Exam 1 (Term 2) Study Guide
A client asks the nurse why expelled flatus is foul-smelling. What should the nurse respond? 1. The actions of microorganisms within the gastrointestinal tract are responsible for the odor. 2. The clients emotions are causing the gas formation. 3. The sensory nerves in the rectum are being stimulated. 4. The client has swallowed too much air while eating.
1
A client has a new order for a medication that does not have a termination date. The nurse would place this medication order under which classification on the clients medication administration record? 1. Standing 2. PRN 3. STAT 4. Single
1
A client has a spinal cord injury at the cervical spine area. The nurse realizes that this injury will affect which aspect of urinary elimination in the client? 1. Elimination of urine from the bladder 2. Ability of the kidneys to absorb solutes 3. Ureteral function 4. Urethra function
1
A client has experienced a narcotic overdose. What acidbase imbalance should the nurse expect to observe in this client? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
1
A client has received an oil retention enema. The nurse should instruct the client that the enema will take effect within 1. 1 to 3 hours. 2. 10 to 20 minutes. 3. 5 to 10 minutes. 4. 10 to 15 minutes.
1
A client is having a lumbar puncture. In which position should the nurse place the client? 1. Lateral with head bent toward the chest and knees flexed onto the abdomen 2. Lying prone, with the knees drawn up toward the abdomen 3. Sitting bent over from the waist with legs extended 4. Supine with knees pulled toward the chest
1
A client is prescribed a diagnostic test requiring a 24-hour stool specimen. What should this test indicate to the nurse? 1. Analyze the stool for dietary products and digestive secretions. 2. Detect the presence of bacteria or viruses. 3. Detect the presence of ova and parasites. 4. Determine the presence of occult blood.
1
A client is prescribed a saline enema. Because this solution is hypertonic, the nurse would expect the enema to cause which action? 1. Exerts osmotic pressure and draws fluid from the interstitial space into the colon 2. Exerts a lower osmotic pressure than the surrounding interstitial fluid 3. Exerts the same osmotic pressure as the interstitial fluid surrounding the colon 4. Stimulates peristalsis by increasing the volume in the colon and irritating the colon
1
A client is rushed to the emergency department with what the physicians suspect to be necrosis of the urinary diversion stoma. What evidence presented by the client leads to this conclusion? 1. Black with sloughing 2. Moist stoma 3. Pink and shiny 4. Slight bleeding from stoma
1
A client is to have an echocardiogram. Which statement by the client indicates the teaching about the test has been effective? 1. Im told this test causes no discomfort. 2. I will have to walk on a treadmill. 3. I will need to remain NPO. 4. I will need to take my pulse prior to the test.
1
A client tells the nurse about the need to get up several times throughout the night to void. The nurse suspects the client is experiencing nocturia due to which factor? 1. Decrease in bladder tone 2. Decrease in blood supply 3. Decrease in number of nephrons 4. Decrease in cardiac output
1
A client who has been prescribed a narcotic for chronic back pain is demonstrating signs of withdrawal. The nurse identifies these symptoms as being 1. physical dependence. 2. psychological dependence. 3. plateau. 4. drug allergy.
1
A nurse colleague learns that a grandchilds day-care center is planning a class on sexuality for 3- and 4-year-olds. Discussion of this plan should include what concept? 1. At this age, education regarding sexuality should come from parents. 2. Children are sexual beings from before birth. 3. Understanding the body and sexuality are a part of growth and development. 4. Sexual activity is beginning at earlier and earlier ages.
1
A research article the nurse is reading discusses the prevalence of androgyny in persons 20 to 30 years old. What should the nurse keep in mind when caring for clients who are androgynous? 1. They do not limit behaviors to one gender over the other. 2. They are attracted to people of the same gender. 3. They often repress their sexual feelings. 4. They hold rigid stereotyped gender role expectations.
1
An older client is having difficulty handling the specimen cup for a clean catch urine specimen. What can the nurse do to help this client? 1. Provide a clean funnel to pour the urine into the specimen cup. 2. Document that the specimen could not be obtained. 3. Catheterize the client for the specimen. 4. Ask the physician to obtain the specimen.
1
During a sexual assessment, a client tells the nurse about a preference for oralgenital sex. How should the nurse instruct this client? 1. Explain the need to follow safe sex practices. 2. Explain the need to use contraception. 3. Explain the importance of having an annual HIV test. 4. Explain thy routine gynecologic examinations are not necessary.
1
During administration of an intradermal injection, the nurse notices that the outline of the needle bevel is visible under the clients skin. How should the nurse proceed? 1. Recognize that this is an expected finding in a properly administered intradermal injection. 2. Withdraw the needle, prepare a new injection, and start again. 3. Insert the needle further into the skin at a deeper angle. 4. Turn the needle so that the bevel is down and inject the medication slowly, looking for development of a bleb.
1
The client has been placed on a 1200-mL oral fluid restriction. How should the nurse plan for this restriction? 1. Allow 600 mL from 73, 400 mL from 311, and 200 mL from 117. 2. Instruct the client that the 1200 mL of fluid placed in the bedside pitcher must last until tomorrow. 3. Offer the client softer, cold foods such as sherbet and custard. 4. Remove fluids from diet trays and offer them only between meals. Correct Answer: 1
1
The client is admitted to the acute care unit with a phosphorus level of 2.3 mg/dL. Which nursing intervention would support this clients homeostasis? 1. Encourage consumption of milk and yogurt. 2. Enforce strict isolation protocols. 3. Encourage consumption of a high-calorie carbohydrate diet. 4. Strain all urine.
1
The high school student tells the school nurse that during biology the class learned that alcohol is associated with erectile dysfunction. The student wonders why so many girls get pregnant during evenings when alcohol is consumed. The nurse should plan a response based upon which concept? 1. Alcohol is a central nervous system depressant that affects judgment. 2. Erectile dysfunction only occurs after years of alcohol abuse. 3. Alcohol is a sexual stimulant. 4. Erectile dysfunction occurs only in men older than 50.
1
The home care nurse is reviewing a list of clients prior to making visits. For which client should the nurse plan interventions to decrease the risk of developing constipation? 1. An adult who is on bed rest 2. An infant who is breast-fed 3. A school-age child at recess 4. A toddler who is now walking
1
The mother of a 1-month-old infant is concerned because the infant has had vomiting and diarrhea for 2 days. What instruction should the nurse give this infants mother? 1. Have the infant be seen by a physician 2. Give the infant at least 2 ounces of juice every 2 hours. 3. Measure the infants urine output for 24 hours. 4. Provide the infant with 50 mL of glucose water.
1
The nurse initiates a blood transfusion for a client. What action should the nurse take next? 1. Stay with the client and closely observe him for the first 5 to 10 minutes of the transfusion. 2. Assign the UAP to sit with the client for 15 minutes. 3. Advise the client to notify the nurse if he experiences any chilling, nausea, flushing, or rapid heart rate. 4. Return to the room and take a set of vital signs in 15 minutes.
1
The nurse is adding medication to an existing intravenous setup. Which nursing action is indicated? 1. Close the infusion clamp. 2. Ensure that the IV bag is full prior to adding medication. 3. Do not remove the IV bag from the pole. 4. Briskly shake the IV bag after injecting the medication.
1
The nurse is assessing a clients urinary elimination. Which factor should the nurse keep in mind as influencing this elimination? 1. Age 2. Body image 3. Knowledge 4. Socioeconomic status
1
The nurse is caring for a client who is receiving intravenous fluids that are not regulated on an electronic controller. In order to calculate the rate of the IV flow in drops per minute, the nurse must know the number of drops per milliliter of fluid the tubing delivers. Where should the nurse look for this information? 1. On the packaging of the tubing 2. In the charting from the nurse who started the infusion 3. In the drug reference book 4. On the roller clamp of the tubing
1
The nurse is caring for a client with a urinary diversion. For which type of diversion should the nurse plan care for this client? 1. Incontinent urinary diversion 2. The kock pouch. 3. Neobladder 4. Nephrostomy
1
The nurse is concerned that a client is at risk for the development of urinary tract infections. What did the nurse assess to come to this conclusion? 1. The client is wearing tight clothing. 2. The client is employed as a computer operator. 3. The client drinks 810 8-ounce glasses of water and low-calorie beverages each day. 4. The client exercises for 3060 minutes most days of the week.
1
The nurse is delegating activities regarding fecal elimination to unlicensed assistive personnel (UAP). Which activity can UAP safely perform to meet a clients fecal elimination needs? 1. Provide a fracture pan to a client on bed rest. 2. Provide a client who has a fecal impaction and prolapsed rectum with a cleansing enema. 3. Change a clients ostomy device. 4. Irrigate a clients ostomy.
1
The nurse is developing strategies for the relief of menstrual cramping to teach a group of young clients. What should be the focus of these strategies? 1. Increase of blood flow to the uterine muscle 2. Avoidance of uterine contraction 3. Minimization of menstrual flow 4. Decrease in estrogen production
1
The nurse is preparing educational materials to be used when instructing clients on testicular and breast self-examination. What would be applicable for both sets of instructions? 1. Perform palpation in the shower. 2. Perform the examination lying down. 3. Perform the examination once each week. 4. Perform the examination bimonthly.
1
The nurse is preparing to administer a medication that the agency designates as high alert. What action should the nurse take? 1. Ask another registered nurse to verify the medication. 2. Call the pharmacist to check the efficacy of the medication. 3. Decline to administer the medication unless there is a physician present. 4. Request that the nursing supervisor administer the medication.
1
The nurse is preparing to assess a clients fecal elimination status. Which activity will the nurse complete during this assessment? 1. Obtain a nursing history. 2. Interpret results of diagnostic tests. 3. Perform a physical examination. 4. Set goals with the client.
1
The nurse is preparing to collect a throat culture from a client. What client response indicates to the nurse that teaching about this test has not been effective? 1. I need to hyperextend my neck. 2. I need to say ah.' 3. I will need to sit up. 4. The nurse will use a light.
1
The nurse is providing medications to a client. After identifying the client, the nurse should take which action? 1. Inform the client as to the intended action of the medication. 2. Administer the drug. 3. Document that the drug was provided. 4. Evaluate the effectiveness of the drug.
1
The nurse is taking care of a client who states that he ignores the urge to defecate when he is at work. Which response should the nurse make to explain why this practice should be changed? 1. If you continue to ignore the urge to defecate, the urge is ultimately lost. 2. It is best to suppress the urge rather than suffer embarrassment at work. 3. This is a common practice, and it will strengthen the reflex later. 4. You will get the urge later; dont worry.
1
The nurse uses the PLISSIT format in helping clients who have sexual dysfunction. Which action by the nurse best reflects the SS section of this format? 1. Use the nurses knowledge about how disease affects sexuality to offer specific suggestions for the client. 2. Focus interventions on explaining the somatic sexual difficulties and their treatment. 3. Offer the client a list of expected sexual side effects of drugs or treatments. 4. Identify any concerns the client has regarding attraction to the same sex.
1
The nurse wants to delegate the application of a condom catheter to unlicensed assistive personnel (UAP). What must the nurse assess prior to delegating this task? 1. Assess whether the client has unique needs. 2. Measure the clients intake. 3. Assist the client out of bed to a chair. 4. Assess changes in the clients mobility status.
1
The parent of a 20-month-old is very concerned because the baby touches the genital area during diaper changes. How should the nurse respond to this concern? 1. At 20 months this touching is not a sexual experience. 2. Masturbation to orgasm is common and normal at this age. 3. Genital stimulation should not be occurring until the age of 2 1/2 or 3. 4. Babies are sexual beings, but this activity should be discouraged.
1
Which goals should the nurse identify as appropriate for a client with the nursing diagnosis Urinary Pattern Alteration related to an enlarged prostate? 1. The client will avoid bladder distention. 2. The client will maintain fluid imbalance. 3. The client will remain free of skin breakdown. 4. The client will voice increased discomfort.
1
While preparing to administer an eye ointment, the nurse inadvertently squeezes the tube, discarding the first bead of medication. What action should the nurse take at this point? 1. Administer the eye ointment as ordered, as the first bead of ointment should be discarded anyway. 2. Notify the pharmacy and request a new, unopened tube of ointment. 3. Have a second licensed nurse witness the waste and sign the chart. 4. Continue to squeeze the tube until a clear line of ointment has been discarded from the tip.
1
A client tells the nurse about rarely feeling thirsty. The nurse realizes that further assessment is needed to evaluate Standard Text: Select all that apply. 1. status of osmotic pressure. 2. vascular volume. 3. presence of angiotensin. 4. urine output. 5. body weight.
1,2,3
The nurse is preparing to assess a clients sexual health. What will the nurse include in this assessment? Standard Text: Select all that apply. 1. Sexual self-concept 2. Body image 3. Gender identity 4. Contraceptive choices 5. Employment
1,2,3
A client has occasional bouts of constipation, and asks the nurse what can be done to prevent these episodes in the future. What should the nurse instruct the client to do? Standard Text: Select all that apply. 1. Establish a regular exercise regimen. 2. Include high-fiber foods, such as vegetables, fruits, and whole grains, in the diet. 3. Maintain fluid intake of 2000 to 3000 mL a day. 4. Do not ignore the urge to defecate. 5. Use over-the-counter medications to treat constipation.
1,2,3,4
The nurse has completed care with a client who has a new ostomy. What should the nurse document about the care provided? Standard Text: Select all that apply. 1. Any change in stoma size 2. Condition of the skin around the stoma 3. Amount and type of drainage 4. Clients response to the procedure 5. Degree of bowel sounds after care provided
1,2,3,4
The nurse is preparing medications for a client. What should the nurse do to ensure that the correct medication is provided to the client? Standard Text: Select all that apply. 1. Make sure it is the right client. 2. Make sure it is the right medication. 3. Make sure it is the right dose. 4. Make sure it is the right route. 5. Make sure it is for the right diagnosis.
1,2,3,4
The nurse is performing ostomy care for a client. Place in order the steps the nurse will perform to do this care. Standard Text: Click and drag the options below to move them up or down. Choice 1. Clean and dry the peristomal skin and stoma. Choice 2. Prepare and apply the skin barrier. Choice 3. Empty the pouch and remove the ostomy barrier. Choice 4. Assess the stoma and peristomal skin. Choice 5. Apply the pouch. Choice 6. Place a piece of tissue or gauze over the stoma and change it as needed.
1,2,3,4,5,6
An older client tells the nurse that in order to have a daily bowel movement, the client uses laxatives most days of the week. What should the nurse tell this client? Standard Text: Select all that apply. 1. Normal patterns of elimination are different for everyone. 2. Increase fiber intake to 2035 grams a day. 3. Engage in enjoyable exercise. 4. Ignore the urge to have a bowel movement. 5. Drink six to eight glasses of fluid daily.
1,2,3,5
The nurse is instructing a client on ways to manage stress urinary incontinence. What should be included in this clients teaching? Standard Text: Select all that apply. 1. Limit intake of caffeine. 2. Limit intake of alcohol. 3. Increase intake of citrus juices. 4. Limit evening fluid intake. 5. Increase intake of beverages with artificial sweeteners.
1,2,4
When discussing the orgasmic phase of the sexual response cycle, what should the nurse include as physiological changes that affect both sexes? Standard Text: Select all that apply. 1. The respiratory rate can increase up to 40 breaths per minute. 2. Involuntary muscle spasms occur throughout the body. 3. The heart rate decreases to 20 beats below normal. 4. Systolic blood pressure can increase 2030 mm Hg above normal. 5. Diastolic blood pressure can decrease 2050 mm Hg below normal.
1,2,4
A client is prescribed a medication to be administered through the parenteral route. The nurse would expect that this medication will be provided through which method? Standard Text: Select all that apply. 1. Subcutaneous injection 2. Intramuscular injection 3. The oral route 4. Intradermal injection 5. Intravenous infusion
1,2,4,5
The nurse has provided an otic medication to a client. What should the nurse document about this medications administration? Standard Text: Select all that apply. 1. Name of the drug 2. The strength 3. The appetite of the client 4. The number of drops 5. The response of the client
1,2,4,5
The nurse is caring for a client who has just had a lumbar puncture. What should the nurse document about this clients procedure? Standard Text: Select all that apply. 1. Date and time performed 2. The physicians name 3. The clients ability to void after the procedure 4. The color, character, and amount of cerebrospinal fluid withdrawn 5. The clients status after the procedure
1,2,4,5
During an assessment, the nurse notes that a clients stool is black. Which medication should the nurse consider as causing this clients change in stool color? Standard Text: Select all that apply. 1. Iron 2. Aspirin 3. Antacids 4. Antibiotics 5. Pepto-Bismol
1,2,5
The nurse who is teaching a client breast self-examination describes inspection of the breasts before a mirror. Which findings should the nurse tell the client should be evaluated by a health care provider? Standard Text: Select all that apply. 1. Puckering of the skin 2. Flattening of the breast from the side view 3. Free movement of the breast over the chest wall 4. Symmetry of the nipples 5. Change in shape
1,2,5
A client is complaining of pain with urination. The nurse realizes that the client needs to be assessed for which health problems? Standard Text: Select all that apply. 1. Urethral stricture 2. Renal failure 3. Urethral injury 4. Bladder injury 5. Urinary infection
1,3,4,5
An older female client with a history of urinary tract infections has an indwelling urinary catheter. What should the nurse do to reduce this clients risk of developing an infection because of the catheter? Standard Text: Select all that apply. 1. Maintain a sterile closed drainage system. 2. Clean the peri-urethral area with antiseptics. 3. Ensure the catheter and tubing are not kinked. 4. Wash his or her hands before manipulating the catheter. 5. Keep the collection bag below the level of the bladder.
1,3,4,5
The nurse is caring for a client with a fecal incontinence pouch. What should the nurse do when caring for this client? Standard Text: Select all that apply. 1. Assess perianal skin. 2. Irrigate the pouch every shift. 3. Maintain the drainage system. 4. Change the bag every 72 hours. 5. Explain the purpose of the system to the client.
1,3,4,5
A client has just completed a bone marrow biopsy. What should the nurse document about the client at this time? Standard Text: Select all that apply. 1. Clients tolerance of the procedure 2. Bowel sounds 3. The site for bleeding 4. Status of deep tendon reflexes 5. Presence of pain and any pain medication received
1,3,5
A client is prescribed an oral medication. When reviewing this medication, the nurse realizes it might not be the route of choice for this client because the client is experiencing Standard Text: Select all that apply. 1. nausea. 2. anxiety. 3. vomiting. 4. pain from cuts and abrasions. 5. irritated gastric mucosa.
1,3,5
A client is scheduled for a bronchoscopy. What should the nurse instruct the client about this procedure? Standard Text: Select all that apply. 1. Tissue samples may be taken for biopsy. 2. Eating will not be permitted for 12 hours. 3. A local anesthetic is sprayed on the throat. 4. Bed rest for 8 hours is necessary after the test. 5. Informed consent is required for this procedure.
1,3,5
After an assessment, the nurse determines that a client has strong sexual health. What did the nurse assess in the client? Standard Text: Select all that apply. 1. Knowledge about sexual behavior 2. Reluctance to discuss sexual history 3. Utilization of birth control method that fits lifestyle 4. Statement that there are no issues with sexuality 5. Discussing sexual problems with healthcare provider
1,3,5
The nurse is documenting the insertion of a retention catheter for a client. What should be included in this documentation? Standard Text: Select all that apply. 1. Catheter size 2. Location of the drainage bag 3. Amount of urine that drained after insertion 4. Name of the physician who prescribed the insertion of the catheter 5. Client tolerance of the procedure
1,3,5
The nurse is teaching a class of young adult men and women. What self-examination schedules should the nurse instruct these participants to follow? Standard Text: Select all that apply. 1. Monthly breast self-exams for women 2. Yearly breast self-exams for men 3. Weekly testicular self-exams for men 4. Monthly breast self-exams for men 5. Yearly vulvar self-exams for women
1,4
A client tells the nurse that the pharmacy will not fill a prescription that was written by the physician. Upon closer examination, what should the nurse determine is missing from the prescription? Standard Text: Select all that apply. 1. Rx symbol 2. Clients diagnosis 3. Clients Social Security number 4. Dispensing instructions for the pharmacist 5. Number of refills
1,4,5
The nurse needs to obtain a urine specimen from a client with an indwelling urinary catheter. What should the nurse do when collecting this specimen? Standard Text: Select all that apply. 1. Withdraw 30 mL of urine for a routine urinalysis. 2. Perform catheter care before obtaining the specimen. 3. Apply sterile gloves before retrieving the urine specimen. 4. Send the specimen immediately or refrigerate it for later pickup. 5. Clamp the drainage tubing for 30 minutes if there is no urine in the catheter.
1,4,5
A clients urine pH is 8.0. What further assessments would be indicated for this client? Standard Text: Select all that apply. 1. Intake of fruits and vegetables 2. Intake of cranberries 3. Intake of high-protein foods 4. Symptoms of diarrhea 5. Symptoms of a urinary tract infection
1,5
The nurse is preparing to discontinue a clients intravenous infusion. Which actions should the nurse take when removing the catheter from the vein? Standard Text: Select all that apply. 1. Pull the catheter out in line with the vein 2. Apply pressure to the site while removing the catheter. 3. Pull the catheter out at an angle perpendicular to the vein. 4. Bend the clients elbow if bleeding at the site persists after removal. 5. Apply pressure to the site after the catheter is removed for 2 to 3 minutes.
1,5
A client asks the RN why it is more difficult to use a bedpan for defecating than sitting on the toilet. Which would be the nurses best response? 1. The sitting position decreases the contractions of the muscles of the pelvic floor. 2. The sitting position increases the downward pressure on the rectum, making it easier to pass stool. 3. The sitting position increases the pressure within the abdomen. 4. The sitting position inhibits the urge to urinate, allowing one to defecate.
2
A client has a bowel movement of hard, dry, but formed stool. The nurse associates these characteristics with 1. bowel incontinence. 2. constipation. 3. diarrhea. 4. fecal impaction.
2
A client has been admitted with incontinence. What should the nurse expect to assess in this client? 1. Client is wearing cotton undergarments. 2. Leakage of urine occurs when client laughs. 3. Leakage of urine occurs when talking with the client. 4. The skin of the client is clear without discoloration.
2
A client has had a subclavian central venous catheter inserted. What should the nurse assess as a priority for this clients care? 1. Presence of bibasilar crackles 2. Tachycardia 3. Decreased pedal pulses 4. Headache
2
A client is admitted to the hospital after vomiting for 3 days. Which arterial blood gas results should the nurse expect to find in this client? 1. pH 7.30; PaCO2 50; HCO3 27 2. pH 7.47; PaCO2 43; HCO3 28 3. pH 7.43; PaCO2 50; HCO3 28 4. pH 7.47; PaCO2 30; HCO3 23
2
A client is being treated for tuberculosis, and the doctor writes an order to collect a sputum specimen. What is the rationale behind this order? 1. To test for acid-fast bacillus 2. To assess the effectiveness of therapy 3. To identify origin, structure, function, and pathology of cells 4. To identify the specific organism
2
A client is having issues with urinary elimination. What should the nurse instruct this client to promote urinary elimination? 1. Dont interrupt your day by going to the bathroom; wait until youre at a good stopping place. 2. Drink 8 to 10 glasses of water daily. 3. Urine color changes are not important. 4. Wash with soap and water every other day.
2
A client is prescribed a new medication. The pharmacy notifies the nurse that the dosage is outside of route prescribing limits. The nurse is unable to reach the prescribing physician about the order. What should the nurse do? 1. Give the medication to the client as prescribed. 2. Withhold the medication. 3. Give one-half of the medication dose prescribed. 4. Administer the medication through the oral route.
2
A client is prescribed propranolol (Inderal). What should the nurse instruct the client about this medication? 1. The medication should be discontinued abruptly. 2. Notify the physician if you experience urinary retention. 3. Take a laxative every day. 4. Take the medication on an empty stomach.
2
A client is prescribed to receive a cleansing enema. What should the nurse instruct the client prior to administering this enema? 1. Hold the solution for a short time. 2. Lie in the left lateral position. 3. Lie in the right lateral position. 4. Take fast breaths through the nose.
2
A client is scheduled for a nuclear imaging test. What should the nurse instruct the client about this test? 1. It is the use of a magnetic field to produce an image of a body part or organ. 2. A radioisotope will be injected to determine organ functioning as being either hot or cold. 3. It produces a three-dimensional image of an organ. 4. It is more sensitive than an x-ray image.
2
A client recovering from a transurethral resection of the prostate (TURP) with a three-way indwelling catheter expresses the need to urinate. Which action should the nurse take to help this client? 1. Deflate and then reinflate the balloon. 2. Irrigate the catheter. 3. Reposition the catheter. 4. Retape the catheter to the abdomen.
2
A hospitalized client tells the nurse of the inability to have a bowel movement because too many people are around. What should the nurse do to promote normal fecal elimination for this client? 1. Provide a laxative. 2. Assist the client to the bathroom to ensure privacy. 3. Restrict fluids. 4. Assist the client with ambulation.
2
A young adult single mother of a second-grade child has to make a decision regarding the teacher her child will have in third grade and asks the nurse for advice. All other variables being equal, which choice is best? 1. A woman with 35 years of teaching experience 2. A man who is 40 years old 3. A newly graduated 22-year-old man 4. A 30-year-old woman
2
After eating dinner, a client asks for help to get to the bathroom because of an extreme urge to defecate. The nurse realizes that the client has experienced which physiological function of the colon? 1. Flatus 2. Mass peristalsis 3. Haustral churning 4. Peristalsis
2
An older client receiving intravenous fluids at 175 ml/hr is demonstrating crackles, shortness of breath, and distended neck veins. The nurse recognizes these findings as being which complication of intravenous fluid therapy? 1. An allergic reaction to the antibiotics in the fluid 2. Fluid volume excess 3. Pulmonary embolism 4. Speed shock
2
At which point of preparing medication from an ampule does the nurse anticipate using a filter needle? 1. Filter needles are not used for this preparation. 2. When drawing the medication from the ampule. 3. When administering the medication to the client. 4. Both for drawing up the medication and for administering the medication.
2
Before administering a medication to a client, the nurse checks the clients pulse, blood pressure, and laboratory values. The nurse is performing which right of medication administration? 1. Medication 2. Assessment 3. Route 4. Dose
2
During a routine physical, an 11-year-old tells the nurse that many students in school are doing it. How should the nurse respond to this statement? 1. Tell the client to talk with parents about sexual matters. 2. Ask what doing it means to this client. 3. State that sexual activity is not appropriate at age 11. 4. Stay silent and wait for the client to continue the discussion.
2
In discussion with teenagers, the nurse chooses to use the term sexually transmitted infection rather than sexually transmitted disease. What is the rationale for this choice? 1. Infection is a much more precise term for the transmission that occurs. 2. The word disease may elicit guilt, shame, and fear in the client. 3. Sexually transmitted disease does not receive as much third-party reimbursement as does sexually transmitted infection. 4. These terms can be used interchangeably and there is no good rationale for using one over the other.
2
Ten minutes after the transfusion of a unit of packed red blood cells was initiated, the client complains of a headache. The nurse assesses that the client has slight shortness of breath and feels warm to the touch. What action by the nurse is priority? 1. Notify the clients physician. 2. Discontinue the transfusion. 3. Slow the rate of the transfusion. 4. Prepare to resuscitate the client.
2
The client who has an IV with an intermittent infusion lock in place wishes to shower. What action should be taken by the nurse? 1. Have the UAP discontinue the lock. 2. Cover the lock with an occlusive dressing. 3. Place a piece of cloth tape under the lock, wrapping the top in a U shape. 4. Tell the client that a bed bath is necessary until the IV is discontinued.
2
The client who regularly uses a metered-dose inhaler four times a day tells the nurse that it is difficult to tell when the canister is empty. What instruction should the nurse give this client? 1. Place the canister in a bowl of water. If the canister floats, it is not empty. 2. When you get a new canister, divide the number of puffs that is listed on the label by four. That will tell you how many days the canister will last. 3. You can tell that the canister is empty when you can no longer smell the medication when you activate the plunger. 4. When you feel like you are no longer getting maximum effect from the medication, your canister is empty.
2
The daughters of an 80-year-old man who is aphasic after suffering a cerebrovascular accident (stroke) express concern that their father is always exposing and playing with himself and his catheter while they are in the room. Upon assessment, the nurse finds the client pulling on and rubbing his penis. What is the nurses priority action? 1. Tell the client to keep his hands away from his penis. 2. Assess the clients penis for irritation from the catheter. 3. Ask the client to keep his linens at waist level when he has visitors. 4. Collaborate with the physician regarding medications to control this behavior.
2
The female client has experienced recurrent candidiasis with intense vaginal itching and excoriation. After treatment the client is reexamined, and the nurse practitioner finds presence of a white, cheesy discharge. What recommendation is necessary? 1. Referral to a surgeon for excision of infected tissue 2. Examination and treatment of sexual partner 3. Treatment with a stronger oral antibiotic 4. Routine douches with a topical antibiotic solution
2
The hospitalized client has an order for Tylenol 325 mg 2 tablets every 4 hours prn temperature over 101F. The client complains of a headache. Can the nurse legally administer Tylenol to treat the headache? 1. Yes, as Tylenol is used both for fever and headache. 2. No, not unless the client also has a temperature over 101F. 3. Yes, but the nurse should document the reason why the medication was administered as a temperature elevation. 4. Yes, because the medication is available over the counter, an order is not required.
2
The mother of a 5-year-old tells the nurse that her daughter has always been closer to her than to her husband. The mother expresses concern that, over the last 2 months, the little girl wants to spend all of her time with her father instead of with the mother. The nurse recognizes that this behavior 1. may indicate sexual abuse by the father and should be further investigated. 2. is a normal expectation of a preschooler developing sexuality. 3. indicates that the girl is overidentifying with the male gender. 4. can be a sign of precocious puberty and should be monitored.
2
The nurse determines that an adult clients feces are normal. What did the nurse assess to come to this conclusion? 1. Black in color 2. Cylindrical in shape 3. Pungent in odor 4. Yellow in color
2
The nurse enters the room and finds the adult client masturbating. What action should the nurse take? 1. Tell the client that masturbation is harmful to sexual well-being. 2. Say excuse me and leave the room. 3. Request that the client stop so that care can be provided. 4. Ask the client if there are any sexual concerns that should be discussed.
2
The nurse has completed closed irrigation of a clients retention catheter. What specific information should the nurse document about this procedure? 1. Number of ml of solution used to inflate the balloon of the catheter 2. Abnormal drainage, such as blood clots, pus, or mucous shreds 3. Location of the draining bag 4. Technique used to conduct the irrigation
2
The nurse has just injected insulin subcutaneously into the clients abdomen. What action should the nurse take at this point? 1. Massage the site to encourage absorption. 2. Leave the needle embedded in the clients skin for 5 seconds after administration. 3. Remove the needle rapidly by pulling it quickly from the skin. 4. Cover the injection site with a pressure dressing for at least 15 minutes or until the bleb disappears.
2
The nurse is assisting a client with a diagnostic test. Which role should the nurse expect to perform in the intratest phase? 1. Assess the data. 2. Collect the specimen. 3. Observe the client. 4. Prepare the client.
2
The nurse is caring for the stoma of a client who has a colostomy. Which action is the most appropriate? 1. Apply pressure over the stoma. 2. Clean the stoma and pat dry. 3. Dilate the stoma. 4. Scrub the stoma.
2
The nurse is collecting a sputum specimen from a client. Which action should the nurse take during the collection of this specimen? 1. Collect at least 30 mL of sputum. 2. Offer mouth care. 3. Take shallow breaths. 4. Wear a mask.
2
The nurse is collecting equipment to administer a unit of packed red blood cells. Which IV fluid should be used to initiate the IV for this transfusion? 1. 1,000 mL of lactated Ringers solution 2. 250 mL of normal saline 3. 500 mL of 5% dextrose and water 4. 100 mL of 5% dextrose and 1/2 normal saline
2
The nurse is concerned that an older client is experiencing an adverse effect from a prescribed medication. What did the nurse assess to make this clinical decision? 1. Altered memory 2. Altered organ responsiveness 3. Decreased manual dexterity 4. Decreased visual acuity
2
The nurse is discussing the resolution phase of the sexual response cycle with a group of students in a health education class. What should be included as a physiological change that affects males only? 1. Genitalia and breasts return to pre-excitement states. 2. There is a refractory period during which the body will not respond to sexual stimulation. 3. The heart rate returns to normal. 4. Possible sleepiness or intense relaxation may occur.
2
The nurse is performing urinary catheterization for a client. After using the nondominant hand to separate the clients labia for cleansing, the nurse will maintain this hand as being 1. sterile. 2. contaminated. 3. able to evaluate the effectiveness of the catheter balloon. 4. clean.
2
The nurse is planning to administer medications to a new client. What is the nurses greatest priority in administering these medications? 1. Be certain the medications are given within 15 minutes of the time they are scheduled. 2. Before giving the medications, know what the intended effects are for this client. 3. Assess the clients knowledge of the action of the medications. 4. Document the administration accurately so the reimbursement is correct.
2
The nurse is providing discharge teaching for a client who is being dismissed with prescriptions for a bronchodilator inhaler and a corticosteroid inhaler. What information should the nurse provide regarding the dosage schedule for these two medications? 1. Always use the corticosteroid inhaler first. 2. Use the bronchodilator first. 3. It makes no difference which inhaler is used first. 4. Use the inhalers on alternate days, not on the same day.
2
The nurse should incorporate which instructions into the teaching plan for a client with a urinary diversion? 1. Change the appliance several times a day. 2. Increase fluid intake. 3. Notify the physician if the stoma is deep pink and shiny. 4. Strands of blood may appear in the urine.
2
The nurse suspects that a client is experiencing compromised gastrointestinal function. What assessment data did the nurse use to make this clinical decision? 1. Bowel sounds active in all four quadrants 2. Clay-colored stool 3. Increased appetite 4. Semisolid and moist stool
2
The nurse uses the PLISSIT format in helping clients who have sexual dysfunction. Which action by the nurse best reflects the LI section of this format? 1. In order to avoid causing anxiety, limit the amount of information given to clients regarding adverse sexual side effects of treatments or medications. 2. Give the client accurate but concise information in regard to any sexual questions that might be asked. 3. State information using slang terms to refer to sexual body parts because the client is not likely to know the proper terms. 4. Review current research literature associated with the sexual concerns of the client and partner.
2
The nurse wants to assess a client for orthostatic hypotension. What action should the nurse take? 1. Assess the client for dependent edema and then raise the legs to the level of the heart and reassess for edema. 2. Measure the clients heart rate and blood pressure in both the sitting and standing position. 3. Measure the clients blood pressure before, during, and after administration of a normal saline fluid challenge. 4. Raise the clients legs above heart level and measure the blood pressure.
2
Upon aspirating a saline lock prior to administering intravenous medication, the nurse notes that there is no blood return. What nursing action should be taken? 1. Discontinue this infiltrated lock and restart another site for medication administration. 2. Slowly infuse 1 mL of saline into the lock, assessing for infiltration. 3. Reinsert the needle into the lock and aspirate using more pressure. 4. Pull the intravenous catheter out 1/8 inch and attempt aspiration.
2
What is the responsibility of the nurse when collecting a specimen from a client? 1. Always accompany the client to collect a specimen. 2. Handle the specimen discreetly. 3. Clean technique should be used with all specimen collection. 4. Use day-old specimens.
2
What nursing diagnosis should the nurse select as appropriate to address bowel evacuation for a client who is on bed rest? 1. Bowel Incontinence 2. Constipation 3. Diarrhea 4. Disturbed Body Image
2
What should the nurse instruct a client for obtaining a clean voided urine specimen? 1. Collect at least 5 mL of urine. 2. Collect the first voided specimen in the morning. 3. Keep the specimen on ice. 4. Void in a sterile cup.
2
Which assessment technique will the nurse use first when examining a client with a fecal elimination problem? 1. Auscultation 2. Inspection 3. Palpation 4. Percussion
2
Which nursing diagnosis would be appropriate for a client who has a retention catheter if the drainage bag is found lying on the floor? 1. Risk for Impaired Skin Integrity related to catheter placement 2. Risk for Infection related to improper handling 3. Self-Care Deficit related to presence of a retention catheter 4. Risk for Incontinence related to an obstruction
2
While administering an enema, the client complains of abdominal cramping. What should the nurse do? 1. Raise the height of the solution container. 2. Clamp the flow for 30 seconds, and restart at a slower rate. 3. Discontinue the enema infusion. 4. Assist the client to a supine position.
2
A client is receiving a continuous intravenous infusion. What should the nurse document in the medical record about this infusion? Standard Text: Select all that apply. 1. Latest body temperature 2. Type of solution and flow rate 3. Total intravenous intake for the shift 4. Status of the intravenous catheter site 5. Results of blood pressure measurement
2,3,4
The nurse is concerned that an older client will have difficulty self-administering medications. What did the nurse assess that caused this concern? Standard Text: Select all that apply. 1. Eats several servings of fruits and vegetables each day 2. Altered memory 3. Decreased visual acuity 4. Decreased manual dexterity 5. Limits red meat in the diet
2,3,4
The nurse is conducting a sexual health history with a client. What questions should the nurse ask during this history? Standard Text: Select all that apply. 1. What are your erotic fantasies? 2. Are you currently sexually active? 3. Do you experience any pain with sexual interaction? 4. Do you have difficulty with sexual desire? 5. What do you like the best about having sex?
2,3,4
The nurse is discussing different types of ostomy appliances with a client with a new ostomy. During this discussion, the nurse should keep in mind that an ostomy appliance should Standard Text: Select all that apply. 1. be changed daily. 2. protect the skin. 3. collect stool. 4. control odor. 5. be open, so the client can empty it sporadically throughout the day.
2,3,4
The nurse is instructing a new mother on the method to provide a newly prescribed medication to her 2-month-old infant. What should the nurse include in this teaching? Standard Text: Select all that apply. 1. Mix the medication into the babys formula. 2. Use a nipple so the baby can suck the medication. 3. Use a syringe or dropper to provide the medication. 4. Place a small amount of the medication along the side of the babys cheek. 5. Prepare twice the amount of medication prescribed because the baby will spit out half of it.
2,3,4
A client has received a return-flow enema. What should the nurse document about this procedure? Standard Text: Select all that apply. 1. Number of times the solution was changed. 2. Type of solution. 3. Length of time the solution was retained. 4. The amount, color, and consistency of the return. 5. Client relief of flatus and abdominal distention.
2,3,4,5
While the nurse is measuring blood pressure, the client lifts his hand and fondles the nurses breast. What should the nurse do about this behavior? Standard Text: Select all that apply. 1. Ignore the fondling. 2. Move the clients hand away. 3. Refocus the client on appropriate behavior. 4. Tell the client to stop performing the behavior. 5. Communicate that the behavior is not acceptable.
2,3,4,5
The nurse determines that the effectiveness of a medication is not as great when provided to female clients as it is with male clients. The nurse suspects that this difference in effectiveness is because of which factor? Standard Text: Select all that apply. 1. Occupation 2. Hormones 3. Fat amount 4. Physical activity status 5. Fluid level
2,3,5
The nurse is instructing a female client on how to cleanse the perineum before collecting a clean catch urine specimen for culture and sensitivity. What should the nurse instruct this client to do? Standard Text: Select all that apply. 1. Clean the perineal area using a circular motion. 2. Use all towelettes provided. 3. Use each towelette once, and discard. 4. Clean the perineal area from back to front. 5. Clean the perineal area from front to back.
2,3,5
The nurse is preparing to start an IV in the hand of a client who has very small veins. Which actions would be useful in dilating the veins? 1. Position the hand at heart level. 2. Stroke the vein. 3. Have the client clench and unclench the fist. 4. Slap the back of the clients hand. 5. Massage the vein.
2,3,5
The nurse is providing care to a client during the posttest phase of diagnostic testing. What will the nurse do during this phase? Standard Text: Select all that apply. 1. Provide emotional and physical support to the client. 2. Compare the previous and current test results. 3. Prepare the client for the test. 4. Modify nursing interventions as necessary. 5. Report the results to appropriate health team members.
2,4,5
A client experiencing hard, dry feces is scheduled for an enema. The nurse recognizes that what type of solution would be best for the client? Standard Text: Select all that apply. 1. Hypertonic 2. Hypotonic 3. Soapsuds 4. Oil retention 5. Isotonic
2,5
A client experienced female circumcision as a puberty ritual while living in Africa as a child. For which health problem should the nurse monitor the client as an adult? 1. Early menopause 2. Increased menstrual flow 3. Chronic urinary tract infection 4. Tendency for postpartum hemorrhage
3
A client has a history of an inconsistent fecal elimination pattern. What should the nurse instruct this client to improve this health problem? 1. Drink two to four glasses of water daily. 2. Include more spicy foods and sugar in the diet. 3. Include more whole grains in the diet. 4. Use enemas as desired.
3
A client has orders for the administration of IV fluid at a keep vein open rate in preparation for administration of IV antibiotics starting at noon. When the nurse goes to the room to start the IV, the UAP is preparing to bathe the client. What should the nurse do? 1. Instruct the UAP to wait until the IV is started to bathe the client. 2. Let the UAP start the bath on the opposite side of where the nurse will be starting the IV. 3. Tell the UAP to notify the nurse as soon as the bath is completed. 4. Give the UAP permission to skip the clients bath for today.
3
A client is concerned because he was unable to achieve an erection during his last sexual encounter with his wife. He tells the nurse that he has worried about becoming impotent because he had a sexually transmitted infection as a young adult. What is the nurses best response to this clients concerns? 1. Sexually transmitted infections may result in sexual problems in adults. 2. Erectile dysfunction is the correct term for the inability to achieve or sustain an erection. 3. An occasional incident like this is normal and common and there is no reason to be concerned. 4. The medical diagnosis of erectile dysfunction is not made until the man has erection difficulties in 25% or more of his interactions.
3
A client is diagnosed with an elevated aldosterone level. The nurse realizes that this finding will affect what aspect of urinary elimination? 1. Increased urine output 2. Urinary incontinence 3. Decreased urine output 4. Urinary retention
3
A client is diagnosed with liver disease. The nurse realizes that which element of pharmacokinetics will be affected in this client? 1. Absorption 2. Distribution 3. Biotransformation 4. Excretion
3
A client is scheduled for a barium enema. What is the nursing priority for this client? 1. Assess bowel sounds. 2. Assess for allergies. 3. Cleanse the bowel. 4. Keep the client NPO.
3
A client is scheduled to have abdominal ascites fluid removed. What should the nurse instruct the client about this procedure? 1. A catheter will be inserted into the bladder. 2. A liver biopsy will be done. 3. An abdominal paracentesis will be done. 4. A thoracentesis will be done.
3
A client on diuretic therapy has a serum potassium level of 3.4 mg/dL. Which food should the nurse encourage this client to choose from the dinner menu? 1. Baked chicken 2. Green beans 3. Cantaloupe 4. Iced tea
3
A client recovering from abdominal surgery is demonstrating abdominal distention from trapped flatus. What can the nurse do to help this client? 1. Assist the client to move in bed. 2. Restrict fluids. 3. Obtain an order for a rectal tube. 4. Provide a diet rich in foods that create flatulence.
3
A client speaks about an adult son who is a practicing homosexual and expresses concern by stating: I am so worried about him and I know he is going to hell. What is the most important fact for the nurse to consider in formulating a response to this clients concern? 1. Normal sexuality is described as whatever behaviors give pleasure and satisfaction to those adults involved. 2. Because alternative lifestyles are now so well accepted in society, this parent should not feel so much concern. 3. What constitutes normal sexual expression varies among cultures and religions. 4. Sexual development is genetically determined and not affected by environment.
3
A client tells the nurse about passing out after following a fasting diet for 5 days. Which acidbase imbalance should the nurse expect to assess in this client? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
3
A clients status is deteriorating, and the physician prescribes a medication to be administered immediately one time. The nurse would contact the pharmacy and identify this medication order as being of which type? 1. Standing 2. PRN 3. STAT 4. Single order
3
A clients urinalysis is reported as being normal. What were the clients results? 1. Blood present and no ketones 2. Dark amber color and output less than 500 cc in 24 hours 3. pH 6 and no glucose present 4. Specific gravity 1.035 and faint aromatic odor
3
A recently married couple is trying to conceive a child. The husband is a collegiate athlete and his coach forbids sexual activity for 2 days prior to a game. The wife asks the nurse if abstinence before the game is necessary. What is the best response? 1. As long as intercourse is not involved, there is no reason to avoid sexual activity. 2. Some residual physical weakness is common for up to 18 hours after sex. 3. This is a common myth among athletes, but there is no basis in fact. 4. In fact, sexual activity before intense physical exercise increases stamina and endurance.
3
After obtaining a unit of packed red blood cells for a client, the nurse learns the client needed to leave the care area for an emergency x-ray. What action should the nurse take? 1. Set up the blood with the IV fluid and y-tubing and place it on the IV stand in the clients room to initiate immediately after the client returns. 2. Place the blood in the unit refrigerator until the client returns. 3. Return the blood to the laboratory blood bank until the client returns. 4. Set up the blood with the IV fluid and y-tubing and place it in the unit medication room to initiate immediately after the client returns.
3
During the process of administering medications, the nurse checks the name band for the clients name. What should be this nurses next action? 1. Administer the medication as ordered. 2. Initial the MAR that the medication will be given. 3. Double check the clients identification using a second method. 4. Educate the client regarding the medication to be given.
3
The 15-year-old female tells the nurse that she makes her boyfriend stop intercourse before she has an orgasm so she will not get pregnant. What teaching is necessary for this client? 1. Even though she doesnt get pregnant, she might still get a sexually transmitted infection. 2. Intercourse until orgasm may actually reduce conception because the vaginal contractions help to expel sperm. 3. Conceiving is not related to whether or not the female partner experiences an orgasm. 4. As long as her boyfriend does not ejaculate in her vagina, conception is unlikely.
3
The 45-year-old client reports that she has no interest in sex and that she and her husband have not had intercourse in 16 years. How should the nurse interpret this assessment data? 1. This couple is experiencing sexual dysfunction. 2. The womans lack of sexual desire has resulted in impotence in her husband. 3. If both partners share the same lack of desire, there is often not a problem. 4. This situation is so unnatural that some dysfunction is present.
3
The client complains of burning along the vein in which a medicated IV is infusing. Upon assessment, the nurse finds the IV site is slightly reddened, but not warmer than the surrounding skin, and without swelling. What action should be taken by the nurse? 1. Slow the IV infusion and reassess the area in 15 minutes. 2. Apply ice over the IV site and vein. 3. Discontinue the IV and place a warm pack on the area. 4. Call the physician for direction.
3
The client is to receive an intramuscular injection of a medication that is supplied in a 2-mL cartridge and a second medication that is supplied in a vial. The total amount to be administered of these medications exceeds the volume of the cartridge by 0.5 mL. How should the nurse proceed? 1. Administer the cartridge medication in one injection and the vial medication in a separate injection. 2. Call the pharmacy for advice on administering these medications. 3. Draw both of the medications up into a syringe for administration. 4. Add as much of the vial medication to the cartridge as possible prior to injection, giving the balance in a separate injection.
3
The nurse identifies that the ordered dose for a medication is twice the amount generally administered. What action should the nurse take? 1. Administer the medication as it was ordered. 2. Check to see if previous shift nurses gave the medication. 3. Collaborate with the prescriber about the order. 4. Administer only the standard dose of the medication.
3
The nurse is caring for a client who is being mechanically ventilated. Arterial blood gas analysis reveals respiratory acidosis. Which change in ventilator settings should the nurse anticipate? 1. Decrease in oxygen delivery 2. Decreased tidal volume of each breath 3. Increased respiratory rate 4. Increase in humidification of inspired air
3
The nurse is caring for a client who is recovering from surgery. Which intervention should the nurse implement to decrease the clients possibility of developing hypercalcemia? 1. Measure vital signs every 4 hours. 2. Assist the client to turn, cough, and deep breathe every 2 hours. 3. Assist the client to ambulate around the room at least three times daily. 4. Irrigate the clients nasogastric tube every 2 hours.
3
The nurse is caring for an 80-year-old client with the medical diagnosis of heart failure. The client has edema, orthopnea, and confusion. Which nursing diagnosis is most appropriate for this client? 1. Heart Failure related to edema, as evidenced by confusion 2. Fluid Volume Deficit related to loss of fluids, as evidenced by edema 3. Excess Fluid Volume related to retention of fluids, as evidenced by edema and orthopnea 4. Excess Fluid Volume related to congestive heart failure, as evidenced by edema and confusion
3
The nurse is concerned that an older client with a retention catheter is developing a urinary tract infection. What assessment finding caused this concern? 1. Elevated blood pressure 2. Elevated heart rate 3. Confusion 4. Leg pain
3
The nurse is identifying outcomes for a client with the nursing diagnosis Stress Urinary Incontinence. Which outcome would be related to sphincter incompetence? 1. The client will empty her bladder every time she voids. 2. The client will improve her incontinence within 1 month. 3. The client will perform four to five squeezes for 5 to 10 seconds. 4. The client will stop the flow of urine when voiding.
3
The nurse is planning to administer a bitter-tasting oral medication to a 4-year-old client. What strategy should this nurse plan? 1. Give the medication in orange juice or milk to mask the taste. 2. Tell the child that the medication tastes good. 3. Ask the parents how they give medications at home. 4. Get another nurse to assist by holding the client down.
3
The nurse is preparing a small amount of medication for oral administration. Which nursing action is essential? 1. Draw up the medication in a syringe with a large-gauge needle. 2. Measure the medication at the top of the meniscus. 3. Label the syringe with the medication name, amount, and route. 4. Dilute the medication with water before measuring.
3
The nurse is preparing for pelvic physical examination of a woman who has been medically diagnosed with vaginismus. What equipment should the nurse obtain for this examination? 1. Culture tubes to assess expected vaginal infection 2. Extra cleaning supplies to remove thick external secretions 3. Smaller-than-normal vaginal speculums 4. Equipment for preexamination douche
3
The nurse is preparing to administer a medication to a 6-year-old client. What is the nurses priority action? 1. Administer the exact dosage as ordered. 2. Give the dosage supplied by the pharmacy. 3. Verify that the dosage is within the safe range for this child. 4. Administer no more than one-half of the safe adult dosage.
3
The nurse is preparing to administer a subcutaneous injection to a client. When selecting the needle, the nurse should choose one with a 1. small gauge number. 2. long shaft. 3. long bevel. 4. short bevel.
3
The nurse is providing discharge instructions to a client who has been started on furosemide (Lasix) once daily. What information is essential to include in this information? 1. Take the medication at bedtime. 2. Avoid high-potassium foods. 3. Stand up slowly from a sitting position. 4. Do not take this medication on the days you take digitalis (Lanoxin).
3
The nurse is reviewing laboratory results for a client. Which diagnostic study determines how well blood glucose levels have been controlled in the client? 1. Blood chemistry 2. Capillary blood glucose 3. Hemoglobin A1c 4. Serum electrolytes Correct Answer: 3
3
The nurse is teaching a class on body development to a group of middle school girls. One of the girls asks about using tampons for sanitary protection during menstruation. What advice should the nurse include? 1. Tampons should not be used until the menstrual cycle is well established, usually 2 to 3 years after the first period occurs. 2. Superabsorbent tampons should be used at night to protect from overflow accidents. 3. Tampons should be alternated with sanitary pads to help decrease risk for infection. 4. Tampons should be changed at least every 8 hours.
3
The nurse needs to collect a specimen from a client; however, the nurse has never collected this type of specimen in the past. What should the nurse do? 1. Notify the physician. 2. Ask another nurse to collect the specimen. 3. Consult the nursing procedure manual. 4. Delegate the collection of the specimen to unlicensed assistive personnel.
3
The nurse needs to obtain a sputum specimen from a client. What should the nurse have the client do? 1. Apply sterile gloves. 2. Clear the throat. 3. Cough to bring up secretions. 4. Rinse the mouth with mouthwash prior to the collection.
3
The nurse realizes that which client is at risk for difficulty in urinary elimination? 1. A client who had bladder cancer and now has a newly created ileal conduit 2. A 25-year-old female client with low self-esteem 3. An 80-year-old male reporting frequent urination at night 4. The client with hypertension who takes a diuretic every day for blood pressure
3
The nurse suspects that a clients body is attempting to correct an acidbase imbalance. How will this imbalance be corrected? 1. Slow but efficient respiratory regulation will occur. 2. Primary regulation is through GI system losses. 3. Kidney regulation is powerfully effective. 4. The cardiovascular system is the major buffer.
3
The nurse uses the PLISSIT format in helping clients who have sexual dysfunction. Which action by the nurse best reflects the P section of this format? 1. Ask the physician for permission to discuss sexual topics with the client. 2. Obtain signed informed consent from both the client and the spouse or partner prior to providing them with sexual information. 3. Acknowledge the clients spoken and unspoken sexual concerns when providing care. 4. Document precertification for benefits from the clients insurance company regarding sexual teaching.
3
The nurse who is to administer 2.5 mL of intramuscular pain medication to an adult client notes that the previous injection was administered in the right ventrogluteal site. In which site should the nurse plan to administer this injection? 1. The same site 2. The deltoid 3. The left ventrogluteal 4. The rectus femoris
3
Which intervention would the nurse plan to help a client prevent a urinary tract infection? 1. Encourage the use of bubble baths. 2. Have the client increase sugar in the diet. 3. Instruct the client to empty the bladder completely. 4. Wipe from back to front.
3
Which statement made by a postmenopausal client should the nurse evaluate as indicating the need for further assessment? 1. For some reason, I have more sexual desire than ever. 2. I use water-soluble lubricant to treat my vaginal dryness. 3. I am so glad that I dont need to worry about sex anymore. 4. Sex certainly takes longer than it used to, but Im getting used to that.
3
Why is the nurse writing out the name of the drug morphine sulfate instead of using the abbreviation MS? 1. The hospital has placed MS on its list of do-not-use abbreviations. 2. The Joint Commission requires that the abbreviation MS not be used. 3. Using the abbreviation MS puts the client at risk of medication error. 4. Computerized charting systems will not accept the abbreviation MS.
3
A client needs a test to determine the amount of residual urine. The nurse realizes that this assessment is used for which reason(s)? Standard Text: Select all that apply. 1. To evaluate the glomerular filtration rate 2. To determine the extent of renal failure 3. To determine the amount of retained urine after voiding 4. To determine the need for medications 5. To evaluate fluid volume status
3,4
After reviewing a list of prescribed medications, the nurse plans to complete a sexual history with the client. Which medications in the clients list caused the nurse to make this clinical decision? Standard Text: Select all that apply. 1. Antibiotics 2. Antipyretics 3. Cardiotonics 4. Beta-blockers 5. Anticoagulants
3,4
The nurse is preparing an educational session on the sexual response cycle. What should be included when discussing the physiological changes in females during the excitement phase? Standard Text: Select all that apply. 1. The vagina dries. 2. The length of the vagina narrows and swells. 3. Erection of the clitoris occurs. 4. The breasts enlarge. 5. The uterus elevates.
3,4,5
The nurse is reviewing a new medication order for a client, and determines that the order is incomplete when which element is missing? Standard Text: Select all that apply. 1. Clients address 2. Dispensing instructions for the pharmacist 3. Name of the medication 4. Dosage 5. Route of administration
3,4,5
While reviewing a medication order, the nurse determines that it is written using the metric system. What did the nurse observe to come to this conclusion about the medication order? Standard Text: Select all that apply. 1. Number of ounces 2. Number of drams of the solution 3. Number of milligrams of the medication 4. Number of grains of the medication 5. Number of milliliters of the solution
3,5
A client diagnosed with diabetes asks the nurse about reusing insulin syringes. Assessment reveals that the client has poor personal hygiene and difficulty with fine motor skills. The nurse also knows the client has financial difficulties. What instruction should the nurse give this client? 1. The American Diabetes Association advises that syringes are for single use only. 2. In order to save money, I advise you to reuse syringes up to three times or until the needle feels dull. 3. Only people who practice good personal hygiene can reuse syringes. 4. All clients are different, but I advise you to use a new syringe for each injection.
4
A client is instructed on the care of an indwelling urinary catheter. Which returned demonstration by the client indicates that teaching has been effective? 1. The client empties the drainage bag once a day. 2. The client hangs the drainage bag on the towel rod. 3. The client refuses drinks one to two 8-ounce glasses of fluid each day. 4. The client takes a shower each day.
4
A client with an upper gastrointestinal disorder is experiencing seeping of liquid stool, anorexia, abdominal distention, nausea, and vomiting. The nurse suspects the client is experiencing 1. constipation. 2. diarrhea. 3. trapped flatus. 4. fecal impaction.
4
A client with tattooed eyeliner is scheduled for an MRI. What should the nurse instruct the client about this diagnostic test? 1. Earplugs will be provided. 2. Lie very still. 3. Report any burning sensation. 4. Wear goggles.
4
A clients results from a urinalysis are as follows: pH 5.2, gross cloudiness, WBC 1015, glucose negative, specific gravity 1.012, and protein negative. How should the nurse interpret the results? 1. Dehydration 2. Diabetic ketoacidosis 3. Trauma 4. Urinary tract infection
4
An adult client is prescribed the hepatitis B vaccination. The nurse will administer this medication through which site? 1. Dorsogluteal 2. Rectus femoris 3. Vastus lateralis 4. Deltoid
4
During an assessment, a client tells the nurse of a desire to wear clothing that is typically associated with the opposite sex. The nurse realizes this client is describing which gender identity? 1. Intersex 2. Transgenderism 3. Homosexuality 4. Cross-dressing
4
During morning care, a UAP notes that thick green drainage is seeping around the appliance of a clients new ostomy. What should the UAP have been instructed to do? 1. Clean around the drainage. 2. Remove the ostomy appliance and cover the stoma with toilet tissue. 3. Perform complete ostomy care. 4. Report the drainage to the nurse.
4
The 154-pound adult client has had vomiting and diarrhea for 4 days secondary to a viral infection. What hourly urine measurement would indicate that efforts to rehydrate this client have not yet been successful and should continue? 1. 35 mL per hour 2. 80 mL per hour 3. 50 mL per hour 4. 30 mL per hour
4
The RN is admitting a client to the medical unit for a urinary disorder. Which physical assessment techniques should the nurse use in assessing this clients urinary system? 1. Auscultation and inspection 2. Inspection and percussion 3. Observation and auscultation 4. Palpation and observation
4
The nurse determines that a clients fecal elimination is pale in color. This finding supports which client behavior obtained during the health history? 1. The client rarely eats animal protein, and ingests milk and cheese at several meals each day. 2. The client rarely eats fruits or vegetables. 3. The client uses laxatives routinely. 4. The client drinks 8 to 10 8-ounce glasses of water each day.
4
The nurse is administering a medication to a client as prescribed in order to maintain a specific amount of the medication in the clients bloodstream at all times. The nurse is ensuring that which action is being maintained for this client? 1. Peak plasma level 2. Drug half-life 3. Onset of action 4. Plateau
4
The nurse is applying an external urinary device to a client. Before attaching the device to the drainage bag, what should the nurse do? 1. Wash his or her hands. 2. Document the clients tolerance of the procedure. 3. Instruct the client about the drainage system. 4. Ensure that the condom is not twisted.
4
The nurse is caring for a client who experiences frequent bouts of diarrhea. What should the nurse instruct the client to do? 1. Change the daily routine. 2. Decrease fluid consumption. 3. Increase fiber in the diet. 4. Note the precipitating event.
4
The nurse is caring for a client who is experiencing constipation. Which client behavior indicates that teaching was effective? 1. The client continues to ask for his pain medication. 2. The client decreases his fluid consumption. 3. The client refuses to eat the bran flakes on his tray. 4. The client walks around the unit several times a day.
4
The nurse is caring for a team of four clients who are seriously ill. One of the clients has just received a new cardiac medication. How should the nurse instruct the unlicensed assistive personnel (UAP) who is also caring for this client? 1. Have the UAP assess for any unexpected effects from the medication. 2. Tell the UAP to teach the clients family what to expect from the medication. 3. Have the UAP look the medication up in a drug reference book to read about drug actions and possible side effects. 4. Give the UAP specific instructions regarding what drug actions or side effects to report to the nurse.
4
The nurse is conducting a health history with an older client with arthritis and heart disease. When gathering the sexual history for this client, what question should the nurse ask? 1. Do you have any difficulty with sexual desire and orgasm? 2. How often do you have sexual relations? 3. What type of contraception do you use? 4. Have there been any changes in your sexual functioning that might be related to your illness or the medications you take?
4
The nurse is determining tasks to delegate to unlicensed assistive personnel (UAP). Which task should the nurse question before delegating to this level of health care provider? 1. Measuring intake and output 2. Assessing vital signs for clients who are clinically stable 3. Performing complete morning care for a client recovering from a stroke 4. Inserting a urinary catheter into a client
4
The nurse is identifying goals for a client experiencing diarrhea. What goal should the nurse select for this client? 1. Client will defecate regularly. 2. Client will increase the amount of sugar in the diet. 3. Client will limit fluid intake. 4. Client will regain normal stool consistency.
4
The nurse is instructing a client on ostomy care. What should be included in this teaching? 1. Change the drainage pouch daily. 2. Clothing of a special style will be needed now that a pouch is worn. 3. Stick a pin into the drainage pouch to relieve any gas buildup. 4. Secure the faceplate to the drainage pouch so no skin around the stoma is exposed.
4
The nurse is preparing to administer eardrops to a 6-year-old client. What nursing action is correct? 1. Pull the earlobe down and back to straighten the ear canal. 2. Insert the tip of the applicator into the ear canal. 3. Put the eardrops in the refrigerator for 10 minutes prior to administration. 4. Press gently on the tragus of the ear a few times after administration.
4
The nurse is reviewing instructions provided to a client about an upcoming cystoscopy. Which client response indicates that no further teaching is required? 1. During the procedure the physician will take x-rays. 2. I will be awake for this procedure. 3. The doctor will be able to see my kidneys. 4. The scope is a lighted instrument inserted through the urethra.
4
The nurse is to administer four oral medications to the client via a nasogastric tube. One of the medications is a tablet that has been crushed, one is a capsule that has been opened and the powder removed, and two are supplied in liquid form. How should the nurse administer these medications? 1. Flush the tube, mix the crushed tablet and the capsule powder into the two liquids for administration, and follow by flushing the tube. 2. Mix the crushed tablet and capsule powder in warm water and administer. Flush the tube and administer the mixed liquids. 3. Flush the tube with the mixed liquids first, then administer the crushed tablet and capsule powder mixed in cold water. 4. Mix the crushed tablet and capsule powder individually in warm water. Administer each medication separately, flushing the tube before and after each administration.
4
The nurse uses the PLISSIT format in helping clients who have sexual dysfunction. Which action by the nurse best reflects the IT section of this format? 1. Use information technology such as the Internet to obtain guidance suggestions for the client. 2. Use the technique of informal therapeutic groups to assist the client and partner. 3. Evaluate previous interventions and treatment for success. 4. Recommend intensive therapy with a qualified sex therapist.
4
There is disagreement among the nursing unit staff regarding how much sexual history should be included in adult admission assessments. What standard is generally the most applicable? 1. A complete sexual history must be included in the admission history and physicals. 2. Sexual information should be pursued only if the clients chief complaint indicates possible sexual dysfunction. 3. Sexual assessment should be done by the physician and not repeated by the nurse. 4. The amount of sexual information taken will vary on a case-by-case basis.
4
Which instruction should the nurse give to the client when a stool specimen is to be collected? 1. Defecate in the toilet. 2. Follow sterile technique. 3. Send at least 60 mL of specimen. 4. Void before the specimen is collected.
4
Which nursing intervention is appropriate when caring for a client with a retention catheter? 1. Don sterile gloves. 2. Gently retract the labia majora away from the urinary meatus. 3. Observe urine in the drainage bag. 4. Retape the catheter to the thigh.
4
While administering an intramuscular injection, the nurse notes blood return in the syringe barrel after aspirating. What action should the nurse take? 1. Pull the needle out 1/4 inch and inject the medication. 2. Inject the medication as planned. 3. Notify the physician immediately. 4. Discard the medication and start over.
4
While hospitalized, a client was receiving 15 ml of an oral medication three times a day. When providing discharge instructions, the nurse should teach the client to take how much of this medication at home? 1. 2 teaspoons 2. 1 teaspoon 3. 2 tablespoons 4. 1 tablespoon
4
While preparing to administer a transdermal estrogen patch, the nurse finds the previously applied patch in the clients bed linens. How can the nurse avoid this situation with the patch now being applied? 1. Shave the area where the patch is being applied. 2. Place a heating pad over the area where the patch is applied for 10 minutes after application. 3. Run a finger around the adhesive edges of the new patch before placing it on the clients skin. 4. Press firmly over the patch with the palm of the hand for about 10 seconds after applying it to the skin.
4
A UAP has applied a condom catheter to a client. The nurse should document what information about this procedure? Standard Text: Select all that apply. 1. Number of ml of fluid used to inflate the balloon 2. Location of the drainage bag 3. Name of the UAP who applied the device 4. Time and date that the condom catheter was applied 5. Integrity of the penis
4,5
Unlicensed assistive personnel (UAP) will be conducting a test on a clients urine. What should the nurse instruct the UAP about the test? Standard Text: Select all that apply. 1. Nothing, because the UAP can perform urine testing. 2. Remind the UAP to tell the client the results of the test. 3. Notify the physician with the results of the test. 4. Report the results of the test to the nurse. 5. Save the urine, in case the nurse wants to repeat the test.
4,5