RN Question Trainer Test 1

The adult client is preparing for a plasma cholesterol screening. Which instruction does the nurse give to the client?

Only take sips of water for 12 hours before the test

The client had a kidney transplant yesterday, and the client's adult child has come to visit. The nurse instructs the adult child to take which action?

Perform good hand washing

The nurse performs range-of-motion (ROM) exercises for an elderly client recently immobilized. The nurse identifies which statement as correct about range-of-motion?

ROM assists the elderly to carry out activities of daily living (ADLs)

The nurse supervises an LPN/LVN administering an enema to a client. The nurse determines the LPN/LVNs actions are appropriate if which action is observed?

The LPN/LVN positions the client left Sims' position

Prior to sending a client for a cardiac catheterization, it is most important for the nurse to report which information?

The client has an allergy to shellfish

At 32 weeks gestation, the client has an order for an ultrasound. The nurse determines that the client understands the procedure if the client makes which statement?

The results will inform us of the baby's size

The nurse administers oral verapamil to a client. Which assessments does the nurse make before administering the medication?

The client's heart rate

The nurse cares for the client diagnosed with a pneumothorax resulting from a motor vehicle accident three days ago. The client has a chest tube connected to a three-chamber water-seal drainage system with 20 cm suction. The nurse determines the lung has re-expanded if which observation is made?

The fluid in the water-seal chamber does not fluctuate with respirations

The nurse cares for the elderly client admitted with a possible fractured right hip. During the initial nursing assessment, which observation of the right leg validates this diagnoses?

The leg appears to be shortened and is adducted and externally rotated

The parents of a child diagnosed with hemophilia ask the nurse to explain the cause of the disease. Which response by the nurse is best?

The mother transmits the gene to her son

In the process of a normal adjustment to a terminal illness, the nurse knows that the client's initial denial and isolation will give way to the second stage. The second stage is characterized by which behavior?

Anger

During the mothers' fourth stage of labor, the nurse palpates the client's fundus in which location?

Around the umbilics

The nurse cares for clients in a drug rehabilitation facility. Which complication of IV drug abuse is the nurse most likely to observe?

Cellulitis

The nurse knows that cortisol is responsible for which action?

Converting proteins and fat into glucose

The middle-aged client is admitted to an inpatient psychiatric unit. The client reports a family member is trying to steal the client's property. The client is diagnosed with paranoid disorder. The nurse suspects the client is demonstrating which symptoms?

Delusions of persecution

The nurse prepares the adult client diagnosed with intellectual delay for discharge. The HCP ordered warfarin sodium, 5 mg each day. To maintain client safety, which action does the nurse take first?

Determines the client's comprehension of the medication administration.

The nurse collects the following data: anger directed by client toward staff in the form of frequent sarcastic or crude comments, increased wringing of hands, and purposeless pacing, particularly after the client has used the telephone. On the basis of the data, the nurse makes which nursing diagnosis?

Difficulty with coping

Which type of foods does the nurse encourage for the client diagnosed with hypoarathyroidism

Foods high in calcium

The nurse provides care for a client with a tracheostomy. Which is the priority nursing diagnosis for this client?

Inadequate airway clearance

The HCP inserts a temporary pacemaker in a client following a myocardial infarction. The nurse knows that which outcome is the primary purpose of the pacemaker

Increased the cardiac output

The 18-month-old is admitted to the unit with a diagnosis of laryngotracheobronchitis (LTB). During the initial assessment, the nurse expects to find which early symptoms?

Inspiratory stridor and restlessness

The nurse cares for the prenatal client at 8 weeks gestation with a positive VDRL. When the nurse prepares the teaching plan, it is most important for the nurse to include which information?

Instruct the client about the importance of taking all the medication

The client is evaluated for infertility, and the HCP prescribes clomiphene citrate 50 mg daily for 5 days. The client asks the nurse how the medication works. Which response by the nurse is best?

Clomiphene citrate induces ovulation by changing hormonal effects on the ovary

The nurse cares for a client receiving chlorpromazine. The nurse notes the client is restless, unable to sit still, and reports insomnia and fine tremors of the hands. Which does the nurse identify as the best explanation for these symptoms occurring?

Extrapyramidal adverse effects resulting from this medication

The nurse knows that according to Erikson's stages of psychosocial development, which developmental stage best represent a 50 year old client?

Generativity versus stagnation

Which symptoms alert the nurse to consider an alcohol problem in a client hospitalized for a physical illness?

- tremors - elevated temperature - nocturnal leg cramps

The nurse leads a parenting class for a group of expectant clients. How many extra calories a day does the nurse advice the clients to consume to support breastfeeding?

500

The nurse cares for the postoperative client diagnoses with type 2 diabetes controlled with oral antihyperglycemic agents. The client asks why the health care provider ordered subcutaneous insulin injections after surgery. The nurse's response is based on knowing which physiological process?

Being NPO inhibits normal blood glucose control

The nurse cares for the child diagnoses with pediculosis capitis (head lice) who is being treated with permethrin 1% cream rinse. The nurse includes which information when instructing the child's parents?

Repeat the application of the cream rinse in 7 days if nits are still present

The nurse cares for an older client scheduled for a colon resection this morning. The nurse notes the client had polyethylene glycol-electrolyte solution and a soapsuds enema the previous evening. This morning the client passes a medium amount of soft brown stool. Which conclusion by the nurse is most accurate?

The bowel preparation is incomplete

The nurse performs the Rinne test on a client. Which is an accurate statement of how the first part of this test is performed?

The stem of a vibrating tuning fork is held against the mastoid bone until the client indicates sound can no longer be heard

The nurse recognizes which symptoms are early signs of lithium toxicity?

- fine motor tremors - nausea and vomiting - diarrhea

The nurse on a psychiatric unit of the hospital declines the client's request to organize a party on the unit for the client's friends. The client becomes angry and uses abusive language toward the nurse. Which statement indicates the nurse has an understanding of the client's behavior?

Abusive language is one of the behaviors symptomatic of the client's illness

the nurse identifies which finding has the greatest impact on the elderly's ability to complete activities of daily living (ADLs)?

Apraxia

The HCP orders naproxen sodium for the elderly client. The nurse assesses the client for which symptoms?

Fluid retention and dizziness

The toddler diagnosed with lead poisioning is admitted to the peds unit. The HCP writes an order to encourage fluids. Which fluid is best for the nurse to offer to the toddler?

Milk

The parent of a child with chickenpox asks the clinic nurse why the child will not come down with chickenpox again if exposed to the virus at school at a later date. Which explanation does the nurse give?

Natural active immunity occurs because the child's body actively makes antibodies against the chickenpox virus

A postoperative cataract client is cautioned about not making sudden movements or bending over. The nurse understands that the rationale for this recommendation is to prevent which complication?

Pressure on the ocular suture line

The nurse cares for the client diagnosed with type 1 diabetes reporting decreased vision. The client asks the nurse what caused the visual changes. The nurse's response is based on which statement?

The clients decreased vision is caused by gradual destruction and degeneration of the retina

The 6-month-old is brought to the clinic for a well-baby checkup. During the exam, the nurse expects to observe which assessment findings?

- Sitting with support - Playing peek-a-boo - Rolling from back to abdomen

The nurse cares for clients in the outpatient clinic. In which order will the nurse return the messages?

1. The "soft spot" on the head of the 4 day old feels slightly elevated when asleep 2. The circumcision site of the 3 day old is slightly swollen 3. The umbilical cord of the 5 day old is soft and draining exudate 4. When bed is bumped, a 2 day old rapidly extends the extremities

The nurse cares for the client receiving docusate 100 mg through a gastric tube. The solution contains 150mg/15 ml. The nurse administers how many mls of the solution to the client?

10ml

The nurse cares for the client receiving D5 0.45% NS 1,000 ml to run from 0900 to 1700. The drip factor on the delivery tubing is 20 gtt/ml. At what rate does the nurse set the IV to drip?

42 gtt/min

The child is in the early stages of nephrotic syndrome. The nurse discusses which dietary change with the parents?

Adequate protein, low sodium intake

The nurse cares for the newborn infant diagnoses with fetal alcohol syndrome. The nurse expects to see which characteristics?

An infant with a small head circumference, low birth and undeveloped cheekbones

The nurse is discussing growth and development with the parents of a 4-year-old child. The nurse identifies which type of play as characteristic of this age group?

Associate play

The nurse cares for the client admitted with a diagnosis of a stroke and facial paralysis. Nursing care is planned to prevent which complication?

Corneal abrasion

The 7 year old child is seen in the clinic with a diagnosis of pituitary dwarfism. Which clinical manifestation is the nurse most likely to observe?

Delicate features

The nurse identifies the primary reason for elderly adults to have problems with constipation is because of which process?

Elderly adults engage in less activity and have decreased GI muscle tone

The client, gravida 2 para 1, is admitted with hypertension. The client reports her wedding band is tight. The nurse assesses for which indications of mild pre-eclampsia?

Facial swelling nd proteinuria

The HCP orders hydromorphone hypochloride 15 mg IM for a client. The nurse observes for which adverse effects?

Hypotension and respiratory depression

A client with an endotracheal tube requires suctioning. Which statement is an accurate description of how the nurse performs the procedure?

Inserts the suction catheter until resistance is met, and then withdraws it slightly. Applies suction intermittently as the catheter is withdrawn.

Which action is the best way for the nurse to assess the fluid balance of an elderly client?

Maintain an accurate intake and output

The adolescent is brought to the hospital for treatment of deep partial thickness and full thickness burns sustained in a house fire. An intravenous infusion is started in the client's left forearm. The nurse identifies which reason as the primary purpose for the IV?

Maintain fluid balance

The nurse cares for a 3 month old infant scheduled for a barium swallow in the morning. Prior to the procedure, it is most appropriate for the nurse to take which action?

Make the infant NPO for 3 hours

The nurse cautions the client with hypothyroidism to avoid which implementation?

Narcotic sedatives

The nurse knows which mood-altering drug is most often associated with an increased risk for HIV infection related to IV drug use?

Narcotics

A client comes to the outpatient psychiatric clinic for treatment of a fear of heights. The nurse knows that phobias involve which behaviors?

Projection and displacement

The nurse cares for the client receiving a blood transfusion for approximately 30 minutes. Which symptom indicates a severe allergic reaction is occurring?

Respiratory wheezing

Which observation suggests to the nurse the client had developed an Addisonian crisis?

Restlessness and rapid, weak pulse

The home care nurse visits a new parents and a 2-week-old infant. The client askes the nurse which solid foods to give the child first. Which response does the nurse give?

Rice cereal is usually the first solid food and is started around 4 to 5 months

Which information does the nurse recognize as being the most pertinent to the diagnosis of cholecystitis?

Right upper abdominal pain

Several days after the delivery of a stillborn, the parents say, "We wish we could talk with other couples who have gone through this trauma." Which response by the nurse is best?

SHARE will provide you with this opportunity.

The nurse cares for the client with ataxia. Which action is most important?

Supervise ambulation

The nurse prepares the older client for an IV pyelogram IVP. The client asks the nurse to explain the reason why the procedure is performed. The nurse's response is based on which explanation?

The HCP is able to examine the urinary tract by x-ray

Which statement is documented by the nurse to reflect a client's emotional adjustment to being hospitalized in the ICU?

The client constantly calls for nurses and cries uncontrollably

The nursing team consists of an RN practicing for 6 mo, LPN practicing for 15 yrs, and a nursing assistive personnel who has been caring for clients for 3 yrs. The RN cares for which client?

The client ordered to receive two units of packed cells.

Which is the most important for the rehabilitation nurse to assess during a new client's admission?

The client's personal goals for rehabilitation

The nurse prepares a teaching plan regarding colostomy irrigation. The nurse includes which information?

The colostomy needs to be irrigated at the same time every day

The outpatient clinic nurse cares for an elderly client diagnosed with type 1 diabetes. Because the client is unwilling to perform blood glucose monitoring, the client tests urine for glucose and acetone. The nurse knows that blood glucose monitoring is preferred over urine testing for glucose because of which reason?

The renal threshold for glucose is elevated in the elderly

The client develops a postoperative infection and receives ceftriaxone sodium IV every day. It is most important for the nurse to monitor for which changes?

The surface of the tongue

The HCP writes an order for a state dose of morphine 4 mg IV for pain. Three hours later the client again reports pain, and the nurse administers a second injection of morphine. Which best describes the nurse's liability?

There is no order for a second dose of medication; the nurse is liable

The client in labor is monitored with an internal fetal monitor. The nurse knows which is the most important reason for the fetal monitor?

To monitor the oxygen status of the fetus during labor

The HCP orders mannitol for the client with a closed head injury. Which response does the nurse recognize as desired to this medication?

Urinary output increases to 175ml/hr

The nurse cares for a client diagnoses with gastric reflux due to a hiatal hernia. The client asks the nurse why food and fluids should withheld just before going to bed. Which response by the nurse is most appropriate?

You are less likely to awaken during the night with heartburn if the stomach is empty