50 questions Comprehensive review
The nurse is discussing foot care with a diabetic client and the spouse. The nurse includes which instruction during this informational session? 1.Nausea 2.Diarrhea 3.Headache 4.Sore throat 1.The toenails should be cut straight across. 2.Strong soap should be used to decrease skin bacteria. 3.There is decreased risk of infection when feet are soaked in hot water. 4.Lanolin should be applied to dry feet, especially the heels and between the toes.
1
A client arrives at the emergency department following a blow to the eye from a softball. Which intervention should be implemented by the nurse initially? 1.Apply ice to the affected eye. 2.Perform a thorough eye examination. 3.Irrigate the eye with sterile, cool water. 4.Place the client in a supine position on a stretcher.
1
A client with arthritis of the hands and fingers is having difficulty using a metered-dose inhaler (MDI). The nurse suggests asking the primary health care provider for which prescription? 1.Use of a spacer 2.Use of a nebulizer 3.Use of an oral (pill) form of the medication 4.Use of an intravenous (IV) form of the medication
1
A 16-year-old child is brought to the emergency department by his mother with a complaint that the child just experienced a tonic-clonic seizure. On arrival in the emergency department no apparent seizures were occurring. The mother states that her son is taking medication for the seizure disorder. The nurse plans care, knowing that which medications are used for long-term control of tonic-clonic seizures? Select all that apply. 1.Diazepam 2.Alprazolam 3.Gabapentin 4.Ethosuximide 5.Carbamazepine 6.Methylphenidate
3, 4, 5
The nurse is asked to regulate the flow rate of an intravenous (IV) solution being administered to a client. The IV bag contains 50 mL of solution and the solution is to be administered over 30 minutes. The administration set has a drop factor of 10 drops (gtts)/mL. The nurse should regulate the roller clamp on the infusion set to deliver how many drops per minute? Fill in the blank. Round answer to the nearest whole number.
17
A client scheduled for a skin biopsy asks the nurse how painful the procedure is. The nurse should make which response to the client? 1."There is no pain associated with this procedure." 2."The local anesthetic may cause a burning or stinging sensation." 3."A preoperative medication will be given so you will be sleeping and will not feel any pain." 4."There is some pain, but the health care provider will prescribe an analgesic following the procedure."
2
The nurse is reading about the four different levels of anxiety. Which different categories distinguish and describe each level? Select all that apply. 1.Effects on environment 2.Dysfunctional behavior 3.Effects on problem solving 4.Effects on perceptual field 5.Healthy reaction necessary for survival 6.Physical and other defining characteristics
3, 4, 6
A client complaining of not feeling well is seen in a clinic. The client is taking several medications for the control of heart disease and hypertension. These medications include a beta blocker, digoxin, and a diuretic. A tentative diagnosis of digoxin toxicity is made. Which assessment data supports this diagnosis? 1.Dyspnea, edema, and palpitations 2.Chest pain, hypotension, and paresthesia 3.Double vision, loss of appetite, and nausea 4.Constipation, dry mouth, and sleep disorder
3
The nurse is providing care to a Cuban-American client who is terminally ill. Numerous family members are present most of the time, and many of the family members are very emotional. Which nursing action is most appropriate? 1.Restrict the number of family members visiting at one time. 2.Inform the family that emotional outbursts are to be avoided. 3.Contact the primary health care provider (PHCP) to speak to the family regarding their behavior. 4.Request permission to move the client to a private room, and allow the family members to visit.
4
The nurse is assisting in monitoring a pregnant client receiving nalbuphine for pain management. Which statement is true with regard to the use of nalbuphine? 1.Sleepiness is not likely to occur during the labor process. 2.An amnesic effect is not associated with the use of nalbuphine. 3.Nalbuphine can be used for a client with an opioid dependency. 4.Nalbuphine is not likely to cause significant respiratory depression.
4 Nalbuphine is an opioid agonist-antagonist analgesic. It provides adequate analgesia without causing significant respiratory depression in the mother or neonate. It is not suitable for women with an opioid dependence because the antagonist activity could precipitate withdrawal symptoms (abstinence syndrome) in the mother and her newborn.
The nurse is employed in a long-term care facility as a charge nurse of the night shift. The nurse determines that as a charge nurse, authority appropriately refers to which explanation? 1.Being responsible for what the staff members do 2.Accepting the responsibility for the actions of others 3.Carrying the legal responsibility for the task performance of others 4.The official power to approve an action, command an action, or to see that a decision is enforced
4 The official power to approve an action, command an action, or to see that a decision is enforced
The nurse is assisting in admitting a client who is suspected of having tuberculosis (TB) to the nursing unit. The nurse plans to admit the client to which type of room? 1.Venting through single filters and ultraviolet light 2.Natural lighting with three air exchanges per hour 3.One air exchange per hour and venting to the outside 4.Venting to the outside, six air exchanges per hour, and ultraviolet light
4 Venting to the outside, six air exchanges per hour, and ultraviolet light
A client with diabetes mellitus who takes insulin is seen in the health care clinic. The client tells the nurse that after giving the injection, the insulin seems to leak through the skin. The nurse can appropriately determine the problem by asking the client which? 1."Are you rotating the injection site?" 2."Are you aspirating before you inject the insulin?" 3."Are you using a 1-inch needle to give the injection?" 4."Are you placing an air bubble in the syringe before injection?
1
A primary health care provider prescribes a 24-hour urine collection for vanillylmandelic acid (VMA). The nurse instructs the client in the procedure for the collection of the urine. Which statement by the client would indicate a need for further teaching? 1."I can take any medications if I need to before the collection." 2."When I start the collection, I will urinate and discard that specimen." 3."I will pour the urine into the collection bottle each time I urinate and refrigerate the urine." 4."I will start the collection in 2 days. I cannot eat or drink any tea, chocolate, vanilla, or fruit until the test is completed."
1
The nurse employed in a psychiatric unit receives a client assignment for the day. Which client assigned to the nurse is at the highest risk for committing suicide? 1.A client with severe depression and terminal cancer 2.A client who just had an argument with another client 3.A newly divorced client who has custody of the children 4.A client with mild depression and severe cognitive deficits
1
A woman who is 8 weeks pregnant complains to the nurse about nausea. Which advice should the nurse provide to this client about ways to assist with this problem? Select all that apply. 1.Avoid greasy foods. 2.Eat 5 to 6 small meals each day. 3.Do not drink fluids with meals. 4.Eat highly spiced foods only in evening hours. 5.Refrain from eating anything for 2 to 3 hours after arising.
1, 2, 3
A client receiving long-term therapy with lithium carbonate has a toxic serum lithium level of 1.5 and 2 mEq/L. Which organ functions are the major long-term risk factors? Select all that apply. 1.Renal function 2.Cardiac function 3.Thyroid function 4.Endocrine function 5.Respiratory function 6.Musculoskeletal function
1, 3
The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions by the nurse would be contraindicated? Select all that apply. 1.Restrain the client's limbs. 2.Loosen restrictive clothing. 3.Consider insertion of a padded tongue blade. 4.Remove the pillow and raise the padded side rails. 5.Position the client to the side, if possible, with head flexed forward.
1, 3
The nurse is planning care for a pediatric client experiencing thyrotoxicosis (thyroid storm). Which prescribed medications should the nurse plan to administer? Select all that apply. 1.Atenolol 2.Tramadol 3.Propranolol 4.Methimazole 5.Levothyroxine
1, 3, 4
In planning activities for the depressed client, especially during the early stages of hospitalization, which action is best? 1.Plan nothing until the client asks to participate in the milieu. 2.Encourage the client to participate in a structured daily program of activities. 3.Give the client a menu of daily activities and insist that the client participate in all activities offered. 4.Provide an activity that is quiet and solitary in nature to avoid increased fatigue, such as drawing or reading a book.
2
The nurse instructs a client on pursed-lip breathing and asks the client to demonstrate the breathing technique. Which observation by the nurse indicates that the client is performing the technique correctly? 1. The client breathes in through the mouth. 2.The client breathes out slowly through the mouth. 3.The client avoids using the abdominal muscles to breathe out. 4.The client puffs out the cheeks when breathing out through the mouth.
2
The nurse is collecting data from a client who has a history of untreated cataracts. The nurse checks the client for which associated manifestation? 1.A blank spot in the field of vision 2.Difficulty with driving a car at night 3.Pain in the eyes when in dim light 4.Either excessive itching or tearing of the eyes
2
The police arrive at the emergency department with a client who has seriously lacerated both wrists. Which is the initial nursing action? 1.Administer an antianxiety agent. 2.Examine and treat the wound sites. 3.Secure and record a detailed history. 4.Encourage and assist the client with venting their feelings.
2
Which action, if noted in the new mother, indicates the need for further data collection by the nurse for signs of postpartum depression? 1.The mother is caring for the infant in a loving manner. 2.The mother constantly complains of tiredness and fatigue. 3.The mother demonstrates an interest in the surroundings. 4.The mother looks forward to visits from the father of the newborn.
2
The nurse monitors the laboratory data on a client at risk for coronary artery disease. A fasting blood glucose reading of 200 mg/dL is recorded on the chart. The nurse analyzes this result as indicative of which finding? 1.Decreased, indicating a decreased risk of coronary artery disease 2.Elevated, but would not present a risk for coronary artery disease 3.Elevated, signaling the presence of diabetes mellitus, a risk factor of coronary artery disease 4.Normal, indicating adequate blood glucose control with no risk for coronary artery disease
3
The nurse caring for a client with abruptio placentae is monitoring the client for signs of disseminated intravascular coagulopathy (DIC). The nurse should suspect DIC if which is observed? 1.Rapid clotting times 2.Pain and swelling of the calf of one leg 3.Laboratory values that indicate increased platelets 4.Petechiae, oozing from injection sites, and hematuria
4 Rationale: DIC is a state of diffuse clotting in which clotting factors are consumed, which leads to widespread bleeding.
A client has received instructions on self-management of peritoneal dialysis. The nurse determines that the client needs further teaching if the client makes which statement? 1."I will monitor my weight daily." 2."I will take my vital signs daily." 3."I will use meticulous aseptic technique for dialysate bag changes." 4. ""I will use a strong adhesive tape to anchor the catheter dressing.
4 "I will use a strong adhesive tape to anchor the catheter dressing.
The nurse is assisting a school-age client with type 1 diabetes to follow an appropriate diet. Which recommendations should the nurse make for this client? Select all that apply. 1.Limit concentrated sweets. 2.Consume high-fat, high-protein snacks. 3.Consume snacks between meals and at bedtime. 4.Plan to eat a larger snack during active times of the day. 5.Ensure that calories will be limited to 1800 kcal a day.
1, 3, 4
The health care provider has prescribed morphine sulfate intravenous push for a client with pulmonary edema. Which therapeutic effects should the nurse expect in this client? Select all that apply. 1.Relief of anxiety 2.Decreased respiratory rate 3.Reduction of oxygen consumption 4.Prevention of cardiac dysrhythmias 5.Improvement in efficacy of breathing
1, 3, 5
The nurse reviews the client's serum calcium level and notes that the level is 8.0 mg/dL (2.0 mmol/L). The nurse understands that which condition would cause this serum calcium level? 1.Prolonged bed rest 2.Adrenal insufficiency 3.Hyperparathyroidism 4.Excessive ingestion of vitamin D
1 Rationale: The normal serum calcium level is 9 to 10.5 mg/dL (2.25-2.75 mmol/L). A client with a serum calcium level of 8.0 mg/dL (2.0 mmol/L) is experiencing hypocalcemia. The excessive ingestion of vitamin D, adrenal insufficiency, and hyperparathyroidism are causative factors associated with hypercalcemia. Although immobilization can initially cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia.
The nurse is collecting data from a client with a suspected diagnosis of gastric ulcer. The client tells the nurse that oral antacids are taken frequently throughout the day. The nurse continues to collect data from the client, understanding that the client is at risk for which acid-base disturbance? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis:
2
The nurse in charge of a nursing unit in a long-term care facility is concerned because staff members openly verbalize racial comments about clients on the unit. What should the nurse do to appropriately manage this concern? 1.Ignore the racial comments. 2.Discourage the racial comments. 3.Leave articles about racial prejudice in the nurse's lounge. 4.Report the racial comments to the grievance committee
2 Discourage the racial comments.
A client who has undergone barium enema is being readied for discharge. The nurse determines that the client has understood discharge instructions when the client makes which statement? 1."I will limit fluids." 2."I will continue on a low-fiber diet." 3."I will likely need to take a laxative fairly frequently from now on." 4."I will be sure the barium passes and watch for my stools to return to normal."
4 I will be sure the barium passes and watch for my stools to return to normal.
The nurse is talking with a client with angina about factors that can precipitate an angina attack. Which statement by the client indicates an understanding of the precipitating events? 1."I am going to run a mile each day." 2."I am going to switch to electronic cigarettes." 3."I will walk up two flights of stairs without stopping." 4."I will pay my neighbor to shovel my snow this winter."
4 I will pay my neighbor to shovel my snow this winter."
The client is suspected of having systemic lupus erythematous (SLE). The nurse monitors the client, knowing that which is one of the initial characteristic signs of SLE? 1.Weight gain 2.Subnormal temperature 3.Elevated red blood cell count 4. Rash on the face across the nose and on the cheeks
4 Rash on the face across the nose and on the cheeks
The nurse is teaching the client with myasthenia gravis about prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by which activity? 1.Eating large, well-balanced meals 2.Doing muscle-strengthening exercises 3.Doing all chores early in the day while less fatigued 4.Taking medications on time to maintain therapeutic blood levels
4 Taking medications on time to maintain therapeutic blood levels
A 1-year-old child is seen in the primary health care provider's office with complaints of an elevated temperature that began the previous evening. When gathering subjective data from the mother, the nurse notices that which sign/symptom would most likely indicate the child has acute otitis media? 1.The child is crying and irritable. 2.The temperature is 40° C (104° F). 3.The child is pulling at her ear and rolling her head from side to side. 4.The mother states the child had purulent discharge from the ear last night.
4 The mother states the child had purulent discharge from the ear last night.
A client diagnosed with chronic gastritis has been told that there is too little intrinsic factor being produced. The nurse should explain to the client that which therapy will be prescribed to treat the problem? 1.Antacid use 2.Antibiotic therapy 3.Vitamin B6 injections 4.Vitamin B12 injections
4 Vitamin B12 injections
The nurse is observing a client who is independently performing the application of an ostomy appliance for the first time. Which actions observed demonstrate the need for further teaching? Select all that apply. 1.Assess the stoma and skin. 2.Remove the used pouch and barrier. 3.Perform hand hygiene and don gloves. 4.Lightly scrub the stoma with soap and water. 5.Press the adhesive backing of the pouch against the skin. 6.Cut the opening on the appliance ½ inch larger than stoma.
4, 6
A 1-year-old child is admitted to the hospital for control of tonic-clonic seizures. The nurse should perform which actions in order to protect the child from injury? Select all that apply. 1.Restrict the client's fluid intake. 2.Turn the client to the side during a seizure. 3.Keep side rails and other hard objects padded. 4.Keep hospital room lights on all of the time. 5.Keep a padded tongue blade at the bedside for use during a seizure.
2, 3
The nurse is told in report that a client has a positive Chvostek's sign. Which other data should the nurse expect to find on data collection? Select all that apply. 1.Coma 2.Tetany 3.Diarrhea 4.Possible seizure activity 5.Hypoactive bowel sounds 6.Positive Trousseau's sign
2, 3, 4, 6
A client with a burn injury is applying mafenide acetate to the wound. The client calls the health care provider's office and tells the nurse that the medication is uncomfortable and is causing a burning sensation. Which instructions should the nurse reinforce to the client? 1.Discontinue the medication. 2.Apply a thinner film than prescribed to the burn site. 3.Continue with the treatment because this is expected. 4.Come to the office to see the health care provider immediately.
3
The client at 28 weeks' gestation is Rh negative and Coombs antibody negative. The nurse determines that the client understands what the nurse has taught her about Rh sensitization when the client makes which statement? 1."I know I can never have another child." 2."I am glad I won't have to have these shots if I have another child." 3."I will have to have an injection once a month until the baby is born." 4."I will tell the nurse at the hospital that I had an Rh shot during pregnancy."
4 "I will tell the nurse at the hospital that I had an Rh shot during pregnancy."
Trimethoprim-sulfamethoxazole is prescribed for a client. The nurse should instruct the client to report which symptom if it developed during the course of this medication therapy? 1.Nausea 2.Diarrhea 3.Headache 4.Sore throat
4 .Sore throat
The nurse is caring for a client who has been treated with long-term antipsychotic medication. The nurse plans to monitor for tardive dyskinesia. Which signs should the nurse observe with tardive dyskinesia? 1.Abnormal breathing through the nostrils 2.Severe headache, flushing, tremor, and ataxia 3.Severe hypertension, migraine headache, and "marbles in the mouth" syndrome 4.Abnormal movements and involuntary movements of the mouth, tongue, and face
4 Abnormal movements and involuntary movements of the mouth, tongue, and face
The nurse is reinforcing discharge instructions to a client following surgical treatment for carpal tunnel syndrome. Which statement by the client would indicate a need for further teaching? 1."I should elevate my arm to reduce the swelling." 2."I should use a sling to limit movement and keep my arm elevated." 3. "I should return to the primary health care provider in about 10 days to have the sutures removed." 4."I should perform pronation and supination exercises of my wrist starting 24 hours after surgery."
4 I should perform pronation and supination exercises of my wrist starting 24 hours after surgery."
The nurse is caring for the client diagnosed with tuberculosis (TB). Rifampin, 600 mg by mouth daily is prescribed for the client. The nurse reinforces instructions to the client regarding the administration of this medication. Which statement by the client indicates an understanding of the instructions? 1."I need to limit alcohol intake." 2."I need to take the medication with meals." 3."I will need to take the medication for months." 4."I need to call the primary health care provider if the color of my urine turns red-orange."
3
The nurse provides instructions to a client about the use of an incentive spirometer. The nurse determines that the client needs further teaching about its use if the client makes which statement? 1."I need to sit upright when using the device." 2."I will inhale slowly, maintaining a constant flow." 3."I need to place my lips completely over the mouthpiece." 4."After maximal inspiration, I will hold my breath for 10 seconds and then exhale."
4 After maximal inspiration, I will hold my breath for 10 seconds and then exhale
The nurse is collecting data on an infant with a diagnosis of suspected Hirschsprung's disease. Which question to the mother will most specifically elicit information regarding this disorder? 1."Does your infant have diarrhea?" 2."Is your infant constantly vomiting?" 3."Does your infant constantly spit up feedings?" 4."Does your infant have foul-smelling, ribbon-like stools?"
4 Does your infant have foul-smelling, ribbon-like stools?"
A client with suspected Guillain-Barré syndrome has a lumbar puncture performed. The cerebrospinal fluid (CSF) protein is 750 mg/dL. The nurse analyzes these results as which? 1.Normal 2.Lower than normal, ruling out Guillain-Barré 3.Not significant and unrelated to Guillain-Barré 4.Higher than normal, supporting the diagnosis of Guillain-Barré
4 Higher than normal, supporting the diagnosis of Guillain-Barré
