Hurst Readiness Exam 1
The primary healthcare provider (PHP)has prescribed a saline IM injection for a client who requests pain medication every 2-3 hours. What would be the nurse's best first action? 1. Administer the injection. 2. Take vital signs. 3. Question prescription with primary healthcare provider. 4. Notify the nursing supervisor.
3.
What activities should a nurse recommend to a group of adolescents who have been diagnosed with rheumatoid arthritis? 1. Jogging 2. Volleyball 3. Tennis 4. Bicycle riding 5. Swimming
4., & 5.
The nurse is assessing a client who is being treated with a non-steroidal anti-inflammatory medication (NSAID) for an acute flare-up of gout. Which finding is expected in the assessment? 1. Dramatic decrease in pain after beginning medications. 2. Severe abdominal pain following medication administration. 3. Decreased plasma uric acid levels. 4. Low-grade fever and rash.
1.
The nurse is planning to discuss pain management with a client who experiences chronic pain. How should the nurse best begin this discussion? 1. "Please tell me how I can best help you control your pain." 2. "It is my job to teach you how to deal with your pain." 3. "I will be teaching you how to use guided imagery to decrease your pain." 4. "Your primary healthcare provider has prescribed pain medication for your pain. I will teach you about this medication."
1.
The nurse is teaching a group of pregnant women about hormonal changes during pregnancy. The nurse recognizes that teaching was successful when the women identify which hormone as causing amenorrhea? 1. Progesterone 2. Estrogen 3. Follicle-stimulating hormone (FSH) 4. Human chorionic gonadotropin (hCG)
1.
What discharge instruction should a nurse provide to a client diagnosed with Hepatitis B to provide adequate nutrition? 1. Suggest client eat several small meals a day, with the largest at breakfast. 2. Recommend eating meals in a semi-recumbent position. 3. Administer metoclopramide 1 hour after meals. 4. Avoid fruit juices and carbonated beverages.
1.
Which client in the Labor, Delivery, Recovery, and Postpartum Unit (LDRP) should the nurse see first? 1. Primipara at 39 weeks gestation, who is dilated to three centimeters and at minus two station who states, "I think my water just broke." 2. Multigravida at term who is dilated to six centimers and at minus one station with moderate contractions every five to ten minutes. 3. Primipara at 38 weeks gestation who is dilated to five centimeters and at zero station with strong contractions every four minutes. 4. Multigravida at 36 weeks gestation with pregestational diabetes in for a biophysical profile for fetal well being.
1.
Which client should the charge nurse assign to a new RN? 1. Child needing pre-operative medication prior to reduction of a fracture. 2. Adult client reporting abdominal pain after being beaten up in a fight. 3. Adolescent with sickle cell disease requesting more medication via the patient controlled analgesia device. 4. Child admitted with cystic fibrosis 2 hours ago.
1.
Which finding would indicate to the nurse that a client is at nutritional risk and should receive a dietary consult? 1. Six year old who had surgery 5 days ago, receiving clear liquid diet since surgery. 2. Twelve year old admitted 5 days ago receiving total parenteral nutrition (TPN). 3. Two year old taking only clear liquids since admission 24 hours ago. 4. Nine month old admitted 2 days ago for diarrhea and now on ½ strength formula.
1.
The nurse at the wellness clinic is teaching a client newly diagnosed with insulin-dependent diabetes mellitus. The client asks about beginning an exercise program. The nurse bases the response on the fact that exercise has what effect on the body? 1. Lowers the blood glucose 2. Provides more energy 3. Increases insulin need 4. Reverses complications of diabetes 5. Increases the workload of the liver
1. & 2.
Which client assignments are most appropriate for the charge nurse to delegate to an LPN/VN who works on the pediatric unit? 1. 10 year old paraplegic in for bowel training. 2. 2 year old with asthma newly admitted with dehydration. 3. 3 month old admitted with possible septicemia. 4. 7 year old in Buck's traction for a femur fracture. 5. 10 year old transferred from ICU yesterday with a head injury.
1. & 4.
The nurse administers chemotherapeutic drugs to a client with breast cancer. Where should the nurse dispose of the medication vials? 1. In a puncture-resistant biohazard container 2. In a chemotherapy sharps container 3. In a biohazard waste container 4. In a chemical container
2.
The nurse is administering medication to an elderly client who has no visitors. The client takes the pills, and, as the client hands the medication cup back to the nurse, grabs onto the nurse's hand tightly. What is the most logical rationale for the client's action? 1. Confusion and disorientation. 2. Scared and lonely and grabs the nurse's hand for comfort. 3. Would like to talk with the nurse. 4. Would like to reminisce with the nurse.
2.
The nurse is caring for a client prescribed vancomycin for Methicillin-Resistant Staphylococcus Aureus (MRSA) infection. What nursing intervention is appropriate? 1. Provide the client food or a snack to take with the medication 2. Verify that the client's BUN and creatinine are within normal range 3. Administer an antiemetic prior to vancomycin administration 4. Request the placement of a PICC line for IV administration
2.
The nurse is preparing to collect a capillary blood specimen for measuring blood glucose. Which action is most likely to result in an adequate stick for the client? 1. Place the finger at heart level when making the stick. 2. Warm the finger prior to the stick. 3. Keep the injector loose against the skin. 4. Place the finger above heart level when making the stick.
2.
The nurse is preparing to discharge a client who has been placed on tranylcypromine. The nurse teaches the client about food to avoid while taking this medication. What food choice by the client confirms appropriate understanding of the teaching? 1. Cottage cheese 2. Salami 3. Baked chicken 4. Potatoes
2.
The nurse is teaching a group of clients about selective serotonin reuptake inhibitors (SSRI). Which comment by a client in the group indicates adequate understanding of the effects/side effects of the medications? 1. My weight may decrease while taking this drug. 2. I may expect increased sweating while taking this drug. 3. I may actually feel more depressed while taking this medication. 4. I should feel better within a couple of days after beginning the medication.
2.
The nurse is teaching the family of a newly diagnosed diabetic client about treatment of hypoglycemia at home. Which guidelines should be given to the family of the client? 1. It is not necessary to treat mild hypoglycemia indicated by irritability. 2. Treat a mild episode with 10-15 grams of carbohydrate. 3. The client should consume 12 ounces of regular cola. 4. The client should consume 2 cups of orange juice without added sugar.
2.
Which client can a nurse manager safely transfer from the telemetry unit to the obstetrical unit in order to receive a new admit? 1. Client admitted with possible tuberculosis (TB) awaiting skin test results. 2. Client diagnosed with seizure disorder. 3. Client with a new pacemaker scheduled to be discharged in the morning. 4. Client with a history of mild heart failure prescribed one unit of packed red blood cells for anemia.
2.
Which statement by a client scheduled to be discharged home following treatment for alcoholism would indicate to the nurse that further instruction is necessary? 1. "I will read labels to be sure there is no hidden alcohol in food." 2. "I should go to an Alcoholics Anonymous meeting when I feel the need to drink alcohol." 3. "I can call the clinic or my sponsor whenever I feel tempted to drink alcohol." 4. "Even one glass of alcohol can cause me to start drinking regularly again."
2.
Which assessment findings does the nurse expect to find when assessing a client admitted to the emergency department with left sided congestive heart failure? 1. Ascites 2. Bibasilar crackles 3. Orthopnea 4. Hepatomegaly 5. Anorexia
2. & 3.
The nurse is preparing a client for surgery. Which methods are appropriate for the nurse to use in removing excessive body hair? 1. Shaving the hair with a razor. 2. Removing the hair with clippers. 3. Lathering the skin with soap and water prior to shaving with a razor. 4. Using a depilatory cream. 5. Always use a new, sharp razor.
2. & 4.
The nurse is caring for a client with chronic renal failure who receives dialysis treatment. Which findings would indicate to the nurse that the client's AV shunt is patent? 1. A bruit is heard with a stethoscope. 2. A thrill is felt on palpation. 3. There is a blood return on the venous side of the shunt. 4. Urine output greater than 30 mL/hr. 5. There is a strong radial pulse in the arm with the AV shunt.
1, & 2.
A child is admitted to the hospital with a temp of 102.2°F ( 39.0°C), lethargic, and no urinary output in 6 hours. Which prescription would be priority for the nurse to initiate for this child? 1. Blood cultures times two 2. Ceftriaxone 250 mg IV every 12 hours 3. Start IV & monitor site. 4. 1/2 normal saline at 40 mL/hr
1.
A client diagnosed with depression asks the nurse, "What is causing me to be depressed so often?" What is the best response by the nurse? 1. "There are a number of reasons that may contribute to depression, such as a decreased level of chemicals in your brain. " 2. "You experience depression because of your elevated levels of thyroid hormones." 3. "The primary healthcare provider will have to explain to you what is causing your depression." 4. "Tell me what you think causes you to be depressed."
1.
A client has a prescription for digoxin 0.125 mg IV push every morning. Prior to administering digoxin, the nurse notes that the digoxin level drawn this morning was 0.9 ng/mL. Which action would be most important for the nurse to take? 1. Administer the digoxin. 2. Hold the digoxin. 3. Notify the primary healthcare provider. 4. Repeat the digoxin level.
1.
A client has been taking enoxaparin 40 mg subcutaneous once a day for 1 week. Which action should the nurse take? exhibit: Hgb - 15 g/dl (2.3 mmol/l) Hct - 42% Platelets - 110,000/ mm3 aPTT - 110 seconds INR - 1.2 1. Administer protamine sulfate 50 mg over 10 minutes. 2. Type and cross match for 2 units PRBCs 3. Increase enoxaparin dose to increase INR 4. Give the scheduled dose of enoxaparin
1.
A home care nurse is preparing to perform venipuncture on a client to draw blood. As the nurse gathers supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of losing control. How should the nurse communicate with this client? 1. Use simple words. 2. Speak loudly to the client. 3. Do not speak to the client at this time. 4. Use open-ended questions to ask what is wrong.
1.
A newly admitted client with schizophrenia tells the nurse, "The doctor is trying to steal my organs for science." Which response by the nurse would be most therapeutic? 1. Are you feeling afraid now? 2. I am here with you. 3. Let's discuss something else. 4. You know that is not true.
1.
The client is worried and distracted, and explains to the nurse that because of the direct admission from the primary healthcare provider's office there was no preparation to be away from home. The client is concerned about the length of stay, pets that need care, and bills that require payment. Which response from the nurse would be most helpful to this client? 1. An unexpected hospital admission can be very stressful. I will notify the case manager who specializes in helping clients with situations like yours. There is a telephone here so that you can contact your family and friends. 2. I know how you feel. I will be sure to tell your night nurse in shift report that you will probably need something to help you sleep tonight. 3. An unexpected hospital admission can be very stressful. Is there anyone who I can call for you? 4. I can call your primary healthcare provider for you and ask if you could go home today, t
1.
The nurse has been educating a client on a new prescription for amitriptyline 25 mg PO twice a day. The nurse recognizes that teaching has been successful when the client makes which statement? 1. I will wear long sleeves and a hat when I go for my afternoon walks. 2. I will limit my alcohol intake to one glass of red wine with supper. 3. I need to limit my fluid intake in order to avoid fluid retention. 4. I need to maintain a high calorie diet and eat 6-8 small meals a day.
1.
The nurse in the clinic would recognize which client statement as most indicative of gallbladder disease? 1. "Yesterday, when I ate a hamburger and french fries, my belly really hurt." 2. "I have been gaining a lot of weight lately." 3. "My stools are darker. Sometimes they are even black." 4. "When I start hurting, it helps if I drink milk or have a small snack."
1.
A client is admitted to the hospital with a platelet count of 132,000 mm3 and a white cell count of 8,495 cells/mcL. What interventions should the nurse implement? 1. Monitor stools for occult blood. 2. Place on fall prevention. 3. Place client in protective isolation. 4. Restrict venipunctures. 5. Limit visitors.
1., 2., & 4.
The drug nadolol is prescribed for a client with stable angina. Which findings would indicate to the nurse that the drug is effective? 1. Decreased anxiety 2. Relief of chest pain 3. Bounding pulses 4. Lowered blood pressure 5. Bradycardia
1., 2., & 4.
The nurse is teaching a group of clients who have reduced peripheral circulation how to care for their feet. What points should the nurse include? 1. Check shoes for rough spots in the lining. 2. File toenails straight across. 3. Cover feet and between toes with creams to moisten the skin. 4. Break in new shoes gradually. 5. Use pumice stones to treat calluses.
1., 2., & 4.
Which nurse is providing cost effective care to a client? 1. Providing palliative care to a terminally ill client. 2. Beginning discharge planning on admit. 3. Counseling clients on cigarette smoking cessation. 4. Educating a group of parents on the importance of childhood immunizations. 5. Performing a postop wound dressing change using clean gloves.
1., 2., 3., & 4.
A nurse is teaching a client about post-procedure thoracentesis nursing care. Which statements should the nurse include? 1. Checking your vital signs frequently. 2. Examining the dressing for bleeding. 3. Listening to and percussing your lungs. 4. Positioning you with your affected lung down. 5. Palpating around the incision site for air under the skin.
1., 2., 3., & 5.
Which information obtained during a well-baby checkup of a 3 month old infant would the nurse need to report to the primary healthcare provider? 1. Parent states infant tastes salty. 2. Frequent coughing with thick, blood-streaked sputum. 3. Foul-smelling, greasy stools. 4. Able to hold head upright without head wobbling. 5. No weight gain since last check-up.
1., 2., 3., & 5.
In order to prevent injury or discomfort and maximize overall performance, what essential elements of ergonomic principles should the nurse utilize when caring for clients? 1. Promote maximal stability by utilizing a wide base of support. 2. Maintain a low center of gravity. 3. Use both the arms and the legs when performing strenuous activity. 4. Save effort by lifting rather than rolling, turning, or pivoting. 5. Utilize muscles of the back rather than muscles of the shoulders. 6. Obtain assistance from other nurses or nurse assistants as needed.
1., 2., 3., & 6.
A nurse manager notices that unit nurses consistently forget to ask clients to rate their pain level on a scale of 0-10. What strategies could the nurse manager initiate to improve performance? 1. Provides "just in time" posters outlining the importance of pain assessment. 2. Conducts brief in-services for each shift. 3. Counsels nurses when pain level scale is not utilized. 4. Ensures that a complete and clear performance standard exists. 5. Assesses nurses' reasons for not using pain level scale. 6. Disciplines offenses through unpaid time off.
1., 2., 3., 4. & 5.
The nurse is caring for a client with a perineal burn. The skin is not intact. What signs are suggestive of infection? 1. Color Changes 2. Drainage 3. Odor 4. Fever 5. Bleeding 6. Increased Pain
1., 2., 3., 4. & 6.
The client has been working on weight loss for 8 months and has been successful in losing 35 lbs (15.9 kg). The client is now entering the maintenance phase of the health promotion plan. Which strategies are important for the nurse to emphasize as the client enters this phase? 1. On-going support from weight-loss program personnel. 2. Periodic weigh-ins with the nurse. 3. Discontinue programmatic exercise plan. 4. Relapse prevention plan. 5. Continued peer support.
1., 2., 4. & 5.
The nurse is planning care for a client who has a fractured hip. Which nursing interventions should the nurse plan to use for impaired physical mobility? 1. Turn every two hours 2. Place a pillow between legs when turning 3. Sit in a chair three times per day 4. Encourage fluid intake 5. Encourage ankle and foot exercises
1., 2., 4. & 5.
A client is being admitted with a diagnosis of cirrhosis of the liver. What assessment findings should the nurse anticipate in this client? 1. Firm, nodular liver 2. Ascites 3. Increased serum albumin levels 4. Increased ALT and AST levels 5. Lowered ammonia levels 6. Bleeding from the GI tract
1., 2., 4., & 6.
A new nurse is documenting in a client's electronic record. Which documentation would the charge nurse evaluate as appropriate documentation by the new nurse? 1. Forty year old admitted with diagnosis of cholecystitis to room 410 for surgical services. 2. Appears to be having abdominal discomfort. 3. Permit signed for laparoscopic cholecystectomy after discussing procedure with surgeon. 4. Pre op Diazepam 10.0 mg given po. 5. Transferred to surgical suite per stretcher with side rails up, in stable condition.
1., 3, & 5.
The nurse is teaching the client with asthma on proper use of an inhaler. Which statements by the client indicates that teaching has been successful? 1. "Exhale completely before using my inhaler." 2. "Use my steriod inhaler before the bronchodilator." 3. "Inhale slowly and push down firmly on the inhaler." 4. "Rinse my mouth with water after using my inhaler." 5. "Wait 5 minutes between puffs."
1., 3. & 4.
What should the nurse include when educating a client about the use of nitroglycerin sublingual. 1. Do not swallow nitroglycerin. 2. Keep the medication is a moist, warm place. 3. The medication may burn when taken. 4. Sit or lie down when taking this medication. 5. The most common side effect is vomiting.
1., 3., & 4.
When performing an admission assessment, what should the nurse recognize as signs/symptoms of hyperthyroidism? 1. Nervousness 2. Weight gain 3. Exophthalmos 4. Loss of appetite 5. Constipation 6. Hot and sweating
1., 3., & 6.
Which task would be appropriate for the charge nurse to assign to a LPN/VN? 1. Collect data on a new client admit. 2. Administer morphine IVP to a two day post-op client. 3. Bolus feeding a client who has a gastrostomy tube. 4. Reinserting a nasogastric tube (NG) that a client accidentally pulled out. 5. Monitor patient control analgesic (PCA) pump pain medication being delivered to a client.
1., 3., 4., & 5.
What laboratory results would the nurse anticipate finding in a client receiving chemotherapy who is experiencing pancytopenia? 1. White blood cell count of 3,800 (3.8 x 109/L) 2. White blood cell count of 15,000 (15.0 x 109/L) 3. Platelet count of 90,000/µL (90 x 109/L) 4. Platelet count of 450,000/µL (450 x 109/L) 5. Red blood cell count of 3.0 million/mcL (3.0 x 1012/L) 6. Red blood cell count of 7.3 million/mcL (7.3 x 1012/L)
1., 3., 5.
What side effects would the nurse expect to find in a client who has received too much levothyroxine? 1. Angina 2. Bradycardia 3. Hypotension 4. Heat intolerance 5. Tremors
1., 4., & 5.
The client has suicidal ideations with a vague plan for suicide. The nurse who is teaching the family to care for the client at home should emphasize which points? 1. Family members are responsible for preventing future suicidal attempts. 2. When the client stops talking about suicide, the risk has increased. 3. Warning signs, even if indirect, are generally present prior to a suicide attempt. 4. One suicide attempt increases the chance of future suicide attempts. 5. Report sudden behavioral changes.
2., 3., 4. & 5.
The nurse reassesses the client's pain level after administering an oral analgesic. The client states that the pain is better but continues to report a backache. Which non-pharmacologic interventions may help the client's backache? 1. Educating the client regarding pain and pain control. 2. Assisting the client into a side lying position. 3. Providing a back massage. 4. Providing heat therapy. 5. Using distraction techniques.
2., 3., 4. & 5.
A Hispanic mother and her child visit the primary healthcare provider's office due to a fever that the child has been having for two or three days. Upon entering the room, the nurse immediately asks what is happening with the child and begins to check the temperature. Which response is likely from the mother? 1. Accepts the treatment of the nurse and think that it is appropriate. 2. Takes offense to the abrupt nature of the treatment. 3. Thinks that the nurse is busy and needs to rush. 4. Thinks that the nurse is very efficient.
2.
A client arrives at the emergency department with a pneumothorax. A chest tube is inserted and placed to 20 cm of suction. Two hours later, the nurse notes tidaling in the water-seal chamber. Based on this data, what intervention should the nurse initiate? 1. Ausculate the lung sounds. 2. Document the finding. 3. Notify the primary healthcare provider. 4. Place the client on oxygen.
2.
A client comes into the clinic for a routine check-up during the second trimester of pregnancy. The client reports gastrointestinal (GI) upset and constipation. The nurse reviews the client's medications. Which client medication is most commonly associated with GI upset and constipation? 1. Calcium supplement 2. Ferrous sulfate 3. Folic acid 4. Cetirizine
2.
A client is admitted to the intensive care unit after overdosing on meperidine. What is the nurse's first priority? 1. Maintain continuous cardiac monitoring. 2. Administer naloxone hydrochloride 0.4 mg IV every 2-3 minutes prn. 3. Provide alprazolam 0.25 mg PO PRN. 4. Initiate intravenous fluid resuscitation with lactated ringers at 125 mL/hr.
2.
A client is admitted to the medical unit with an acute onset of fever, chills and RUQ pain. Vital signs are: T 99.8°F (37.7°C), P 132, RR 34, B/P 142/82. ABG results are: pH-7.53, PaCO2 30, HCO3 22. The nurse determines that this client is in what acid/base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
2.
A client is being treated in the emergency department for dehydration. Which central venous pressure (CVP) reading would the nurse identify as the desired response to treatment? 1. -1 mm Hg 2. 4 mm Hg 3. 10 mm Hg 4. 15 mm Hg
2.
A client is taking a nonsteroidal anti-inflammatory drug (NSAID) for the relief of joint pain. A gastrointestinal bleed is suspected. Which laboratory value alerts the nurse to the possibility that the client is chronically losing small amounts of blood? 1. Prolonged bleeding time 2. Elevated reticulocyte count 3. Decreased platelet count 4. Elevated bands
2.
A client returned to the unit following a total hip replacement. What statement by the client would indicate to the nurse that teaching has been successful? 1. "I will try to keep my legs together as close as possible." 2. "I will not elevate the head of the bed." 3. "I know that I cannot ever swim again." 4. "I can resume my exercises at the gym within one month."
2.
A client who has had a laparoscopic cholecystectomy develops pain in the left shoulder. Vital signs, laboratory studies, and an electrocardiogram are within normal limits. What does the nurse recognize as a contributing cause of the pain? 1. Surgical cannulation of the bile duct is causing spasm and pain. 2. Carbon dioxide used intraperitoneally is irritating the phrenic nerve. 3. Large abdominal retractors used in the procedure compressed a nerve. 4. Side lying position in the operating room generated pressure damage.
2.
A nurse is teaching a renal transplant client about self care after discharge. As part of the information about transplant rejection, the nurse cautions the client to notify the primary healthcare provider of which occurrence? 1. Ecchymosis of incision 2. Tenderness over the kidney 3. Frequent polyuria 4. Subnormal temperature
2.
The emergency responders enter the emergency department with a client in cardiac arrest. One of the responders is performing chest compressions. What is the best assessment for the nurse to determine if the responder is compressing with enough force and depth? 1. Dilated pupils after 1 minute of CPR 2. Presence of a carotid pulse with each compression 3. Cardiac rhythm on the monitor 4. Rise and fall of client's chest with ventilations
2.
A soldier who returned from combat 2 months ago was admitted to a psychiatric unit with a diagnosis of Dissociative Fugue. The police found the client wandering down the street in a daze after fighting with a stranger. Which nursing interventions should the nurse implement? 1. Directly observe the client at least every 4 hours. 2. Maintain a low level of stimuli. 3. Remove all dangerous objects from environment. 4. Convey a calm attitude toward the client. 5. Discourage client's expression of negative feelings.
2., 3. & 4.
The nurse sees that the new medication noted in a recent prescription is on the client's list of allergies. In the role of client advocate, what actions should the nurse take to ensure client safety? 1. Document the medication with times and doses to be given, then administer the medication as ordered. 2. Notify the primary healthcare provider immediately that the medication prescribed is on the client's list of medication allergies. 3. Stop the medication on the client's medication administration record. 4. Check the client's allergy band against the list of client allergies documented in the medical record. 5. Call the pharmacy to see if the medication needs to be changed.
2., 3. & 4.
What symptoms does the nurse expect to see in a client with bulimia nervosa? 1. Amenorrhea 2. Feelings of self-worth unduly influenced by weight 3. Recurrent episodes of binge eating 4. Recurrent inappropriate compensatory behavior to prevent weight gain 5. Lack of exercise
2., 3. & 4.
As part of the screening process to identify if a client is obese, the nurse calculates the client's body mass index (BMI). Weight - 180 pounds Height - 5' 5" Calculate the BMI to the whole number. Enter the answer for the question below.
29.95 or 30
What should the nurse include when teaching a client in renal failure about peritoneal dialysis? 1. Instill 250 ml of fluid into the peritoneal cavity over 30 minutes. 2. Use cool effluent when instilling into the peritoneal cavity. 3. Following the prescribed dwell time, lower the bag to allow the fluid to drain out. 4. The fluid that is returned should be clear in appearance. 5. If all the fluid does not drain out, place the bed in the Trendelenburg position. 6. A sweet taste may be experienced when peritoneal dialysis is used.
3, 4, & 6
The nurse is caring for a client on the medical unit. The client has an IV of 1000 mL D5W with 50,000 units heparin. The infusion is to run at 60 mL per hour. How many units/hour is the client receiving? Round answer to the nearest whole number. Enter the answer for the question below.
3,000 units/hr
A client of Jewish faith has requested a Kosher diet. Which food tray would the nurse provide to the client? 1. Medium rare steak, potato salad, peas and coffee 2. Ham sandwich, chips, fruit salad and juice 3. Broiled white fish, baked potato, mixed salad and tea 4. Baked chicken, vegetable medley, rice and milk
3.
A confused elderly client is brought to the emergency department by a family member who states the client fell down a flight of stairs. In addition to multiple facial contusions, x-rays reveal a spiral fracture of the left forearm. After assisting the primary healthcare provider in applying a short arm cast, the nurse identifies which action as a priority in discharge planning? 1. Ask the family to restrict the client to the first floor. 2. Instruct the client on home safety issues. 3. Notify social services to arrange a home visit. 4. Discuss cast care with client and family.
3.
A new mother calls the clinic and tells the nurse, "I don't have any help taking care of my 3 week old baby. I don't know what to do. I just feel like I can't take care of him anymore. I wish I never had him sometimes. Maybe then my husband would spend more time at home." What would be the nurse's best response? 1. "You are experiencing maternity blues, which will go away on its own." 2. "You are just tired. Tell your husband that you need his help." 3. "Come to the clinic now so that we can help you." 4. "Have you thought about getting a family member to help with the baby?"
3.
A newly admitted client tells the nurse, "I am hearing voices." Which response by the nurse is most appropriate? 1. Your head is turned to the side as if you are listening to voices. 2. I don't hear anyone but you speaking. 3. Tell me what the voices are saying to you. 4. Let's talk about your anxiety right now.
3.
A nurse is caring for a 65 year-old client diagnosed with dehydration. The client has been receiving intravenous normal saline at 150 mL/hour for the past 4 hours. Which finding would the nurse need to notify the primary healthcare provider? 1. Blood pressure 136/84 2. Report of nausea 3. Anxiety 4. Urinary output at 50 mL/hour
3.
A primary healthcare provider has prescribed sterile saline 1.5 mL IM every 4 hours as needed for pain for a client who reports frequent "severe" headaches. What action should the nurse take? 1. Administer the medication as prescribed. 2. Obtain pre-filled syringes from the pharmacy. 3. Discuss client rights with the primary healthcare provider. 4. Tell the client what has been prescribed.
3.
An elderly client receives instructions regarding the use of warfarin sodium. Which statement indicates to the nurse that the client understands the possible food interactions which may occur with this medication? 1. "I'm going to miss having my evening glass of wine now." 2. "I told my daughter to buy spinach for me. I'll have to eat more servings now." 3. "I will have to watch my intake of salads, something that I really love." 4. "I am going to begin eating more fish and pork and leave beef alone now."
3.
The client is admitted to the hospital following a motor vehicle accident and has sustained a closed chest wound. The nurse notes paradoxical chest wall movement. Which problem does the nurse suspect? 1. Mediastinal shift 2. Tension pneumothorax 3. Flail chest 4. Pulmonary contusion
3.
The client with bleeding esophageal varices has a Blakemore tube in place. What piece of equipment should be present at the bedside? 1. Tracheostomy set 2. Clamps 3. Surgical scissors 4. Tourniquet
3.
The nurse is admitting a client with a fifteen year history of poorly controlled diabetes mellitus. During the initial assessment the client reports experiencing "numb feet." What nursing action takes priority? 1. Check blood glucose level. 2. Assess for proper shoe size. 3. Examine the client's feet for signs of injury. 4. Test sensory perception in the client's feet.
3.
The nurse is caring for a newly admitted client with diabetes mellitus. The initial assessment reveals that the client is unresponsive, BP is 98/64, Resp 38, HR 100, T 97.2ºF (36.2º C). The nurse notes a fruity smell on the client's breath. The nurse recognizes that the client is in which acid-base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
3.
The primary healthcare provider instructs the nurse to place body tissue obtained from a biopsy into a container with formalin prior to sending it to pathology. The nurse has not handled formalin before. What would be the nurse's best action? 1. Call the pathology department for directions on formalin's use and precautions. 2. Look formalin up in the drug handbook 3. Read about formalin on the Material Safety Data Sheet (MSDS). 4. Explain to the primary healthcare provider that nurses are not allowed to use formalin.
3.
Which client should the nurse, working the Emergency Department (ED), see first? 1. Client diagnosed with Chronic Obstructive Pulmonary Disease (COPD) who has a non-productive cough. 2. Client who is a diabetic and has an infected sore on the foot. 3. Client with adrenal insufficiency who feels weak. 4. Client with a fracture of the forearm that has been placed in a splint.
3.
When caring for young adult clients, which developmental tasks would the nurse expect to see? 1. Satisfying and supporting the next generation. 2. Reflecting on life accomplishments. 3. Developing meaningful and intimate relationships. 4. Giving and sharing with an individual without asking what will be given or shared in return. 5. Developing sense of fulfillment by volunteering in the community.
3. & 4.
An alert client presents to the emergency department with vomiting for 3 days and has been unable to keep food or fluids down for the last 24 hours. Which imbalances does the nurse suspect this client has? 1. Hypocalcemia 2. Hypermagnesemia 3. Hypokalemia 4. Metabolic alkalosis 5. Respiratory acidosis
3., & 4.
What impaired functions does the nurse expect to observe in the client admitted with an injury to the frontal lobe of the brain? 1. Decreased sensation to touch. 2. Impaired vision. 3. Impaired speech. 4. Decreased concentration. 5. Decreased hearing.
3., & 4.
A client at 32 weeks gestation is admitted to the obstetric unit with a BP of 142/90 and 1+ proteinurea. Since no private rooms are available, the charge nurse must assign the client to a semi-private room. Which client should the charge nurse assign this client to room with? 1. Postpartum woman who delivered at term. 2. Woman in preterm labor at 35 weeks gestation. 3. Woman with placenta previa at 37 weeks gestation. 4. Pre-term labor client with twins at 28 weeks gestation.
4.
A client is admitted for observation following an unrestrained motor vehicle accident. A bystander stated that the client lost consciousness for 1-2 minutes. On admission, the client reports a headache and had a Glasgow coma scale (GCS) of 14. The GCS is now 12. What is the priority nursing intervention for this client? 1. Continue to assess every 15 minutes. 2. Stimulate the client with a sternal rub. 3. Administer acetaminophen with codeine for headache. 4. Notify the primary healthcare provider.
4.
A client with Graves' disease and exophthalmos returns to the clinic for evaluation. Which assessment indicates to the nurse that the client is adhering to the teaching plan? 1. Moist, shiny, soft hair 2. Resting heart rate of 120 3. Adheres to the prescribed low-sodium diet 4. An absence of corneal irritation
4.
After report, the nurse is assigned to care for 4 adult clients. Which client should the nurse assess first? 1. Admitted 3 hours ago post appendectomy with small amount of drainage on dressing. 2. Diagnosed with early onset of Alzheimer's disease with confusion. 3. Post operative internal fixation of the femur with crust forming on the Steinman pins. 4. Receiving treatment for dehydration, and is now picking at bedding and IV tubing.
4.
An unlicensed assistive personnel (UAP) has explained how to prevent the spread of infection to the charge nurse. Which statement by the UAP indicates that further teaching is needed? 1. "Soap and water should be used for hand washing when our hands are visibly soiled." 2. "Gloves do not have to be worn when taking a client's vital signs or passing out meal trays." 3. "Standard precautions should be used on all clients." 4. "When caring for a client who has a suppressed immune response, a N95 mask should be worn."
4.
During shift change the night charge nurse reports to the day charge nurse that a client, admitted with an ingestion of unknown drugs, received a prescription for physical restraint at 3:00 am because the client was incoherent, combative, and attempting to leave the facility. On last assessment at 7:00 am, the client was still combative. What is the best action by the day shift charge nurse? 1. Since the client is still combative, continue the restraints. 2. Remove restraints until the primary healthcare provider writes the prescription. 3. Assign an unlicensed assistive personnel (UAP) to check on the client periodically. 4. Obtain a prescription from the primary healthcare provider.
4.
The nurse approaches a client who entered the emergency department following a fall down a flight of stairs. The client is unresponsive with snoring and wheezes with respirations. How would the nurse best open the client's airway? 1. Endotracheal tube (ET) 2. Head tilt-chin lift maneuver 3. Oropharyngeal airway 4. Jaw thrust maneuver
4.
The nurse is planning care for a newly admitted client who has an Arabic surname and whose spouse is wearing a traditional head covering. After verifying that the client prescriptions include a regular diet as tolerated, how would the nurse best meet the religious dietary needs for this client? 1. Allow the client to select whatever is acceptable from a regular meal tray. 2. Review the client's admission data to determine any dietary restrictions. 3. Call the dietician to discuss special dietary needs with the client's spouse. 4. Ask the client about dietary preferences needed to meet religious guidelines.
4.
The unlicensed assistive personnel (UAP) reports to the nurse that a client with Alzheimer's has been walking into rooms on the unit and stating, "This is my room, so get out!" What is the best instruction the nurse can give to the UAP? 1. Calmly sit with the client and have the client repeat the room number at frequent intervals. 2. Have the client remain in the room so the client can become familiar with it. 3. Place a sign on the client's door that clearly has the client's name so the client can identify it. 4. Hang a familiar object on the door to enhance room recognition.
4.
These clients have arrived at the emergency department (ED) following an explosion at a local industrial plant. The ED is operating under disaster protocol. Which client should be treated first? 1. The client whose blood pressure is 40 palpable, heart rate 30, and respirations 6. 2. The comatose client with fixed and dilated pupils. 3. The unresponsive client with an open head fracture and visible white matter. 4. The client with a sucking chest wound and tension pneumothorax.
4.
What task by the RN should be performed first? 1. Changing a burn dressing that is scheduled every four hours. 2. Administering scheduled IV antibiotic. 3. Teaching a new diagnosed diabetic about diet and exercise. 4. Assessing a newly admitted client.
4.
Which client diagnosis would require the nurse to initiate droplet precaution? 1. Methicillin-resistant Staphylococcus aureus (MRSA) 2. Varicella 3. Vancomycin-resistant enterococci (VRE) 4. Whooping cough
4.
The nurse is caring for a client on the pediatric unit. The primary healthcare provider prescribes phenytoin 30 mg by mouth every 8 hours for a client weighting 18 kg. The recommended dosage is 5 mg/kg/day. What does the nurse determine is the safe dosage for the child in mg/day? Round your answer to the nearest whole number.
90 mg/day
A nurse observes a fire has started in the trash can of a client's room. What steps should the nurse take? Place steps in priority from first to last. Remove the client from the room. Close the door to the client's room. Activate the fire alarm. Obtain the fire extinguisher. Extinguish the fire.
Rescue the client; activate the alarm; contain the fire in the client's room; extinguish the fire.
