LDR Review
A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse should teach the client that which of the following factors puts her at risk for lithium toxicity?
the client runs 4 miles outdoors every afternoon
A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following action should the nurse take?
Secure the restraints using a quick-release tie.
The nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse suspects that the client is suffering from post-traumatic stress disorder when the client states:
"In my dreams, all I can see are the wounded reaching out and trying to grab me."
A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alteration in function should the nurse expect? A Difficulty reading B Inability to recognize his family members C. Right hemiparesis D. Aphasia
B
A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?
Changes in the cervix
A client with Parkinson's disease is taking diphenhydramine 25mg PO 3x a day, what therapeutic outcome would the nurse expect to see?
Decreased tremors
If a child is admitted with a suspected diagnosis of Wilms Tumor.. what will the sign say?
Don't palpate the abdomen
A nurse is monitoring a client who was admitted with a sever burn injury and is receiving IV fluid resuscitation therapy. the nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?
Heart Rate
a nurse is teaching a client who has CKD and a new prescription for epoetin alfa. the nurse should instruct the client to increase dietary intake of which of the following substances.
Iron
A nurse is caring for a client who is undergoing a lumbar puncture. Which of the following is the priority action for the nurse to take to maintain privacy for the client?
Pull the curtain around the clients bed
A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take?
Remove the catheter and insert another into a different site.
A nurse is caring for a client who has bipolar disorder and has been taking lithium for 1 year. Before administering the medication, the nurse should check to see that which of the following tests have been completed?
Thyroid hormone Rationale: Thyroid testing is important because long-term use of lithium may lead to thyroid dysfunction.
A parent calls a clinic and reports to a nurse that has 2 month old infant is hungry more than usually but has projectile vomiting immediately after eating. Which of the following responses should the nurse make?
"bring your baby in to the clinic today" Projectile vomiting followed by hunger are characteristic of pyloric stenosis. The infant needs to be examined in the clinic by a provider as soon as possible.
A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord?
2 arteries and 1 vein
a nurse is preparing to administer vaccines to a 1 year old child. which of the following are given: SATA A. MMR B. Varicella C. DTaP D. Rotavirus E. HPV
A, B, C
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.) A. Increased heart rate B. Increased blood pressure C. Increased respiratory rate D. Increase hematocrit E. Increased temperature
A, C, E
A 4 year old child is restraint to taking medication. which of the following strategies should the nurse use to elicit the child's cooperation? a. Offer the child a choice of crushed pills or elixir b. Tell the child it is candy c. Hide the medication in ice cream or juiced. d. Tell the child he will have to have a shot instead
A, offer a choice?
A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make? A. "It's a minor inconvenience, which you should ignore." B. "In most cases it only lasts until the 12th week, but it will continue if you have poor bladder tone." C. "There is no way to predict how long it will last in each individual client." D. "It occurs during the first trimester and near the end of the pregnancy."
D
A nurse is inserting an IV catheter for an older client in preparation for an outpatient procedure. Which of the following veins should the nurse select? A. Dorasal metacarpal B. Radial Vein C. Anticubital D. median Vein in forearm
D Because it's distal to other potential venipuncture sites and it avoids areas of flexion
A nurse is providing teaching for a client who has gastroesophageal reflux disease (GERD) about ways to manage his condition. Which of the following instructions should the nurse include?
Eat 4 small meals each day Or avoid eating 3 hours before bedtime
A nurse is providing care for a surgeon on a medical surgical unit. A nurse from another unit asks the nurse about the surgeons medical diagnosis. The nurse responds that he is unable to provide the information requested. The nurse is displaying which of the following ethical principals?
Non maleficence
A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take?
Prevent Aspiration
.A school nurse is assessing a child for pediculosis capitis. Which of the following manifestations should the nurse recognize as an indication of this condition? A. Firmly attached white particles on the hair B. Itching and scratching of the head C. Patchy areas of hair loss D. Thick yellow crusted lesion on a red base
A
A nurse is caring for a client who has poison ivy and is prescribed diphenhydramine. Which of the following instructions should the nurse give regarding the adverse effect of dry mouth associated with diphenhydramine?
Chew on sugarless gum, or hard, sour candies
A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take? A. Inform the client that privileges are related to participation in therapy. B. Limit visiting hours until the client begins to participate in therapy. C. Allow the client to control the timing and frequency of the therapy. D. Establish a plan of care with the client that sets attainable goals.
D
A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a MVA. Identify the sequence of actions the nurse should take. 1) Perform GCS assessment 2) Establish IV access 3) Open the airway using jaw-thrust maneuver 4) determine effectiveness of ventilator efforts 5) remove clothing for a thorough assessment
3,4,2,1,5 A (airway), B (breathing), C (circulation), D (disability), E (exposure)
. A nurse is completing an admission assessment on an adolescent client who is a vegetarian. He eats milk products but does not like beans. Which of the following items should the nurse suggest the client order for lunch to provide the nutrients most likely to be lacking in his diet? A. Peanut butter and jelly sandwich B. Baked potato topped with sour cream C. Bagel with cream cheese D. Fruit salad
A
A nurse at a prenatal clinic is caring for a client who is in her first trimester of pregnancy. The client tells the nurse that she is upset because, although she and her husband planned this pregnancy, she has been having many doubts and second thoughts about the upcoming changes in her life. Which of the following is an appropriate response by the nurse? a."Ambivalent feelings are quite common for women early in pregnancy." b."Perhaps you should see a counselor to discuss these feelings further." c."Have you spoken to your mother about these feelings?" d."Don't worry. You will be fine once the baby is born.
A
A nurse in a family planning clinic is caring for a 17-year-old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make? A."What part of the exam makes you most nervous?" B."Don't worry, I will be with you during the exam." C."All you need to do is relax." D."A pelvic exam is required if you want birth control pills."
A
A nurse is admitting a child who has leukemia. Which of the following clients should the nurse place in the same room with this child? A. A child who has nephrotic syndrome B. A child recovering from a ruptured appendix C. A child who has rheumatic fever D. A child who has cystic fibrosis
A
A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first? a. Test the drainage for glucose b. Suction the nostril c. Notify the physician d. Ask the client to blow his nose
A
A nurse is caring for a 12-month-old toddler who is hospitalized and confined to a room with contact precautions in place. Which of the following toys should the nurse recommend in order to meet the developmental needs for the kid? A. Large building blocks B. Hanging crib toys C. Modeling clay D. Crayons and a coloring book
A
A nurse is caring for a 4-year-old child who has a new diagnosis of diabetes mellitus and is distressed after an insulin injection. Which of the following play activities should the nurse recognize is therapeutic in helping the child deal with the injection? A needleless syringe and a doll B A video game C A story book about a child who has diabetes D A period of play in the playroom
A
A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client's blood work, the nurse notices she does not have immunity to rubella. Which of the following times should the nurse understand is recommended for rubella immunization? A. Shortly after giving birth B. In the third trimester C. Immediately D. During her next attempt to get pregnant
A
A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the following findings support this diagnosis? A.Painless red vaginal bleeding B. Increasing abdominal pain with a non-relaxed uterus C. Abdominal pain with scant red vaginal bleeding D Intermittent abdominal pain following passage of bloody mucus
A
A nurse is reviewing data for four children. Which of the following children should the nurse assess first? A. A 10-year-old child who has sickle cell anemia who reports severe chest pain. B. A 7-year-old child who has a diabetes insipidus and a urine specific gravity of 1.016 C. A 1 year old toddler who has roseola and a temperature of 39 C (102.2 F) D. A 4-year-old who has asthma a PCO2 of 37 mm Hg
A
A nurse is teaching a client who has been taking prednisone to treat asthma and has a new prescription to discontinue the medication. The nurse should explain to the client to reduce the dose gradually to prevent which of the following adverse effects: A. adrenocortical insufficiency B severe dehydration C rebound pulmonary congestion D hyperglycemia
A
While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnosis should the nurse identify as being the priority in the client's care? A) Impaired tissue perfusion B) Alteration in body image C) Alteration in activity intolerance D) Impaired skin integrity
A
A nurse is taking a health history of a client who reports occasionally taking several over-the-counter medications, including H2 receptors antagonist (H2RA). Which of the following outcomes indications the H2RA is therapeutic? A. Relief of heartburn B. Cessation of diarrhea C. passage of flatus D. Absence of constipation
A ?
A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a durtiong of 1min and a frequency of 3min. The nurse obtains the following vitals: fetal heart rate 130/min, maternal heart rate 128/min, and maternal blood pressure 92/54mmHg. Which of the following is the priority action for the nurse to take? A. Notify the provider of the findings. B. Position the client with one hip elevated. C. Ask the client if she needs pain medication. D. Have the client void.
B Based on Maslow's hierarchy of needs, the client's need for an adequate blood pressure to perfuse herself and her fetus is a physiological need that requires immediate intervention. Supine hypotension is a frequent cause of low blood pressure in clients who are pregnant. By turning the client on her side and retaking her blood pressure, the nurse is attempting to correct the low blood pressure and reassess.
A nurse is caring for a client who is in her first trimester of pregnancy and asks the nurse if she can continue to exercise during pregnancy. Which of the following responses by the nurse is appropriate? A. "Exercising during pregnancy is not recommended." B. "Daily jogging for up to 30 minutes is fine throughout the pregnancy." C. "Activities that raise the body temperature, such as saunas and hot tubs, are safe until the third trimester." D. "It is recommended that pregnant clients limit their exercise routine to stretching activities on a mat several times a week."
B. While weight-bearing exercises might become uncomfortable in the last trimester, they are generally not contraindicated, providing the client stays hydrated and avoids becoming overheated for extended periods.
A nurse in an substance abuse clinic is assessing a client who recently started taking disulfiram. The client reports having discontinued the medication after experiencing severe nausea and vomiting. Which of the following reasons should the nurse suspect to be a likely cause of the client's distress? A. The client demonstrated an allergic response to the medication B. The client experienced a common side effect to the medication C. The client consumed alcohol while taking the medication D. The client took an overdose of the medication
C
A nurse on an oncology unit is preparing to administer doxorubicin to a client who has breast cancer. Prior to beginning the infusion, the nurse verifies the client's current cumulative lifetime dose of the medication. For which of the following reasons is this verification necessary? a. An excess amount of doxorubicin can lead to myelo suppression b. Exceeding the lifetime cumulative dose limit of doxorubicin might cause extravasation. c. An excess amount of doxorubicin can lead to cardiomyopathy d. Exceeding the lifetime cumulative dose limit of doxorubicin might produce red tinged urine and sweat.
C An excess amount of doxorubicin can lead to cardiomyopathy Doxorubicin is an anti-neoplastic antibiotic used in the treatment of various cancers. Irreversible cardiomyopathy with congestive heart failure can result from repeated doses of doxorubicin, and prolonged use can also cause severe heart damage, even years after the client has stopped taking it. The maximum cumulative dose a client should receive is 550 mg/m2 or 450 mg/m2with a history of radiation to the mediastinum.
A nurse is caring for a client who has Cushing's syndrome. The nurse should recognize that which of the following are manifestations of Cushing's syndrome? (Select all that apply.) A. Alopecia B. Tremors C. Moon face D. Purple striations E. Buffalo hump
C,D, E
A nurse is completing discharge teaching with a client following arthroscopic knee surgery. Which of the following instructions should the nurse include in the teaching? A. Remain on bedrest for the first 24 hr. B. Keep the leg in a dependent position. C. Apply ice to the affected area. D. Begin active range of motion.
C. Apply Ice to the affected area
A nurse is reviewing the medical record of a client who has been on levothyroxine for several months. Which of the following findings indicates a therapeutic response to the medication? A. Decrease in level of thyroxine (T4) B. Increase in weight C. Increase in hr of sleep per night D. Decrease in level of thyroid stimulating hormone (TSH).
D In hypothyroidism, the nonfunctioning thyroid gland is unable to respond to the TSH, and no endogenous thyroid hormones are released. This results in an elevation of the TSH level as the anterior pituitary continues to release the TSH to stimulate the thyroid gland. Administration of exogenous thyroid hormones, such as levothyroxine, turns off this feedback loop, which results in a decreased level of TSH.
A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client? A. Temperature B. Fetal heart rate (FHR) C. Bowel sounds D. Respiratory rate
D. Magnesium sulfate is typically administered to a client in preterm labor to achieve the tocolytic (uterine relaxation) effect. Magnesium sulfate depresses the function of the central nervous system, causing respiratory depression. Baseline assessment of respiratory status, checking the respiratory rate frequently, and reassessment of respiratory status with each change in dosage of magnesium sulfate is the primary focus when assessing the client. There is a narrow margin between what is considered a therapeutic dose and a toxic dose of magnesium sulfate.
A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?
Dry the skin
A Hospice nurse is caring for a client with terminal cancer and is taking PO morphine, the client has had to increase the dose this week to obtain pain relief. What should the nurse document?
The client has developed a tolerance to the medication
A nurse at an ophthalmology clinic is providing teaching to a client who has open angle glaucoma and a new prescription for timolol eye drops. Which of the following instructions should the nurse provide?
The medication should be applied on a regular schedule for the rest of the client's life.
