Quiz 1

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? 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.

1,2,3

What strategies for smoking prevention could the school nurse recommend to the community task force? 1. Have a "Pledge Campaign" asking students not to use tobacco. 2. Include effects of smoking in health classes. 3. Enlist help from celebrities who are against smoking. 4. Conduct a "Don't Smoke" poster contest aimed at seventh graders. 5. Start a smoking cessation class for students who currently smoke.

1,2,3,4 (all primary)

What signs and symptoms will the nurse look for when caring for an infant with severe dehydration? 1. Dark, yellow urine 2. Lethargic 3. Bulging fontanels 4. Tachypnea 5. Decreased urine output

1,2,4,5

Which food items, if chosen by a new unlicensed assistive personnel (UAP), would indicate to the nurse that the UAP understands a clear liquid diet? 1. White grape juice 2. Gelatin 3. Vanilla pudding 4. Lemon Popsicle 5. Fat free Broth 6. Tea with honey

1,2,4,5,6

A client diagnosed with gout has received instruction on maintaining a low-purine diet. Which statements, if made by the client, would indicate to the nurse that teaching was successful? 1. "I will eliminate foods from my diet that contain 150 mg or more of purine per serving." 2. "Rather than drinking a glass of wine, I should drink a glass of beer." 3. "Losing weight can help reduce the uric acid levels in my blood." 4. "Potatoes, rice, and barley are high in purine and should be eliminated from my diet." 5. "Vegetables that should be limited to 2 times/week include cauliflower, spinach, and mushrooms." 6. "Increasing fluid intake to 8-10 cups/day will help to eliminate purines through my urine."

1,3,5,6

A client who has been diagnosed with chronic venous insufficiency has received teaching regarding how to prevent venous stasis ulcerations. Which statements by the client indicate to the nurse that teaching has been effective? 1. "Stationary standing should be kept to a minimum." 2. "It is important to avoid wearing constricting clothes longer than 2 hours." 3. "Elevation of my legs should be done for 15 minutes every 4-6 hours." 4. "Protecting my legs from trauma is very important." 5. "I will wear compression stockings every day." 6. "I will elevate the foot of my bed 6 inches (15.24 cm) when I sleep."

1,4,5,6

A client in the third trimester of pregnancy arrives at the emergency room reporting general illness. The client is noted to have a blood glucose level of 390 mg/dL and is diagnosed with gestational diabetes. The primary healthcare provider prescribes 30 units of NPH insulin subcutaneously stat. What is the nurse's priority action? 1. Administer the dose of insulin immediately. 2. Question the type of insulin prescribed. 3. Insert an IV for an insulin infusion. 4. Question the dose of the insulin.

2 (must be quickly reduced)

The nurse should wear gloves when administering which medication? 1. Lorazepam 1mg orally. 2. Nitroglycerin ointment 2% 0.5 inch to chest. 3. Ceftriaxone 250mg intramuscularly. 4. Metronidazole 500mg intravenous piggyback. 5. Humalog 8 units subcutaneously.

2,3,5,

The nurse inadvertently administered the wrong medication to a client. Place the tasks to be completed in order of priority. 1. alert the unit manager 2. complete an incidence report 3. obtain vitals 4. report what happened to the HCP

3, 4, 1, 2

A client comes to an obstetric clinic for a routine prenatal checkup at 32 weeks gestation. The nurse palpates the client's abdomen to determine fetal position so that fetal heart sounds can be assessed. It is determined that the fetal position is left occipital anterior (LOA). Where should the nurse place the Doppler to hear fetal heart sounds? 1. Below the umbilicus, on the mother's left side. 2. Below the umbilicus, on the mother's right side. 3. Above the umbilicus, on the mother's right side. 4. Above the umbilicus, on the mother's left side.

1

An emergency room nurse is assessing a child with a suspicious spiral fracture to the right arm. The nurse is aware the best evidence to support possible child abuse is what? 1. Inconsistency between injury and explanation of the cause. 2. Child withdraws when the parent tries to hug or comfort. 3. Parents leave the room when questioned about the injury. 4. Lack of parental concern with injury or pending treatment.

1

The charge nurse walks into the client's room as the staff nurse is preparing the client for discharge. The charge nurse overhears the staff nurse giving the client her phone number. The staff nurse says, "Call me when you get home, and maybe we can get together sometime." What should the charge nurse do first? 1. Interrupt the staff nurse and complete the discharge. 2. Tell the staff nurse in the client's presence that the action is inappropriate. 3. Make no comment, and let the staff nurse continue to talk with the client. 4. Stay with the client until ready to leave the unit.

1

The nurse is reviewing sequential lab results on a newly admitted client with multiple health issues. Critical changes in which body system require the nurse to immediately notify the primary healthcare provider? 1. Renal 2. Endocrine 3. Pulmonary 4. Cardiovascular

1

Which assessment findings would the nurse expect to see in a client diagnosed with idiopathic thrombocytopenic purpura (ITP)? 1. Ecchymosis 2. Bleeding gums 3. Palpable spleen 4. Pain 5. Petechiae

1, 2, 3, 5 (spleen & liver often palpable)

The nurse is preparing a client for transport to the radiology department for a left lung tissue biopsy. Which actions should the nurse make certain have been completed? 1. The consent form is signed. 2. The operative site is prepped with a razor. 3. The most recent lab work is on the chart. 4. Any preoperative medication is given as prescribed. 5. Person performing the procedure has marked the site.

1, 3, 4, 5 (site should be prepped with clippers to avoid injury to the pt & decrease entrance for bacteria)

The nurse is caring for a client diagnosed with dementia. Which task can the nurse assign to the unlicensed assistive personnel (UAP)? 1. Assist the client with toileting. 2. Inform family that the client needs a Computed Tomography (CT) scan. 3. Accompany the client while walking in the hall. 4. Reorient the client frequently. 5. Apply restraint belt for client safety.

1,3,4

The nurse is caring for a client with increased intracranial pressure (ICP). Which actions would increase the client's ICP? 1. Using restraints 2. Elevating head 3. Performing Valsalva 4. Blowing nose 5. Keeping client supine 6. Suctioning

1,3,4,5,6

The nurse is teaching comfort measures to a postpartum client with an episiotomy and external hemorrhoids. Which teaching points should the nurse include? 1. Apply ice to perineum for first 12 hours. 2. Take sitz baths at temperature of 107.6°-111.2°F (42-44°C). 3. Use witch hazel compresses on rectal areas for hemorrhoids. 4. Take ibuprofen for pain. 5. Apply topical anesthetics to perineal area. 6. Avoid sexual intercourse until episiotomy has healed.

1,3,4,5,6

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? 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

1,3,5 (+ Allen= patency!)

A primary healthcare provider has prescribed chlorpromazine 150 mg by mouth twice a day. The pharmacy sends chlorpromazine oral concentration: 100 mg/mL. How many mL should the nurse administer for each dose? Round answer using one decimal point.

1.5 mL

An elderly client is admitted to the outpatient unit with anemia and is receiving a blood transfusion. What is the nurse's priority assessment? 1. Monitor for peripheral edema. 2. Assess breath sounds. 3. Keep bedrails up at all times. 4. Monitor hemoglobin every 6 hours.

2

An elderly client with dementia has just been admitted to a long-term care facility. When orienting the client to the environment, the nurse knows that what is the most important initial action? 1. Explain the process of sending meal requests. 2. Show client how to use the call bell in the room. 3. Provide a tour of the entire facility and grounds. 4. Instruct client on the location of emergency exits.

2

The nurse is talking with the spouse of an alcoholic client. Which statement by the client's spouse is evidence of codependent behavior? 1. "I frequently tell my spuse that drinking alcohol is ruining our relationship." 2. "I go and pick my spouse up from the bar when not home by midnight." 3. "I do not go out drinking with my spouse, and will not drink at home either." 4. "I have told my spouse that I am willing to attend a counseling session when my spouse wants to stop drinking."

2

The nurse is teaching a group of high school students about car accident prevention. Who would the nurse include as the highest risk for a motor vehicle crash (MVC)? 1. Males who have just turned 19 years of age. 2. Drivers who have recently acquired a driver's license. 3. A group of students that carpool to the senior prom. 4. Female students who drive to weekly football games.

2

A client has been taking tranylcypromine for approximately two weeks. The client is visiting the nurse at the local mental health center for follow up and group therapy. Which client comment indicates a lack of understanding of the medication that could result in a medical emergency? 1. I know that I must take this medication until my primary healthcare provider tells me to stop. 2. It is frustrating to have to follow dietary restrictions. 3. I am getting a cold, and I am going to take some over the counter cold medicine. 4. I am going to have broccoli salad and roasted turkey for lunch today.

3

A client with a history of eczema has been admitted with cellulitis of the left forearm. Which admission order should the nurse question immediately? 1. Start IV of normal saline at 100 mL per hour. 2. Keep left arm elevated on pillow at all times. 3. Apply ice packs to affected area every shift. 4. Ibuprophen 800 mg po every 6 hours prn pain.

3

A small community has experienced a severe tornado that hit a shopping mall and caused extreme damage and suspected mass casualties and injuries. What should be done first? 1. Triage victims and tag according to injury. 2. Assess the immediate area for electrical wires on the ground. 3. Activate the community emergency response team. 4. Begin attending to injuries as they are encountered.

3

How closely monitored is access to a facility's health information system? 1. No monitoring; the system is password protected. 2. Monitored intermittently. 3. Monitored closely and constantly for inappropriate use. 4. Monitored daily and sporadically.

3

The nurse is caring for a client in an outpatient clinic. The client's spouse died 8 months ago. Which statement by the client suggests that the client is achieving resolution of grief? 1. "I am starting a new life, so I have removed all of the pictures from the wall that remind me of my spouse." 2. "I'm so lonely and I'm not sure life is worth living now." 3. "Although it hasn't been easy, I accept the loss of my soul mate." 4. "If only we had spent more time together before the illness got so severe."

3

What is the first intervention the emergency department (ED) nurse should implement when caring for a lethargic toddler with a diagnosis of near-drowning? 1. Torso warming 2. Start intravenous infusion 3. Administer oxygen 4. Prepare for nasogastric intubation

3

Following a lumbar puncture, the client reports a headache on a pain scale of 8 out of 10. What priority action should the nurse perform? 1. Instruct the client to drink at least 8 ounces of water. 2. Close room blinds to darken the environment. 3. Assist the client into a supine position in bed. 4. Notify primary healthcare provider of client's complaints.

3 (stops leaking which causes a headache)

A mother of a newborn is crying and tells the nurse, "I am worried about my baby. His Apgar score was 6 and the nurses had to help him breath for a while." What response should the nurse make to this mother? . "Don't worry about what score your baby received on the Apgar. The nurses know how to take care of him." 2. "Stop crying. Your baby is fine now and will continue to get stronger as the day progresses." 3. "Your baby's Apgar score was normal. The score was 6 at 1 minute which is typical." 4. "It is normal for you to feel this way. Let me explain what the Apgar score is used for."

4

How should the nurse interpret the arterial blood gas (ABG) results of a client admitted with dehydration? 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis

4

The nurse is caring for a poorly controlled type 2 diabetic client. Lab results include a BUN of 22mg/dL (7.85 mmol/L) and a creatinine of 1.9 mg/dL (0.67 mmol/L). The nurse checks the client's blood sugar and it is 218mg/dL (12.09 mmol/L). Current medications include metformin and exenatide. What is the priority concern with this client taking metformin? 1. Metformin is not controlling the client's blood glucose. 2. Metformin and exenatide should not be administered together. 3. Metformin can cause hypoglycemia. 4. Metformin is contraindicated with an elevated creatinine level.

4

What foods should the nurse inform the pt to avoid for three days prior to a guaiac test? 1. Chicken 2. Carrots 3. Apple 4. Raw broccoli 5. Steak 6. Turnip greens

4, 5, 6 (also red meats, cantaloupe, radish, and horseradish)