Module 10 Exam:
A nurse is assisting with data collection for a child with rheumatic fever. Which question does the nurse ask the parents to elicit information specific to the development of the disease? "Has he had a sore throat in the last few months?" "Has he been excessively tired or lethargic?" "Has he complained of a backache recently?" "Has he had any loss of appetite?"
"Has he had a sore throat in the last few months?"
A client has just had a plaster leg cast applied, and the nurse has given the client instructions on cast care. Which statement by the client indicates the need for further instruction? "I may feel cool while the cast is drying." "I shouldn't use anything to scratch underneath the cast." "I can dry the cast faster if I use a hairdryer on the hot setting." "If I smell any odor from the cast, I should call the doctor."
"I can dry the cast faster if I use a hairdryer on the hot setting."
The nurse has instructed a client who is about to begin external radiation therapy in how to maintain optimal skin integrity during therapy. Which statement by the client indicates a need for further instruction? "I need to keep the sun off the radiation site." "I can use over-the-counter cortisone cream on the radiation site if it gets red." "I need to wash the skin at the radiation site with a mild soap and water and pat it dry." "I need to be careful not to wash off the marks that the radiologist made on my skin."
"I can use over-the-counter cortisone cream on the radiation site if it gets red."
A nurse provides instructions to a client about measures to prevent an acute attack of gout. The nurse determines that the client needs additional instructions if the client makes which statement? "It's important for me to drink a lot of fluids." "Physical and emotional stress can cause an attack." "I don't need medication unless I'm having a severe attack." "A fad diet or starvation diet can cause an acute attack."
"I don't need medication unless I'm having a severe attack."
A nurse provides instructions to a client with rheumatoid arthritis about joint exercises that are important to prevent deformity and reduce pain. Which statement by the client indicates the need for further instruction? "I should avoid all exercise when my joints are inflamed." "I should always maintain good posture." "I should stop my exercises if I get tired." "Doing range-of-motion exercises every day will ease the pain."
"I should avoid all exercise when my joints are inflamed."
A nurse provides instructions to a client with chronic obstructive pulmonary disease (COPD) about the positions that are most effective in alleviating dyspnea. Which statement by the client indicates a need for further instruction? "I should sit up in my recliner." "I should sit on the side of my bed and lean on the overbed table." "I should stand with my back and hips against the wall and my shoulders bent slightly forward." "I should lie on my right side in bed."
"I should lie on my right side in bed."
A home care nurse has provided instructions to the father of a child with croup regarding treatment measures. Which statement by the father indicates a need for further instruction? "I can run the hot water in my bathroom and cuddle her in the steamy room." "I can open the freezer door and encourage her to breathe in the cool air." "I should put a steam vaporizer in her room." "I'll take her out into the cool, humid night air."
"I should put a steam vaporizer in her room."
The nurse teaches a client with gastroesophageal reflux disease (GERD) about measures to prevent reflux during sleep. The nurse determines that the client needs additional instructions if the client makes which statement? "I should sleep flat on my right side." "The histamine antagonist will help me." "I should take an antacid at bedtime." "I should avoid eating in the 3 hours before bedtime."
"I should sleep flat on my right side."
A home care nurse is providing instructions to the mother of a 3-year-old with hemophilia regarding care of the child. Which of these statements by the mother indicate a need for further instructions? Select all that apply. "I will be so glad when my baby outgrows all of this bleeding." "I need to cancel all of the dental appointments that I've made for him." "I should check the house for any household items that could fall over easily." "I should move furniture with sharp corners out of the way and pad the corners of the furniture." "If he gets a cut, I should hold pressure on it until the bleeding stops."
"I will be so glad when my baby outgrows all of this bleeding." "I need to cancel all of the dental appointments that I've made for him."
A nurse provides home care instructions to a client with a below-the-knee amputation (BKA) about residual limb and prosthesis care. Which statement by the client indicates a need for further instruction? "I can wash my leg with a mild soap." "I'll put lotion on my stump a few times a day." "I need to check my leg for irritation every day." "I should wear a sock over my stump."
"I'll put lotion on my stump a few times a day."
A female client who has undergone placement of a sealed radiation implant asks the nurse whether she can take a walk around the nursing unit. How should the nurse respond to the client's request? "Short walks are OK." "Do you think that a walk around the unit will tire you out?" "You need to stay in your room for now." "Yes, it's fine to take a walk around the nursing unit."
"You need to stay in your room for now."
A nurse finds a hospitalized child unresponsive. A quick assessment reveals that the child is not breathing and does not have a pulse. The nurse initiates cardiopulmonary resuscitation (CPR). How many chest compressions per minute does the nurse deliver? 100 50 15 30
100
A nurse arrives at the scene of a client experiencing a cardiac/respiratory arrest and begins to assist with cardiopulmonary resuscitation (CPR) of an adult. The nurse delivers compressions by pushing down on the chest to which depth? 2 inches 4 inches 1½ inches 1 inch
2 inches
A nurse notes that a client has ST-segment depression on the electrocardiogram (ECG) monitor. With which potassium reading does the nurse associate this finding? 4.5 mEq/L 3.1 mEq/L 4.2 mEq/L 5.4 mEq/L
3.1 mEq/L
The nurse is administering cardiopulmonary resuscitation (CPR) to an adult client. Which compression/ventilation ratio is correct? 15:2 15:1 30:2 20:2
30:2
A nurse is working in the emergency department. Which client should be assessed first A client who has been experiencing nausea and vomiting for 12 hours A client with new-onset dizziness A client with new-onset atrial fibrillation with a rate of 118 beats/min A client admitted with a recent ear injury
A client with new-onset atrial fibrillation with a rate of 118 beats/min
A nurse is assigned to care four clients on the medical-surgical unit. Which client should the nurse see first on the shift assessment? A client admitted with pneumonia with a fever of 100°F and some diaphoresis A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema A client undergoing long-term corticosteroid therapy with mild bruising on the anterior surfaces of the arms A client with congestive heart failure with clear lung sounds on the previous shift
A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema
A nurse is caring for a client with Crohn disease whose magnesium level is 1.0 mg/dL. Which assessment findings does the nurse expect to note? Select all that apply. Skeletal muscle weakness Decreased deep tendon reflexes Abdominal distention Hypotension Trousseau sign
Abdominal distention Trousseau sign
A woman in labor suddenly complains of abdominal tenderness and pain and states that she felt as though "something ripped." Which manifestations does the nurse suspect are caused by uterine rupture? Select all that apply. Absence of fetal heart tones Severe abdominal pain Increased frequency of uterine contractions Bradypnea Increased blood pressure
Absence of fetal heart tones Severe abdominal pain
A nurse notes that a client's serum potassium level is 5.8 mEq/L. The nurse interprets this as an expected finding in the client with? Wound drainage Heart failure being treated with loop diuretics Diarrhea Addison disease
Addison disease
An emergency department (ED) nurse receives a telephone call from emergency medical services and is told that a client who has sustained severe burns of the face and upper arms is being transported to the ED. Which action does the nurse, preparing for the arrival of the client, plan to implement first? Initiating an intravenous (IV) line Administering 100% humidified oxygen Cleansing the burn wound Inserting a Foley catheter
Administering 100% humidified oxygen
A client arrives at the emergency department with complaints of a headache, hives, itching, and difficulty swallowing. The client states that he took ibuprofen (Motrin) 1 hour earlier and believes that he is experiencing an allergic reaction to this medication. After ensuring that the client has a patent airway, which intervention does the nurse prepare the client for first? Administration of an intravenous (IV) glucocorticoid Administration of pain medication to relieve the client's headache Administration of normal saline solution Administration of a subcutaneous injection of epinephrine (Adrenalin)
Administration of a subcutaneous injection of epinephrine (Adrenaline)
A nurse is reviewing the medical records of the clients for the assigned 7 a.m.-7 p.m. shift. Which client will the nurse monitor most closely for excessive fluid volume? A 65-year-old client with a nasogastric tube attached to low suction following partial gastrectomy An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/hr A 35-year old client who is vomiting undigested food after eating A 48-year-old client receiving diuretics to treat hypertension
An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/hr
A client in the third trimester of pregnancy is experiencing painless vaginal bleeding, and placenta previa is suspected. For which of the following interventions does the nurse prepare the client? A manual (digital) pelvic examination Administration of oxytocin (Pitocin) An ultrasound examination Internal fetal monitoring
An ultrasound examination
A nurse attending a recertification course in basic life support (BLS) for health care professionals is practicing BLS on an infant mannequin. Where does the nurse place the fingers to assess the infant's pulse? Behind the knee Neck Antecubital fossa of the arm Wrist
Antecubital fossa of the arm
A nurse receives a telephone call from a neighbor, who says that her child was just hit in the eye with a swing. The nurse rushes to the neighbor's house and notes that the child has sustained a contusion of the eye. The nurse advises the child's mother to immediately perform which action? Call an optometrist. Irrigate the eye with cool water. Apply ice to the affected eye. Call an ambulance.
Apply ice to the affected eye.
A client who sustained a fracture of the left arm requires the application of a plaster cast. The nurse tells the client that the procedure for applying the cast involves which step? Administering a local anesthetic to the fractured arm Applying soft padding and stockinette over the fractured arm, followed by the application of the cast material Soaking the left arm in a warm-water bath for 2 hours before cast application Debriding any open wounds and applying antibiotic ointment before the cast material is applied
Applying soft padding and stockinette over the fractured arm, followed by the application of the cast material
A visitor to the long-term care center runs out of the dining room and yells, "My mom is choking on her peanut butter sandwich!" What is the nurse's first action? Ask if she has nut allergies. Call for the rapid response team. Ask the client if she can speak. Assess for the presence of a carotid pulse.
Ask the client if she can speak.
A cardiac monitor alarm sounds, and a nurse notes a straight line on the monitor screen. Which action should the nurse take immediately? Check the cardiac leads and wires. Call a code. Obtain a rhythm strip from the monitor device. Assess the client.
Assess the client.
A client arrives in the emergency department for treatment of a surface injury sustained when sand blew into the eye. Which action does the nurse take first? Placing ice on the eye Removing the sand particles Irrigating the eye with sterile saline solution Assessing the client's vision
Assessing the client's vision
A child with a diagnosis of pertussis (whooping cough) is being admitted to the pediatric unit. As soon as the child arrives to the unit, the nurse takes which action first? Weighs the child Administers the prescribed antibiotic Attaches the child to a pulse oximeter Takes the child's temperature
Attaches the child to a pulse oximeter
A stapedectomy is performed on a client with otosclerosis. During the preparations for discharge, which home care instruction does the nurse reinforce for the client? Rinse the ear canal at least twice a day to clear out any excess drainage. Expect excessive ear drainage for about 2 weeks. It is all right to shower as long as the ear dressing is changed immediately after the shower. Avoid rapidly moving the head and bending over for at least 3 weeks.
Avoid rapidly moving the head and bending over for at least 3 weeks.
A nurse enters a client's room and finds the client unconscious. The nurse quickly determines that the client is not breathing. Which action does the nurse take first? Counting the client's carotid pulse for 15 seconds Placing an oxygen mask on the client Checking the client's pulse oximetry reading Beginning chest compressions
Beginning chest compressions
The alarm on a client's cardiac monitor goes off, and the nurse rushes to the client's bedside and finds the client unconscious. After noting the following rhythm on the monitor, the nurse immediately takes which action? Checks for a radial pulse Assesses the client's neurological status Begins cardiopulmonary resuscitation (CPR) Increases the flow rate of the client's intravenous infusion
Begins cardiopulmonary resuscitation (CPR)
A hospitalized client with chronic renal failure has returned to the nursing unit after a hemodialysis treatment. Which parameters contained in the predialysis and postdialysis documentation does the nurse utilize to determine whether the procedure was effective? Potassium and creatinine levels Weight and BUN Blood urea nitrogen (BUN) and creatinine levels Blood pressure and weight
Blood pressure and weight
A nurse is obtaining subjective data from the mother of a child admitted to the hospital with a diagnosis of intussusception. Which occurrences does the nurse expect the mother to report? Hard, pale stools Projectile vomiting Bloody mucus stools and diarrhea Scleral jaundice
Bloody mucus stools and diarrhea
A nurse provides instructions to the mother of a newborn with hyperbilirubinemia who is being breastfed. The nurse determines that the mother understands the instructions if the mother says that she will perform which action? Bottle feed only Provide water feedings between breast feedings Feed her newborn less frequently until the bilirubin level drops Breastfeed the newborn every 2 to 3 hours
Breastfeed the newborn every 2 to 3 hours
A nurse is preparing a teaching plan for the parents of an infant with a ventricular peritoneal shunt. Which of the following questions does the nurse plan to include? Expect increased urine output with the shunt. Position the infant on the side of the shunt for sleep. Call the health care provider if the infant is lethargic. Call the health care provider if the anterior fontanel bulges when the infant cries.
Call the health care provider if the infant is lethargic.
A nurse is caring for a hospitalized client who is undergoing peritoneal dialysis. The nurse notes that the outflow is less than the inflow on the first exchange. What should the nurse do first? Hang the second exchange and continue to monitor the outflow. Reposition the client. Check the system for kinks. Irrigate the catheter.
Check the system for kinks.
Buck extension traction is applied to the right leg of a client who sustained a right hip fracture. Which intervention should the nurse expect to see included in the plan of care? Applying lanolin to the skin of the right leg once per shift Removing the traction weights to provide skin care Assessing the pin sites at least every 8 hours Checking the skin integrity of the right leg at least every 8 hours
Checking the skin integrity of the right leg at least every 8 hours
A client with a spinal cord injury suddenly complains of a pounding headache. The nurse quickly arrives at the bedside and notes that the client is diaphoretic, his blood pressure has increased, and his heart rate has slowed. Suspecting that the client is experiencing autonomic dysreflexia, the nurse elevates the head of the client's bed and takes which immediate action? Notifies the health care provider Checks to see whether the client has a prescription for an antihypertensive Documents the event Checks the client's bladder for distention
Checks the client's bladder for distention
A home care nurse visits a pregnant client with a diagnosis of mild preeclampsia. During the assessment, the client tells the nurse that she has had an upset stomach and pain in the epigastric area. The nurse should perform which action? Administer an antacid to the client and tell her to take a dose every 6 hours. Tell the client to avoid lying flat. Contact the client's health care provider. Instruct the client to eat a small portion of food every 2 to 3 hours.
Contact the client's health care provider.
A nurse is monitoring a client after transurethral resection of the prostate for benign prostatic hypertrophy. The client has a bladder irrigation infusing, and the urine output is a light cherry color. An hour later the nurse notes that the urine output is now bright red in color with clots and that the client's blood pressure has dropped. Which action by the nurse is appropriate? Placing pressure on the bladder to aid expulsion of any additional clots Continuing to monitor the client Contacting the health care provider Increasing the flow rate of the intravenous (IV) solution
Contacting the health care provider
A nurse is monitoring a client who has just undergone radical neck dissection. The nurse notes that the client's blood pressure has dropped from 132/84 to 90/50 mm Hg and that the pulse has increased from 78 to 96 beats/min. On the basis of these findings, the nurse takes which immediate action? Obtains a pulse oximeter Suctions the client Contacts the health care provider Increases the rate of the client's intravenous (IV) solution
Contacts the health care provider
A nurse is monitoring a client who is in the active phase of labor and has been experiencing contractions that are coordinated but weak. Which finding indicates to the nurse that the client may be experiencing hypotonic contractions? Fetal hypoxia Increased frequency and longer duration of contractions Contractions that can be indented easily with fingertip pressure at their peak Discomfort with each contraction
Contractions that can be indented easily with fingertip pressure at their peak
The nurse assists with data collection on a client who has a diagnosis of left-sided heart failure. Which findings does the nurse expect to note? Select all that apply. Crackles on auscultation of the lungs Dependent edema Dyspnea Neck vein distention Abdominal distention
Crackles on auscultation of the lungs Dyspnea
A client with gastroenteritis who has been vomiting and has diarrhea is admitted to the hospital with a diagnosis of dehydration. For which clinical manifestations that correlate with this fluid imbalance would the nurse assess the client? Select all that apply. Increased blood pressure Decreased urine output Increased respiratory rate Decreased respiratory depth Decreased pulse
Decreased urine output Increased respiratory rate
A client with cancer of the larynx is receiving external radiation therapy of the neck. Which side effect related specifically to the site of irradiation does the nurse tell the client to expect? Dysphagia Diarrhea Dyspnea Headache
Dysphagia
A client is found to have viral hepatitis, and the nurse provides home care instructions to the client. The nurse should reinforce which instruction? Limit the intake of alcohol. Maintain strict bed rest. Take acetaminophen (Tylenol) for discomfort. Eat small, frequent meals that are low in fat and protein and high in carbohydrates.
Eat small, frequent meals that are low in fat and protein and high in carbohydrates.
A nurse is providing discharge instructions to a client after outpatient surgery for cataract removal. The nurse determines that the client needs additional instructions if the client indicates that he will take which measure? Leave the eye patch in place until he has been seen by the health care provider. Expect to experience pain, nausea, and vomiting after the procedure. Limit activity for 24 hours. Take acetaminophen (Tylenol) for discomfort.
Expect to experience pain, nausea, and vomiting after the procedure.
A nurse is providing instructions to a nursing assistant about effective measures for communicating with a hearing-impaired client. The nurse instructs the nursing assistant communicate with the client in which way? Face the client when talking, keeping the hands away from the mouth Raise his voice when talking to the client Talk directly into the client's impaired ear Be cordial and smile when talking to the client
Face the client when talking, keeping the hands away from the mouth
The wife of a client with angina pectoris calls the health care provider's office and reports to the nurse that her husband is experiencing chest pain and has taken 2 sublingual nitroglycerin tablets 5 minutes apart, with no relief. The nurse tells the client's wife to: Take her husband to the emergency department (ED) immediately. Have her husband rest and, if no relief is obtained, call back. Discuss the situation with the health care provider, who will call her as soon as he gets into the office. Give her husband a third tablet and, if no relief is obtained, call an ambulance to have him transported to the ED.
Give her husband a third tablet and, if no relief is obtained, call an ambulance to have him transported to the ED.
An ambulatory care nurse is providing home care instructions to the mother of a child who had a tonsillectomy. The nurse determines that the mother needs further instruction if she indicates that she will take which action? Give acetaminophen (Tylenol) to her child for discomfort. Avoid giving citrus juices to her child. Have her child use a straw to make drinking easier. Give her child extra fluids to relieve a foul odor from the mouth.
Have her child use a straw to make drinking easier.
A client with chronic renal failure is undergoing his first hemodialysis treatment, and the nurse is monitoring the client for signs of disequilibrium syndrome. For which signs of this syndrome does the nurse monitor the client? Bradycardia and hypothermia Irritability and generalized weakness Fever and tachycardia Headache and confusion
Headache and confusion
A nurse is reviewing the assessment findings and laboratory results of a child with a diagnosis of new-onset glomerulonephritis. Which finding would the nurse expect to note? Cloudy yellow urine Increased creatinine level Hypertension Low serum potassium
Hypertension
A nurse is monitoring a client with hyperparathyroidism for signs of hypercalcemia. For which of the following clinical manifestations, associated with this electrolyte imbalance, does the nurse assess the client? Select all that apply. Increased urine output Chvostek sign Hyperactive deep tendon reflexes Muscle weakness Paresthesias
Increased urine output Muscle weakness
A nurse is assessing a child with increased intracranial pressure who has been exhibiting decorticate posturing. The nurse notes extension of the upper and lower extremities, with internal rotation of the upper arms and wrists and the knees and feet. The nurse makes which determination about the child's condition? Is unchanged from the previous neurological assessment Indicates decreased intracranial pressure Indicates deterioration in neurological function Indicates improved neurological status
Indicates deterioration in neurological function
The nurse is participating in a care planning conference for a patient with acquired immunodeficiency syndrome (AIDS). What is the nurse's highest priority in providing care to this client? Identifying risk factors related to contracting AIDS with the client Instituting measures to prevent infection in the client Discussing the cause of AIDS with the client Providing emotional support to the client
Instituting measures to prevent infection in the client
A nurse is assisting with data collection on a 12-month-old child with iron-deficiency anemia. Which finding does the nurse expect to note in this child? Hyperactivity Reddened cheeks Lethargy Bradycardia
Lethargy
A nurse provides home care instructions to a client with Ménière disease about measures to control and treat vertigo. The nurse provides which explanation? Lie down when vertigo occurs and keep a light on in the room. Increase fluid intake to at least 3000 mL/day. Move the head from the right to the left when vertigo occurs to determine the extent of its effects. Limit sodium in the diet.
Limit sodium in the diet.
A nurse is caring for a client who has undergone resection of an abdominal aortic aneurysm (AAA). Which action should the nurse implement to prevent graft occlusion? Monitoring bowel sounds Limiting elevation of the head of the bed to 45 degrees Checking pedal pulses distal to the graft site Monitoring urine output
Limiting elevation of the head of the bed to 45 degrees
Mastitis is diagnosed in a client who recently gave birth. The nurse should provide which client teaching? Moist heat will increase circulation and may be used before the breasts are emptied. Breastfeeding must be discontinued until the condition resolves. Wearing a bra will increase the discomfort. Antibiotics are not usually used to treat this disorder.
Moist heat will increase circulation and may be used before the breasts are emptied.
A nurse is assessing a client with a diagnosis of acquired immunodeficiency syndrome (AIDS) for signs of Pneumocystis jiroveci infection. Which sign of the infection is the earliest manifestation? Fever Dyspnea at rest Nonproductive cough Dyspnea on exertion
Nonproductive cough
A client has an arteriovenous fistula in place for hemodialysis. What should the nurse do to assess the patency of the fistula? Palpate for a vibrating sensation at the fistula site. Infuse 50 mL of normal saline once per 24 hours. Irrigate the fistula with 3 mL of normal saline solution. Flush the fistula with 1 mL of heparin solution once per shift.
Palpate for a vibrating sensation at the fistula site.
A client in active labor says "something is sticking out of me." The nurse notes that the umbilical cord is protruding from the vagina. The nurse summons the registered nurse while taking which immediate action? Prepare the client for cesarean delivery. Push the cord gently back into the vagina. Place the client in the knee-chest position. Prepare to administer a tocolytic medication.
Place the client in the knee-chest position.
A nurse has been assigned to care for an infant with tetralogy of Fallot. The infant suddenly exhibits rapid, deep respirations; irritability; and cyanosis. The nurse determines that the infant is experiencing a hypercyanotic episode and immediately performs which action? Calls a code Holds the infant in an upright position Places the infant in the knee-chest position Contacts the respiratory therapy department
Places the infant in the knee-chest position
A nurse has admitted a client with a diagnosis of tuberculosis (TB) to the nursing unit. Which finding that confirms the diagnosis does the nurse expect to see documented in the client's record? A Mantoux skin testing result that indicates 5 mm of redness Cough and expectoration of mucopurulent sputum Positive result on an acid-fast bacillus smear Night sweats and a low-grade fever
Positive result on an acid-fast bacillus smear
A nurse is reviewing this rhythm strip from a cardiac monitor. Which type of abnormal beats does the nurse recognize? Ventricular fibrillation Premature ventricular contractions (PVCs) Sinus bradycardia Ventricular tachycardia
Premature ventricular contractions (PVCs)
A client who has a tracheostomy has wet, noisy respirations, and sputum can be seen at the top of the tracheostomy. The nurse will take which action first when suctioning this client's tracheostomy? Use the tip of the oropharyngeal suction catheter to remove the sputum. Insert the suction tubing until resistance is felt. Dip the suction tip into the sterile water to moisten the catheter. Preoxygenate the client.
Preoxygenate the client.
A nurse is participating in a care planning conference regarding the care for a client with a new diagnosis of Graves disease. Which intervention does the nurse expect to see included in the plan? Providing a high-calorie, high-protein diet Keeping the room warm Encouraging frequent ambulation and activities Placing extra blankets on the client
Providing a high-calorie, high-protein diet
A nurse assessing a client in the fourth stage of labor notes that the uterine fundus is firmly contracted and is midline at the level of the umbilicus. On the basis of this finding, the nurse most appropriately performs which action? Massages the fundus Records the findings Helps the mother void Contacts the health care provider
Records the findings
A nurse in the newborn nursery is monitoring a neonate born to a mother with diabetes mellitus. For which of the following findings does the nurse monitor the neonate most closely? Hyperglycemia Respiratory distress syndrome Hypercalcemia Hypobilirubinemia
Respiratory distress syndrome
A nurse provides dietary instructions to the mother of a child with celiac disease. Which of the following foods does the nurse tell the mother to include in the child's diet? Rice Rye crackers Oatmeal biscuits Wheat cereal
Rice
A nurse is reviewing home care instructions to a client with Parkinson disease about measures to avoid rigidity and to overcome tremor and bradykinesia. The nurse reinforces which information? Exercise in the evening to combat fatigue. Sit in soft, deep chairs. Rock back and forth to start movement. Perform tasks with only the hand that has the tremor.
Rock back and forth to start movement.
A client who experiences frequent episodes of chest pain is admitted to the hospital for cardiac monitoring. The client suddenly complains of chest pain, and the nurse obtains a 12-lead electrocardiogram (ECG). Which finding would the nurse expect to note in the event of an ischemic episode? ST-segment depression Peaked T waves An isolated premature ventricular contraction (PVC) Widened QRS complex
ST-segment depression
A client is transported to the recovery area of the ambulatory care unit after cataract surgery. In which position does the nurse place the client? Prone on the side that has undergone surgery On the side that has undergone surgery Semi-Fowler Supine
Semi-Fowler
A nurse is assessing a newborn for fetal alcohol syndrome (FAS). Which finding would the nurse expect to note in the newborn? Greater-than-average head circumference Short palpebral fissures and a flat midface Greater-than-average length Higher-than-normal birth weight
Short palpebral fissures and a flat midface
A nurse is caring for a hospitalized child with a diagnosis of Kawasaki disease. During the subacute phase, the nurse monitors the child closely for which manifestation? Failure to thrive Signs of congestive heart failure (CHF) A high fever Bleeding
Signs of congestive heart failure (CHF)
A nurse is caring for a client experiencing hyponatremia who was admitted to the medical-surgical unit with fluid-volume overload. For which clinical manifestations of this electrolyte imbalance does the nurse monitor this client? Select all that apply. Decreased urine output Hyperactive deep tendon reflexes Slow pulse Skeletal muscle weakness Hyperactive bowel sounds
Skeletal muscle weakness Hyperactive bowel sounds
A nurse in a newborn nursery receives a telephone call from the delivery room and is told that a newborn with spina bifida (meningomyelocele type) will be transported to the nursery. Which item does the nurse, preparing for the arrival of the newborn, make a priority of placing at the newborn's bedside? Sterile dressing Flashlight Blood pressure cuff Cardiac monitor
Sterile dressing
A nurse is monitoring a client with deep vein thrombosis (DVT) for signs of pulmonary embolism. For which common sign of pulmonary embolism does the nurse assess the client? Fatigue Yellowish sputum Sudden onset of dyspnea Tenderness in the calf
Sudden onset of dyspnea
A nurse is teaching a client with diabetes mellitus who requires insulin about methods of preventing diabetic ketoacidosis (DKA) when the client is ill. The nurse reinforces which client instruction? Take the prescribed insulin dose even if he is unable to eat. Contact the health care provider when the premeal blood glucose value is greater than 350 mg/dL. Contact the health care provider if a fever over 102°F occurs. Refrain from eating or drinking during periods of vomiting.
Take the prescribed insulin dose even if he is unable to eat.
A nurse provides home care instructions to a client after a scleral buckling procedure. The nurse should reinforce which client teaching point? That vision will be perfectly clear immediately after surgery To maintain strict bedrest for 48 hours To expect bloody drainage on the eye dressing That redness and swelling of the eyelids and conjunctiva are expected
That redness and swelling of the eyelids and conjunctiva are expected
During a client's yearly eye examination, the nurse checks the intraocular pressure. The nurse notes that the pressure in the right eye is 12 mm Hg and 19 mm Hg in the left. The nurse explains the results in which manner? That he needs to increase his fluid intake because the pressure in the right eye is low That the intraocular pressure in both eyes is normal That he has glaucoma in the right eye That he has glaucoma in the left eye
That the intraocular pressure in both eyes is normal
A client with a leg fracture who has been placed in skeletal traction is transported to the orthopedic unit after surgery. Which finding would indicate the need to take action? The traction weights are hanging freely. The clamps on the traction frame are tight. The traction knots are intact. The traction ropes are unable to move over the pulleys.
The traction ropes are unable to move over the pulleys.
A client who is recovering from a brain attack (stroke) has residual dysphagia. Which measure does the nurse plan to implement at mealtimes? Placing food in the affected side of the client's mouth Giving the client thin liquids Giving foods that are primarily liquid Thickening all liquids served
Thickening all liquids served
A health care provider writes a prescription for the administration of intravenous (IV) potassium chloride to a client with hypokalemia. The nurse should reinforce which client instructions? This medication is diluted in a large bag of IV fluid and infused slowly into your vein. A catheter will be inserted to drain your bladder. A large intravenous line will be inserted into your chest vein. This infusion requires use of a large caliber IV tubing.
This medication is diluted in a large bag of IV fluid and infused slowly into your vein.
A mother calls the clinic and tells the nurse that her newborn's umbilical cord site looks red and swollen. The nurse should give the mother which instruction? That this is a normal occurrence To increase the number of cord site cleanings each day To place an ice pack on the cord for 10 minutes three times a day To bring the newborn to the clinic
To bring the newborn to the clinic
A client has undergone creation of an Indiana pouch for urine diversion after cystectomy, and the nurse provides instructions about reservoir catheterization. The nurse provides which client teaching? That if mucus drains from the reservoir, the health care provider should be contacted That sometimes force is needed to insert the catheter into the reservoir To plan to drain the reservoir every 2 to 3 hours initially To obtain 26F catheters from the medical supply store for the irrigations
To plan to drain the reservoir every 2 to 3 hours initially
A nurse is assisting with data collection of a client with mild preeclampsia. Which sign indicates improvement in the client's condition? Blood pressure 148/94 mm Hg Trace protein in the urine Complaint of headache Blood urea nitrogen (BUN) of 40 mg/dL
Trace protein in the urine
A nurse is teaching a client who is experiencing homonymous hemianopsia after a brain attack (stroke) about measures to overcome the deficit. The nurse reinforces which client instruction? Wear a patch on the affected eye. Wear eyeglasses 24 hours a day. Turn the head to scan the lost visual field. Keep all objects in the impaired field of vision.
Turn the head to scan the lost visual field.
A nurse is having dinner at a restaurant when a man sitting at the next table collapses and falls to the floor. The nurse yells for help and quickly notes that the client is not breathing and does not have a pulse. The nurse initiates cardiopulmonary resuscitation (CPR) immediately, and the restaurant manager rushes to the scene with an automatic external defibrillator (AED). What should the nurse do next? Perform CPR until emergency medical services arrives Check for a pulse for 30 seconds before continuing CPR Stop the resuscitation efforts Use the AED
Use the AED
A nurse answers the call bell of a client who has been fitted with an internal cervical radiation implant, and the client states that she thinks that the implant has fallen out. The nurse checks the client and sees the implant lying in the bed. Which action should the nurse take first? Reinserting the implant into the client's vagina Calling the health care provider Using long-handled forceps to place the implant in a lead container Picking up the implant with gloved hands and placing it in sterile water
Using long-handled forceps to place the implant in a lead container
A nurse is reading the medical record of a pregnant client in the second trimester with a diagnosis of abruptio placentae. Which clinical manifestation of the disorder does the nurse expect to see documented? Lack of uterine activity Constipation Painless vaginal bleeding Uterine tenderness
Uterine tenderness
A nurse is administering care to a client with angina pectoris who is attached to a cardiac monitor. The monitor alarm sounds, and the nurse notes the rhythm shown here. How does the nurse interpret the rhythm? Sinus bradycardia Ventricular tachycardia Sinus tachycardia Atrial fibrillation
Ventricular tachycardia
A nurse is participating in a care planning session for a client with a sealed radiation implant. Which stipulation does the nurse expect to see included in the plan? Visitors must remain at least 2 feet from the client. The client may be maintained in a semiprivate room as long as the client uses a commode. A dosimeter badge must be placed on the client's bedside stand. Visitors must be limited to one half-hour per day.
Visitors must be limited to one half-hour per day.
A nurse is caring for a client who is being treated for congestive heart failure and has been assigned a nursing diagnosis of excessive fluid volume. Which finding causes the nurse to determine that the client's condition has improved? Dyspnea Weight loss of 4 lb in 24 hours 1+ edema in the legs Moist crackles in the lower lobes of the lungs
Weight loss of 4 lb in 24 hours
A nurse is caring for a client with acute pancreatitis who will be admitted to the hospital. Into which position that will ease the abdominal pain does the nurse assist the client? Supine with the legs straight Side-lying with the head of the bed flat Prone With the knees drawn up to the chest
With the knees drawn up to the chest
A client who experienced a brain attack (stroke) exhibits right-sided unilateral neglect. The nurse caring for this client plans to place the client's personal care items in which manner? Just out of the client's reach on the right side Within the client's reach on the left side Within the client's reach on the right side Just out of the client's reach on the left side
Within the client's reach on the right side
A nurse is caring for a child with newly diagnosed type 1 diabetes mellitus who is receiving insulin. The child suddenly exhibits tachycardia and beings to sweat and tremble, and the nurse determines that the child is experiencing a hypoglycemic reaction. The nurse would immediately give the child which item? A teaspoon of sugar ½ cup of diet cola A sugar cube ½ cup of fruit juice
½ cup of fruit juice
