Hurst

What signs/symptoms would the nurse expect to assess in a client diagnosed with tabes dorsalis neurosyphilis due to untreated syphilis? Select all that apply 1. Abnormal gait 2. Blindness 3. Hyperreflexia 4. Stiff neck 5. Hearing loss

1. Abnormal gait 2. Blindness

A five year old is in kindergarten and goes to the nurse's office where she reports a "stomachache". While there, the nurse observes that the child has a large bruise on her upper arm and bruises on both ears. What should the nurse do first? 1. Ask the student about the bruises on the arms and ears. 2. Do nothing as bruises are common in 5 year old children. 3. Report the injuries immediately to the parents. 4. Discuss the findings with the child's teacher.

1. Ask the student about the bruises on the arms and ears.

The nurse has determined that a bedridden client diagnosed with a stroke is at risk for venous thromboembolism (VTE). What interventions should the nurse initiate? Select all that apply 1. Measure the calf and thigh daily. 2. Apply sequential compression device to legs. 3. Position paralyzed leg with each distal joint higher than the proximal joint. 4. Place a trochanter roll at the hip. 5. Perform passive range of motion exercises once daily. 6. Monitor for pain by assessing Homan's sign.

1. Measure the calf and thigh daily. 2. Apply sequential compression device to legs. 3. Position paralyzed leg with each distal joint higher than the proximal joint.

Which nursing actions should the nurse initiate for a client with signs of increased intracranial pressure (ICP)? You answered this question Incorrectly 1. Encourage coughing and deep-breathing. 2. Administer corticosteroids. 3. Position client in the prone position. 4. Determine ability to swallow prior to administering po fluids. 5. Maintain head in neutral alignment. Rationale

2. Administer corticosteroids 4. Determine ability to swallow prior to administering po fluids. 5. Maintain head in neutral alignment.

When providing care to a client diagnosed with pheochromocytoma, which actions could the nurse safely delegate to the unlicensed nursing personnel (UAP)? Select all that apply 1. Explain the purpose of the vanillylmandelic acid test. 2. Remove caffeinated beverages from the client's meal tray. 3. Remind client not to smoke. 4. Instruct the client to limit activity. 5. Monitor hydration status.

2. Remove caffeinated beverages from the client's meal tray. 3. Remind client not to smoke.

A nurse is receiving morning report on the cardiovascular unit. What client should be the nurse's priority assessment? 1. A client with ejection fraction of 20% and dyspnea at rest. 2. A client with a chest tube to suction and sub-q emphysema. 3. A client two days past abdominal aortic aneurysm repair with decreased pedal pulses. 4. A client coronary artery bypass graft three days ago with WBC 17,000 mm3. Rationale Strategies

3. A client two days past abdominal aortic aneurysm repair with decreased pedal pulses.

What should the nurse instruct a client to avoid when prescribed digoxin? 1. Corn 2. Apples 3. Black licorice 4. Milk

3. Black licorice

The nurse is caring for an elderly client who is approaching death and expressing intense despair and anxiety. Based on Erikson's theory, the nurse recognizes that this client's despair and anxiety would most likely be based on what? 1. An inappropriate desire for youthfulness and staying young. 2. The decision to never marry. 3. The lack of a sense of wholeness, purpose, and a life well lived. 4. The fear of experiencing a painful death.

3. The lack of a sense of wholeness, purpose, and a life well lived.

A preschool child has been rushed to the emergency room after ingesting an undetermined amount of chewable baby aspirin. What action should the nurse take immediately? 1. Inject subcutaneous dose of vitamin K. 2. Induce vomiting with ipecac. 3. Initiate large bore IV line. 4. Insert a nasogastric tube.

4. Insert a nasogastric tube.

A client with renal failure has returned to the unit post kidney transplant. Which postoperative interventions should the nurse provide? Select all that apply 1. Administer furosemide. 2. Maintain fluid replacement at 150 ml per hour for 8 hours. 3. Measure abdominal girth every 24 hours. 4. Weigh daily. 5. Measure urine output every 30 - 60 minutes.

1. Administer furosemide. 4. Weigh daily. 5. Measure urine output every 30 - 60 minutes.

A client diagnosed with terminal cancer wants information about an Advanced Directive for end-of-life care. What information should the nurse include? Select all that apply 1. An Advance Directive includes a Living Will and a Medical Power of Attorney. 2. A person can be designated to make medical decision in the event the client cannot. 3. The spouse can rescind the Advance Directive if the client becomes unresponsive. 4. Anyone over age 18 can have an Advanced directive. 5. The client can indicate desire for Do Not Resuscitate (DNR).

1. An Advance Directive includes a Living Will and a Medical Power of Attorney. 2. A person can be designated to make medical decision in the event the client cannot. 4. Anyone over age 18 can have an Advanced directive. 5. The client can indicate desire for Do Not Resuscitate (DNR).

A quality assurance (QA) manager plans to evaluate performance improvement regarding the implementation of fall precautions of at risk clients. What steps should the QA manager include? You answered this question Incorrectly 1. Chart review for fall precaution documentation. 2. Direct observation of unit staff. 3. Ask staff what fall precautions are taken for at risk clients. 4. Identify at risk clients on unit. 5. Make unannounced visits to the unit for evaluating staff performance.

1. Chart review for fall precaution documentation. 2. Direct observation of unit staff. 4. Identify at risk clients on unit. 5. Make unannounced visits to the unit for evaluating staff performance.

A client presents to the after-hours clinic with reports of pain that occurs with walking but generally subsides with rest. The nurse's assessment reveals coolness and decreased pulses in lower extremities bilaterally. What condition would the nurse recognize these symptoms being most indicative of? 1. Chronic Arterial Insufficiency 2. Chronic Venous Insufficiency 3. Chronic Unstable Angina 4. Chronic Coronary Artery Disease

1. Chronic Arterial Insufficiency

The nurse is working with a LPN/VN and an unlicensed assistive personnel (UAP). Which client would be appropriate for the nurse to assign to the LPN/VN? You answered this question Incorrectly 1. In Bucks traction requiring frequent pain medication 2. 24 hours post appendectomy 3. Diagnosed with cholelithiasis and scheduled for surgery in the AM 4. Admitted 6 hours ago in adrenal insufficiency 5. In diabetic ketoacidosis receiving IV insulin

1. In Bucks traction requiring frequent pain medication 2. 24 hours post appendectomy 3. Diagnosed with cholelithiasis and scheduled for surgery in the AM

A client diagnosed with hypothyroidism has been taking levothyroxine in increasing doses over the past week. Which findings, if present, would indicate to the nurse that the drug dosage is too high? Select all that apply 1. Irritability 2. Weight gain 3. Tachycardia 4. Tremors 5. Headache 6. Bradycardia

1. Irritability 3. Tachycardia 4. Tremors 5. Headache

A client is admitted to the Labor & Delivery Unit with severe preeclampsia. Which nursing intervention does the nurse include in the plan of care for this client? 1. Monitor for headache. 2. Place client in left recumbent position. 3. Insert indwelling urinary catheter. 4. Administer propranolol for BP > 100 diastolic. 5. Initiate external fetal heart monitoring.

1. Monitor for headache. 2. Place client in left recumbent position. 3. Insert indwelling urinary catheter. 5. Initiate external fetal heart monitoring.

What symptoms of meningeal irritation would the nurse anticipate when performing an assessment on a newly admitted client with a diagnosis of bacterial meningitis? Select all that apply 1. Positive Kernig's sign 2. Positive Brudzinski's sign 3. Presence of Babinski's reflex 4. Photophobia 5. Severe headache 6. Nuchal rigidity

1. Positive Kernig's sign 2. Positive Brudzinski's sign 4. Photophobia 5. Severe headache 6. Nuchal rigidity

A nurse wants to find out a better way to perform oral care on unresponsive clients. What is the best first action for the nurse to take in order to achieve this goal? 1. Try different methods of oral care on unresponsive clients to see what works best. 2. Discuss the issue with the leader of the "best practices" committee. 3. Read all the current literature related to oral care on unresponsive clients. 4. Ask the primary healthcare provider to suggest the best oral care procedure.

2. Discuss the issue with the leader of the "best practices" committee.

The nurse is educating a group of teenagers who have expressed an interest in using electronic cigarettes (e-cigarettes). What information about electronic cigarettes should the nurse include? You answered this question Incorrectly 1. Electronic cigarettes are a safe alternative to smoking. 2. It is difficult for consumers to know what electronic cigarette products contain. 3. Nicotine can harm adolescent brain development. 4. Electronic cigarette aerosol generally contains fewer toxic chemicals than the smoke from regular cigarettes. 5. Defective electronic cigarette batteries can cause fires and explosions.

2. It is difficult for consumers to know what electronic cigarette products contain. 3. Nicotine can harm adolescent brain development. 4. Electronic cigarette aerosol generally contains fewer toxic chemicals than the smoke from regular cigarettes. 5. Defective electronic cigarette batteries can cause fires and explosions.

Which task would be appropriate for the nurse to assign the unlicensed assistive personnel (UAP)? 1. Assess any pressure ulcers noted on clients. 2. Report if any client indicates pain. 3. Monitor amount of chest tube drainage. 4. Demonstrate coughing and deep breathing exercises to post-op clients.

2. Report if any client indicates pain.

The client has pustules on the arm from intravenous drug abuse. The microbiology laboratory informs the nurse that the client's cultures are growing methicillin-resistant Staphylococcus aureus (MRSA). Which action would the nurse take? You answered this question Incorrectly 1. Implement droplet precautions immediately. 2. Inform the client to wear a mask when ambulating in the hall. 3. Instruct the client on the importance of hand hygiene. 4. Cover the pustules to prevent drainage. 5. Allow pustules to drain freely.

3. Instruct the client on the importance of hand hygiene. 4. Cover the pustules to prevent drainage.

What measures should the school nurse implement for a child diagnosed with peanut allergies? You answered this question Correctly 1. Keep a lidocaine auto-injector readily available. 2. Obtain assessment data about visual acuity, and health conditions that might affect food allergy management. 3. Maintain contact information for parents and primary healthcare provider. 4. Review history of known food allergens and the severity of previous reactions. 5. Train designated personnel to administer prescribed medication in an anaphylaxis emergency.

3. Maintain contact information for parents and primary healthcare provider. 4. Review history of known food allergens and the severity of previous reactions. 5. Train designated personnel to administer prescribed medication in an anaphylaxis emergency.

The client who is scheduled for a cholecystectomy asks the nurse about her opinion on the surgeon who is going to perform the surgery. The nurse says to the client, "You should get a second opinion because your surgeon has been involved in several client lawsuits." Because the surgeon has not been involved in any client lawsuits, the nurse has initiated which tort? 1. Assault 2. Libel 3. Slander 4. Negligence

3. Slander

A housekeeper has been called to the medical-surgical unit to complete several tasks. Which tasks by the housekeeper has priority? 1. Replace the full sharps container in the medication room. 2. Clean room of discharged client who was isolated with MRSA. 3. Wipe up spilled coffee in the family waiting room. 4. Repair a malfunctioning curtain around a client's bed.

3. Wipe up spilled coffee in the family waiting room.

A terminal client begins reminiscing about the past, expressing grief and regret over life choices. What response by the nurse would best help the client cope at this time? 1. "You can't change the past so try not to dwell on it." 2. "Would you like me to call a priest for you to talk with?" 3. "You still have time to make amends if you want." 4. "I can sit here with you while you continue to talk."

4. "I can sit here with you while you continue to talk."

A military veteran with a history of post-traumatic stress disorder (PTSD) has arrived at the Crisis Center reporting an increase in nightmares, depression and anxiety. The nurse is aware the client would obtain the most immediate relief with what intervention? 1. Increase dose of antianxiety medications. 2. Greater family support interaction. 3. Referral to community support group. 4. Opportunity to verbalize memories.

4. Opportunity to verbalize memories.

A client has just developed an abdominal wound evisceration post bowel resection. In what position should the nurse place the client? 1. Sims' position. 2. Dorsal recumbent. 3. Right side lying in the fetal position. 4. Supine, head of bed at 15 degrees with knees and hips bent.

4. Supine, head of bed at 15 degrees with knees and hips bent.