe items from the area in which the infant is mobile.
D. Remove any unsafe items from the area in which the infant is mobile.
The nurse is caring for a child with a new diagnosis of diabetes. The nurse teaches blood glucose monitoring by allowing the child to practice checking the blood sugar of a toy bear dressed in a hospital gown. The nurse recognizes this approach to be appropriate for what age level? A. preschool age (3 to 5 years) B. adolescence (10 to 19 years) C. school age (5 to 10 years) D. toddler (1 to 3 years)
A. preschool age (3 to 5 years)
The nurse is teaching a female client about taking folic acid supplements for folic acid deficiency anemia. What information should be included in the teaching plan? A. It will take several months to notice an improvement. B. Folic acid should be taken on an empty stomach. C. Iron supplements are contraindicated with folic acid supplementation. D. Oral contraceptive use, pregnancy, and lactation increase daily requirements.
D. Oral contraceptive use, pregnancy, and lactation increase daily requirements.
A registered nurse caring for a client with generalized anxiety disorder identifies a nursing diagnosis of Anxiety. A short-term goal is established as follows: "The client will identify physical, emotional, and behavioral responses to anxiety." Which nursing interventions will help the client achieve this goal? Select all that apply. A. Avoid talking about the client's sources of stress. B. Advise the client that consuming one glass of red wine per day may lessen anxiety. C. Explain to the client that expressing feelings through journal writing may increase anxiety. D. Observe the client for overt signs of anxiety. E. Help the client connect anxiety with uncomfortable physical, emotional, or behavioral responses. F. Introduce the client to new strategies for coping with anxiety, such as relaxation techniques and exercise.
D. Observe the client for overt signs of anxiety. E. Help the client connect anxiety with uncomfortable physical, emotional, or behavioral responses. F. Introduce the client to new strategies for coping with anxiety, such as relaxation techniques and exercise.
A client in early labor is connected to an external fetal monitor. The physician hasn't noted any restrictions on her chart. The client tells the nurse that she needs to go to the bathroom frequently and that her partner can help her. How should the nurse respond? A. "Because you're connected to the monitor, you can't get out of bed. You'll need to use the bedpan." B. "I'll show your partner how to disconnect the transducer so you can walk to the bathroom." C. "Please press the call button. I'll disconnect you from the monitor so you can get out of bed." D. "I'll insert a urinary catheter; then you won't need to get out of bed."
C. "Please press the call button. I'll disconnect you from the monitor so you can get out of bed."
An infant, age 3 months, undergoes surgical repair of a cleft lip. After surgery, the nurse should use which equipment to feed the infant? A. single-hole nipple B. plastic spoon C. paper straw D. rubber dropper
D. rubber dropper
Which source of information helps a nurse formulate nursing diagnoses for a specific client? A. Research articles B. Essential assessment data C. Outcome criteria D. Admission criteria
B. Essential assessment data
A client with gestational hypertension receives magnesium sulfate, 4 g in 50% solution I.V. over 20 minutes. What is the purpose of administering magnesium sulfate to this client? A. To lower blood pressure B. To prevent seizures C. To inhibit labor D. To block dopamine receptors
B. To prevent seizures
The nurse is caring for a multiparous client after vaginal birth of a set of twins 2 hours ago. What should the nurse should encourage the mother and partner to do? A. Bottle-feed the twins to prevent exhaustion and fatigue. B. Plan for each parent to spend equal amounts of time with each twin. C. Avoid assistance from other family members until attachment occurs. D. Relate to each twin individually to enhance the attachment process.
D. Relate to each twin individually to enhance the attachment process.
The parents of a child with rheumatic fever express concern that their other children will develop the disease. Which response from the nurse is best? A. "This disease is not contagious." B. "Your other children are as likely to develop this disease." C. "Medicine is available to prevent this, so check with your primary care provider." D. "Your other children are girls, so they are less likely to get it."
A. "This disease is not contagious."
A 24-year-old client with diabetes mellitus sustains a large laceration that requires suturing. Which statement indicates that the client understands wound healing? A. "It's so hard to predict when this scar will disappear." B. "My scar will fade within 4 months." C. "If I don't get an infection, the scar may fade in 1 to 3 years." D. "This procedure won't leave a scar."
A. "It's so hard to predict when this scar will disappear."
A nurse is caring for a client with gastroenteritis. The nurse administers an as-needed dose of kaolin and pectin mixture as ordered. The nurse should complete which assessment 30 minutes after administering the medication? A. Determine if the client has had any more loose stools. B. Perform a pain assessment. C. Monitor for respiratory depression. D. Determine if the client has relief from nausea.
A. Determine if the client has had any more loose stools.
A client recovering from a closed head injury is restless and agitated. The client still has a central venous catheter in place for antibiotic therapy. The nurse doesn't want to sedate the client, but needs to protect the catheter and other less-restrictive measures have failed. Which method of restraint is best for this client? A. soft wrist restraints applied to both wrists B. soft restraints applied to each extremity C. a vest restraint D. mitt restraints applied to both hands
D. mitt restraints applied to both hands
A nurse who is preparing to boost a client up in bed instructs the client to use the overbed trapeze. Which risk factor for pressure ulcer development is the nurse reducing by instructing the client to move in this manner? A. friction B. impaired circulation C. localized pressure D. shearing forces
D. shearing forces
A primigravid client is 8 weeks' pregnant and has had her first examination. The healthcare provider stated the client has a positive Hegar's sign. The client is concerned that this sign means something is wrong. How should the nurse respond to this client's concerns? A. "This is a good sign. It means the uterus is softened." B. "This is a good sign. It means the cervix has softened." C. "This is a good sign. It means there is a blueish color to the cervix." D. "This is a good sign. It means the size of the uterus is good."
A. "This is a good sign. It means the uterus is softened." The Hegar's sign is determined by the softening of the uterine isthmus. Goodell's sign is a softened cervix because of increased pelvic congestion. Chadwick's sign is the bluish discoloration of the cervix and vaginal mucosa. The size of the uterus is determined by bimanual examination. It is not the same as Hegar's sign.
A primiparous client diagnosed with cystitis at 48 hours postpartum who is receiving intravenous ampicillin asks the nurse, "Can I still continue to breastfeed my baby?" What should the nurse tell the client? A. "You can continue to breastfeed as long as you want to do so." B. "Alternate your breastfeeding with formula feeding to help you rest." C. "You'll need to discontinue breastfeeding until the antibiotic therapy is stopped." D. "You will need to modify your technique by manually pumping your breasts."
A. "You can continue to breastfeed as long as you want to do so."
A client undergoing a bilateral adrenalectomy has postoperative prescriptions for hydromorphone hydrochloride 2 mg to be administered subcutaneously every 4 hours as needed for pain. Why should the nurse administer hydromorphone in small doses? A small dose is: A. less likely to cause dependency. B. less irritating to subcutaneous tissues in small doses. C. as potent as morphine in larger doses. D. excreted before accumulating in toxic amounts in the body.
C. as potent as morphine in larger doses.
A client is scheduled for an intravenous pyelogram. Before the procedure, the nurse learns that the client has a sensitivity to shellfish. What should the nurse do next? A. Administer a cathartic to the client to empty the colon. B. Administer an antiflatulent to the client to relieve gas. C. Keep the client on nothing-by-mouth (NPO) status. D. Notify the health care provider.
D. Notify the health care provider.
The nurse is preparing a community education program about preventing hepatitis B infection. Which information should be incorporated into the teaching plan? A. Hepatitis B is relatively uncommon among college students. B. Frequent ingestion of alcohol can predispose an individual to development of hepatitis B. C. Good personal hygiene habits are most effective at preventing the spread of hepatitis B. D. The use of a condom is advised for sexual intercourse.
D. The use of a condom is advised for sexual intercourse.
A client arrives for an annual physical examination. During the history, the client reports recurrent symptoms of heartburn, a sour taste in the mouth, and hoarseness in the throat. In anticipation of client teaching, illustrate on the diagram the location of the structure which frequently enables these symptoms to occur.
lower esophageal sphincter
A student nurse inserts a nasogastric tube and begins a tube feeding without a radiological confirmation. The client develops pneumonia and is transferred to the intensive care unit. Which parties are liable for negligence? Select all that apply. A. the student nurse B. the nursing instructor C. the assigned nurse D. the physician E. the dietician
A. the student nurse B. the nursing instructor C. the assigned nurse
A client returns to the nursing unit following successful synchronized cardioversion using transthoracic chest wall patches. What should the nurse assess when the client returns to the room? Select all that apply. A. vital signs B. skin of chest wall C. arterial puncture site D. level of consciousness E. cardiac rhythm
A. vital signs B. skin of chest wall D. level of consciousness E. cardiac rhythm
A charge nurse assesses a group of staff nurses as competent individually but ineffective and nonproductive as a team. How should the charge nurse address the staff nurses about these concerns? A. Ask the staff nurses if they feel unhappiness about the current leadership. B. Have the staff nurses express their feelings and emotions. C. Increase staffing to prevent fatigue from overwork and understaffing. D. Incorporate the staff nurses in decision making.
B. Have the staff nurses express their feelings and emotions.
A client with a history of cocaine abuse is receiving intravenous therapy and exits the hospital "to visit a friend." The client returns to the nursing unit 1 hour later, agitated, aggressive, combative, and reporting "chest pain." Place the nurse's actions in priority order from first to last. All options must be used. 1. Obtain an ECG 2. Initiate a referral to obtain drug rehabilitation counseling 3. Obtain a urine sample. 4. Contact the security department.
1. Contact the security department. 2. Obtain an ECG. 3. Obtain a urine sample. 4. Initiate a referral to obtain drug rehabilitation counseling.
The nurse is preparing to administer a flu shot to an adult client. How would the nurse proceed? Place the steps in sequential order. All options must be used. 1. Inject it into the muscle at a 90-degree angle. 2. Clean the injection site with an alcohol pad. 3. Wait 10 seconds before removing needle 4. Gently stretch the skin taut at the site. 5. Put gloves on 6. Locate the deltoid muscle.
1. Put gloves on. 2. Locate the deltoid muscle. 3. Clean the injection site with an alcohol pad. 4. Gently stretch the skin taut at the site. 5. Inject it into the muscle at a 90-degree angle. 6. Wait 10 seconds before removing needle.
The nurse notices a fire in a wastebasket in a client's room. In which order of priority from first to last should the nurse perform the actions? All options must be used. 1. Confine the fire by closing the door to the client's room. 2. Remove the client from the room. 3. Extinguish the fire. 4. Pull the fire alarm at the alarm pull station.
1. Remove the client from the room. 2. Pull the fire alarm at the alarm pull station. 3. Confine the fire by closing the door to the client's room. 4. Extinguish the fire.
A child with nephrosis is placed on prednisone. The dose is 2 mg/kg per day to be administered twice a day. The child weighs 25 lb (11.3 kg). How many milligrams will the child receive at each dose? Record your answer using one decimal place.
11.3 mg
A client with a genitourinary problem is being examined in the emergency department. When palpating the client's kidneys, the nurse should keep in mind which anatomic fact? A. The left kidney usually is slightly higher than the right one. B. The kidneys are situated just above the adrenal glands. C. The average kidney is approximately 5 cm (2?) long and 2 to 3 cm (¾? to 1??) wide. D. The kidneys lie between the 10th and 12th thoracic vertebrae.
A. The left kidney usually is slightly higher than the right one.
An agitated client demands to see the chart to read what has been written about the client. Which statement is the nurse's best response to the client? A. "I'm sorry. The chart is the property of the facility. We don't permit clients to read their charts." B. "You have the right to see your chart. Please discuss your wish with your physician." C. "You may see your chart after you're discharged." D. "Please discuss this matter with your attorney."
B. "You have the right to see your chart. Please discuss your wish with your physician."
An older adult had a myocardial infarction (MI) 4 days ago. At 0930, the client's blood pressure is 102/64 mm Hg. After reviewing the client's progress notes (see chart), what should the nurse do first? A. Give a fluid challenge/bolus. B. Notify the health care provider (HCP). C. Assist the client to walk. D. Administer furosemide as prescribed.
B. Notify the health care provider (HCP).
A client asks the nurse to help make out a will. What should the nurse tell the client? A. "I'm not a lawyer, but I'll do what I can for you." B. "You have a long way to go before you'll need to do that. Let's wait on it a while, shall we?" C. "I don't believe in getting involved in legal matters, but maybe I can find another nurse who will help you." D. "You need to consult an attorney because I'm not trained in such matters. Is there a family lawyer you can call?"
D. "You need to consult an attorney because I'm not trained in such matters. Is there a family lawyer you can call?"
A nurse is caring for a client at 30 weeks' gestation who has tested positive for the human immunodeficiency virus (HIV). What should the nurse tell the client when the client says that she wants to breast-feed her neonate? A. Encourage breast-feeding so that the client can get her rest and get healthier. B. Encourage breast-feeding because it's healthier for the neonate. C. Encourage breast-feeding to facilitate bonding. D. Discourage breast-feeding because HIV can be transmitted through breast milk.
D. Discourage breast-feeding because HIV can be transmitted through breast milk.
A client with multiple sclerosis is taking baclofen. Which sign indicates the drug is having the intended outcome? The client: A. does not have a urinary tract infection. B. has increased energy. C. no longer has double vision. D. has relief from muscle spasms.
D. has relief from muscle spasms.
A nurse overhears a fellow staff member talking about the mother of a child for whom the staff nurse is caring. The nurse is telling others private information that the mother had shared. What is the best response by the nurse overhearing the conversation? A. Report this incident to the nurse-manager. B. Report the incident to the organization's privacy officer. C. Talk to the staff member privately about this. D. Talk to the staff in general about confidentiality.
C. Talk to the staff member privately about this.
When making ethical decisions about caring for preschoolers, a nurse should remember to A. provide beneficial care and avoid harming the child. B. make decisions that will prevent legal trouble. C. do what the nurse would do for a close child or loved ones. D. be sure to do what the physician says.
A. provide beneficial care and avoid harming the child.
The nurse is helping to prepare a client for nonemergency surgery. What should the nurse do? A. Obtain informed consent from the client. B. Explain the surgical procedure. C. Verify the client understands the informed consent form. D. Inform the client about the risks of the surgery to be performed.
C. Verify the client understands the informed consent form.
A client diagnosed with arthritis doesn't want to take medications. Physical therapy and occupational therapy have been consulted for nonpharmacologic measures to control pain. What might physical and occupational therapy include in the care plan to help control this client's pain? A. acupuncture B. an exercise routine that includes range-of-motion (ROM) exercises C. heat therapy and nonsteroidal anti-inflammatory medications (NSAIDs) D. cold therapy
B. an exercise routine that includes range-of-motion (ROM) exercises
While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects A. squamous cell carcinoma. B. actinic keratoses. C. melanoma. D. basal cell carcinoma.
C. melanoma
A 44-year-old client has been experiencing spotting, nausea, vomiting, and fatigue. A positive pregnancy test and an ultrasound confirm a 13 week gestation. The client had three prior miscarriages with no term births. What does the nurse recognize as the greatest risk factor for the client at this time? A. premature birth B. hypertension C. pregnancy loss D. preterm labor
C. pregnancy loss
After being treated for minor cuts, a client appears confused and has trouble focusing on what the nurse is saying. The client reports nausea and dizziness, has tachycardia, and is hyperventilating during the nursing assessment. How would the nurse interpret the level of anxiety? A. mild B. moderate C. severe D. panic
C. severe
A client believes she is experiencing premenstrual syndrome (PMS). The nurse should next ask the client about what symptom? A. menstrual cycle irregularity with increased menstrual flow B. mood swings immediately after menses C. tension and fatigue before menses and through the second day of the menstrual cycle D. midcycle spotting and abdominal pain at the time of ovulation
C. tension and fatigue before menses and through the second day of the menstrual cycle
A client comes to the emergency department with symptoms of chest pain radiating down the left arm, dyspnea, and diaphoresis. An electrocardiogram (EKG) shows ST segment elevation and the client is diagnosed with an ST segment-elevation myocardial infarction (STEMI). To determine if the client is a candidate for thrombolytic therapy, which question should the nurse ask? A. "What time did your chest pain start?" B. "Did you take any nitroglycerine before coming to the emergency department?" C. "Do you have any allergies?" D. "Is this the first time you experienced this type of pain?"
A. "What time did your chest pain start?"
A nurse manager identifies fall prevention as a unit priority. Which actions can the nurses implement to meet these goals? Select all that apply. A. Use bed alarms to remind clients to call for help getting up. B. Apply soft waist restraint to confused clients. C. Maintain a clear path to client bathrooms. D. Make hourly rounds to client rooms. E. Close doors to client rooms at night.
A. Use bed alarms to remind clients to call for help getting up. C. Maintain a clear path to client bathrooms. D. Make hourly rounds to client rooms.
A nurse is providing care for three clients on a medical unit, two of whom are significantly more acute than the third. The nurse is making a concerted effort to ensure that the less acute client still receives a reasonable amount of time, attention, and care during the course of the shift. Which is the nurse attempting to enact? A. justice B. beneficence C. fidelity D. nonmaleficence
A. justice
A child is diagnosed with pituitary dwarfism. Which pituitary agent will the primary care provider most likely order to treat this condition? A. synthetic ACTH B. somatotropin C. desmopressin acetate D. vasopressin
B. somatotropin
A student nurse is reviewing physician orders written on a client's chart. Which entry is written incorrectly because it contains material from the "do not use" list of the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission)? A. epoetin alfa 6500 U SQ daily. B. acetaminophen 550 mg po every 4 hours for fever greater than 102 degrees F. C. diazepam 5 mg po on-call to the OR. D. levothyroxine sodium 0.125 mcg po daily.
A. epoetin alfa 6500 U SQ daily.
Which nursing intervention is the highest priority when a client is placed in restraints? A. monitoring the client every 15 minutes B. assisting with nutrition and elimination C. performing range-of-motion exercise for each limb, one at a time D. changing the client's position every 2 hours
A. monitoring the client every 15 minutes
A registered nurse (RN) has been "care-paired" with a licensed practical nurse (LPN) during the evening shift. Whose care should the RN assign to the LPN? A. the 2-year-old child who has started eating soft, solid foods following a tonsillectomy B. a 12-month-old infant who has a white blood cell (WBC) count of 34/μl and a fever C. a 17-month-old infant with a contusion as a result of a motor vehicle accident 4 hours earlier D. a 22-month-old infant with type 1 diabetes who has a blood glucose level of 277 mg/dl (15.37 mmol/L).
A. the 2-year-old child who has started eating soft, solid foods following a tonsillectomy
A nursing student and a preceptor nurse are discussing nursing liability. Which statement made by the student would indicate to the nurse that the student understands the concept of liability? A. "Clients have 5 years to sue if they feel they have been harmed." B. "Clients can still file a lawsuit outside of the statute of limitations if the the discovery of the harm has been more recent." C. "There is a grace period of 1 year after clients are injured when they can file a law suit." D. "A form of alternative dispute resolution is to have clients sign a waiver before treatment that indicates they cannot sue in case of error."
B. "Clients can still file a lawsuit outside of the statute of limitations if the the discovery of the harm has been more recent."
The child in a new hip spica cast seems to be adjusting to the cast, except that after each meal the child tells the nurse that the cast is too tight. What should the nurse plan to do? A. Administer a laxative prior to each meal. B. Offer smaller, more frequent meals. C. Give the child a mechanical soft diet. D. Offer the child more fruits and grains.
B. Offer smaller, more frequent meals.
Which information should the nurse include in a teaching plan for the client newly diagnosed with chronic obstructive pulmonary disease (COPD)? Select all that apply. A. Pulmonary rehabilitation programs offer very little benefit. B. Pneumococcal vaccination is contraindicated for clients with lung disease. C. High humidity increases the effort of breathing. D. A bronchodilator with meter-dose inhaler should be readily available. E. Smoking cessation is important to slow or stop disease progression.
C. High humidity increases the effort of breathing. D. A bronchodilator with meter-dose inhaler should be readily available. E. Smoking cessation is important to slow or stop disease progression.
A client has a leg immobilized in traction. Which observation by the nurse indicates that the client understands actions to take to prevent muscle atrophy? A. The client adducts the affected leg every 2 hours. B. The client rolls the affected leg away from the body's midline twice per day. C. The client performs isometric exercises to the affected extremity three times per day. D. The client asks the nurse to add a 5-lb (2.3-kg) weight to the traction for 30 minutes per day.
C. The client performs isometric exercises to the affected extremity three times per day.
The nurse is observing a student nurse perform an irrigation of a client's nasogastric (NG) tube. Which action by the student nurse would cause the nurse to stop the procedure? A. The student nurse puts on clean gloves instead of sterile gloves. B. The student nurse allows the fluid in the syringe to flow by gravity into the NG tube. C. The student nurse irrigates the NG tube through the blue air vent port. D. The student nurse disconnects the suction tubing from the NG tube.
C. The student nurse irrigates the NG tube through the blue air vent port.
While a mother is feeding her full-term neonate 1 hour after birth, she asks the nurse, "What are these white dots in my baby's mouth? I tried to wash them out, but they're still there." After assessing the neonate's mouth, the nurse explains that these spots indicate which condition? A. Koplik's spots B. Epstein's pearls C. precocious teeth D. thrush curds
B. Epstein's pearls
A multigravid client at 36 weeks' gestation who is visiting the clinic for a routine visit begins to sob and tells the nurse, "My boyfriend has been beating me up once in a while since I became pregnant, but I can't bring myself to leave him because I don't have a job and I don't know how I would take care of my other children." What is the priority action by the nurse at this time? A. Contact a social worker for assistance and family counseling. B. Help the client make concrete plans for the safety of herself and her children. C. Tell the client that she should not allow anyone to hit her or her children. D. Provide the client with brochures on the statistics about violence against women.
B. Help the client make concrete plans for the safety of herself and her children.
The single parent of a young teenager is being treated for complicated bronchitis at a small rural hospital. The parent does not live in the area and has a poor command of English. The facility is experiencing delays in accessing a translator. In considering whether to allow the teenager to translate medical information for his parent, the nurse should consider that: A. it depends on which language, and how long the delay will be. B. these circumstances may allow the child to translate. C. the child may not be allowed to translate for the parent's care. D. an adult friend or family member must be located to translate.
B. these circumstances may allow the child to translate.
A client is admitted to the pediatric unit with a diagnosis of celiac disease. What finding would the nurse expect in this client? A. a concave abdomen B. bulges in the groin area C. a protuberant abdomen D. a palpable abdominal mass
C. a protuberant abdomen
A client with newly diagnosed type 1 diabetes is scheduled to receive regular insulin 10 units and NPH insulin 20 units every morning. When should the nurse schedule the administration of these medications? A. regular insulin with breakfast; NPH after breakfast B. both insulins 0.5 hours before breakfast C. in two separate syringes with breakfast D. NPH 1 hour before and regular 0.5 hours before breakfast
B. both insulins 0.5 hours before breakfast
A client is seen in the clinic for newly diagnosed hypothyroidism. Which topics should the nurse include in a client teaching plan? Select all that apply. A. high-protein, high-calorie diet B. high-fiber, low-calorie diet C. plan for a thyroidectomy D. use of stool softeners E. thyroid hormone replacements F. review of the procedure for thyroid radiation therapy
B. high-fiber, low-calorie diet D. use of stool softeners E. thyroid hormone replacements
A nurse coming onto the night shift assesses a client who gave birth vaginally that morning. The nurse finds that the client's vaginal bleeding has saturated two perineal pads within 30 minutes. What is the first action the nurse should take? A. Ask the client to get out of bed and try to urinate. B. Call the physician for a methylergonovine order. C. Assess the fundus and massage it if it's boggy. D. Give the client a new pad and check her in 30 minutes.
C. Assess the fundus and massage it if it's boggy.
The nurse is educating a client with type 2 diabetes from France who speaks English as a second language. What behavior alerts the nurse to a possible lack of communication of the educational material? Select all that apply. A. repeating some medical terms B. writing down some information C. asking questions about shopping D. laughing at some of the brochures E. looking away from the speaker
C. asking questions about shopping D. laughing at some of the brochures E. looking away from the speaker
A client tells the nurse that she is concerned because she has not had a bowel movement since the birth of her infant 3 days ago. Which would be the priority intervention by the nurse? A. Encourage bed rest with frequent position changes. B. Increase her consumption of fiber to 25 grams per day. C. Collaborate with the physician for a laxatives order. D. Tell her it is normal not to have a bowel movement for up to 5 days after birth.
B. Increase her consumption of fiber to 25 grams per day.
A laboring client is restless and moving frequently in the bed. She is uncomfortable but refuses pain medication when offered. Which of the following responses from the nurse is most helpful? A. Stand silently at the back of the room. B. Stand next to her at the side of the bed. C. Turn up the volume of the music playing in the room. D. Turn on the television as a focal point.
B. Stand next to her at the side of the bed.
A "read-back" procedure has been implemented on a nursing unit to prevent discrepancies in telephone prescriptions and reports. When should this procedure be implemented? A. When the float nurse gives a written report to the oncoming nurse B. When the nurse receives a critical lab value via phone or in-person from the lab C. When the lab report shows up on the computerized medical record D. When the unit clerk takes a telephone prescription for a stat lab test
B. When the nurse receives a critical lab value via phone or in-person from the lab
A child admitted to the hospital with a serum sodium level of 160 mEq/L (160mmol/L) is receiving 5% dextrose with 0.45 normal saline solution. The mother asks the child's nurse why the child is receiving sodium. What is the nurse's best reply? A. "Your child's sodium is high; I'll stop the infusion and check with the primary care provider." B. "Your child's sodium is high; but if the serum sodium level is decreased too rapidly, it may cause seizures." C. "Your child's sodium is low; we need to give some more sodium IV." D. "Your child's sodium is normal; the solution will maintain the level."
B. "Your child's sodium is high; but if the serum sodium level is decreased too rapidly, it may cause seizures."
A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these findings as signs and symptoms of A. right-sided heart failure. B. acute pulmonary edema. C. pneumonia. D. cardiogenic shock.
B. acute pulmonary edema.
What are important nursing priorities on the first postoperative day for a client who has had an open reduction and internal fixation (ORIF) after a right hip fracture? A. supporting the leg to maintain adduction, ensuring adequate pain control, and maintaining bed rest B. assessing the neurovascular status in the right leg, providing pain control, encouraging position changes, and early ambulation C. assessing for skin integrity, enhancing nutritional status, and encouraging position changes while maintaining bed rest D. reorienting frequently to prevent confusion and disorientation, restricting analgesics, and encouraging pursed-lip breathing
B. assessing the neurovascular status in the right leg, providing pain control, encouraging position changes, and early ambulation
A nurse is caring for a client with poorly managed diabetes mellitus who has a serious foot ulcer. When the nurse informs the client that the physician has ordered a wound care nurse to examine the wound, the client asks why should anyone other than the staff nurse care for the wound. The client states, "It's no big deal. I'll keep it covered and put antibiotic ointment on it." Which responses made by the nurse would be appropriate? Select all that apply. A. "We're very concerned about your foot and we want to provide the best possible care for you." B. "This is a big deal, and you need to recognize how serious it is." C. "You could possibly lose your foot without proper care." D. "Do you want me to tell the physician you refused?" E. "The wound nurse is specially trained to care for diabetic wounds."
A. "We're very concerned about your foot and we want to provide the best possible care for you." C. "You could possibly lose your foot without proper care." E. "The wound nurse is specially trained to care for diabetic wounds."
A 30-year-old client is admitted to the progressive care unit with a C5 fracture from a motorcycle accident. What would be the nurse's priority assessment? A. Bladder distention B. Neurological deficit C. Pulse oximetry readings D. Client feelings about the injury
C. Pulse oximetry readings
A health care provider prescribes carbamazepine 1,200 mg/po/q12h for a client with trigeminal neuralgia. Which action should the nurse take first? A. Administer the medication with meals or with a bedtime snack. B. Encourage the client to promptly report unusual bleeding. C. Question the dose because it exceeds the recommended daily dose. D. Store the drug in a cool, dry place away from sunlight.
C. Question the dose because it exceeds the recommended daily dose.
