NCLEX QUIZ (Ch 16-20)
The nurse is assisting a client immediately before a colonoscopy. The nurse will direct the client and help move into what position? A. Prone. B. Sim's lateral. C. Slight trendelnburg D. Flat with lithotomy stirrups.
B
The nurse is caring for a client with leukemia who is experiencing bleeding into the knee joints. What is the best nursing care for this client regarding joint mobility and activity? A. Encourage short walks around the room every 2 hours. B. Keep the joint immobilized and maintain bed rest for the client. C. Gently put the legs through passive range of motion every 4 hours. D. Keep the legs wrapped with elastic bandages and immobilized in splints.
B
The nurse is providing discharge instructions to a client who as had a splenectomy. The teaching is based on the knowledge that splenectomy clients have: A. Decreased leukocytes. B. Increased platelets. C. Decreased hemoglobin. D. Increased eosinophils.
B
The nurse is preparing discharge teaching for a client with aplastic anemia. What will be important to include in the teaching plan? Select all that apply. A. Take your iron with meals every day and decrease the amount of green, leafy vegetables in your diet. B. Establish a balance between rest and activity: avoid excessive fatigue C. Rest and supplemental oxygen may be required during periods of dyspnea. D. Drink a glass of wine in the evening to help increase your appetite. E. Notify your health care provider if you being to experience frequent bruising. F. Increase your intake of dairy products (milk and cheese) and protein.
B, C, E
The nurse is monitoring an IV infusion of sodium nitroprusside. Fifteen minutes after the infusion is started, the client's blood pressure goes from 190120 mmHg to 120/90 mmHg. What is a priority nursing action? A. Recheck the BP and call the doctor. B. Decrease the infusion rate and recheck the blood pressure in 5 minutes. C. Stop the medication and keep the IV open with D5W. D. Assess the client's tolerance of the current level of BP.
B.
The nurse understands clamping a chest tube may cause what problem? A. Atelectasis. B. Tension pneumothroax. C. Bacterial infections in the pleural cavity D. Decrease in the rate and depth of respiration
B.
A client has a history of atherosclerotic heart disease with a sustained increase in his blood pressure. What is important to discuss with this client before he uses an over-the-counter decongestant? A. Urinary frequency and diuresis. B. Bradycardia and diarrhea. C. Vasoconstriction and increased arterial pressure. D. Headache and dysthrimias.
C
A client in sickle cell crisis is admitted to the emergency department. What are the priorities of care in order of importance? A. Nutrition, hydration, electrolyte balance. B. Hydration, pain management, electrolyte balance. C. Hydration, oxygenation, pain management. D. Hydration, oxygenation, electrolyte balance.
C
A client with chest pain is on a cardiac monitor. The monitor is showing ventricular tachycardia at a rate of 150 beats/min with multiple PVC's. The client is awake and coherent, and oxygen is being administered at a rate if 6 L/min via a nasal cannula. What is the nurse's next action? A. Immediately defibrillate. B. Administer adenosine IV push. C. Assess the blood pressure D. Auscultation lung sounds.
C
Clients with COPD usually receive low-dose oxygen via nasal cannula. The nurse understands that which problem may occur if the client receives too much oxygen? A. Hyperventilation B. Tachypnea C. Hypoventilation or apnea D. Increased snoring
C
In preparing a pediatric client for an appendectomy, the nurse would question which doctor's orders? A. Penicillin 600,000 units IV piggy back, now. B. Obtain signed consent from parents C. Administer enemas until clear. D. 500 ml ringer's lactate solution 50 ml/hr
C.
The nurse is caring for a client being discharged after experiencing infective endocarditis. What is most important to include with the discharge teaching? A. Begin an exercise regimen as soon as possible, progressively increasing intensity each day. B. Monitor urinary output daily and report a change in color or quantity C. Continue antibiotic therapy until the prescription is completed. D. Track and monitor heart rate and blood pressure daily upon arising
C.
Which instruction should be included in discharge teaching for the client with a new prescription for simvastatin? A. Flushing occurs is almost all individuals. B. Sedation is common but will decrease with time. C. Liver enzyme levels should be monitored every few months. D. Watch closely for occurence of postural hypertension.
C.
While a client's wife is visiting, she observes the client's chest draining system and begins to nervously question the nurse regarding the amount of bloody drainage on the system. What is the best response form the nurse? A. "Your husband has been really sick; this must be a very difficult time. Let's sit down and talk about it". B. "I have checked all of the equipment, and is working fine; you do not need to worry". C. "The system is draining collected fluid from around the lungs. The drainage is expected and does not mean that he is bleeding". D. "The chest tube is draining the secretions from his chest; it is important for him to deep breathe frequently".
C.
An older adult client is taking digoxin 0.25 mg once a day and furosemide 40 mg daily. She states having increasing lethargy and nausea over the past 2 days, but is still able to take her medication. Her blood pressure is 150/98 mmHg; pulse is 110 beats/min and irregular; respiratory rate is 18 breaths/min. What laboratory information is most important for the nurse to evaluate? A. Hemoglobin, hematocrit, and white blood cell count B. Arterial blood gases and acid-base balance C. Blood urea nitrogen (BUN) and serum creatinine levels. D. Serum electrolytes level.
D
The nurse is caring for a client who has hypersplenism. What laboratory test finding would indicate that the client has splenomegaly? A. Presence of reed-sternburg cells. B. Elevated red blood cell count. C. Increased Bence-Jones protein in urine D. Presence of howell-jolly bodies in a blood smear.
D
What is desired action of dopamine when administered in the treatment of shock? A. It increase myocardial contractility B. It is associated with fewer severe allergic reactions C. It causes rapid vasodilation of the vascular bed D. It supports renal perfusion by dilation of the renal arteries.
D
The nurse identifies which problems as risk factors for the development of a sickle cell crisis? Select all that apply. A. Recurrence of acute otitis media. B. A fall with swelling at the kneecap and joint. C. Fractured radius requiring internal fixation. D. Recurrence of respiratory tract infection. E. Traveling to a location of higher altitude. F. Dehydration.
D, E, F
In discharge planning for the client with heart failure, the nurse discusses the importance of adequate rest. What information is most important? A. A warm, quite room is necessary. B. Bed rest promotes venous return. C. A hospital bed is necessary. D. Adequate rest decreases cardiac workload.
D.
The nurse is monitoring a client who is experiencing an acute asthma attack. What observations would indicate an improvement in the client's condition? A. Respiratory rate of 18 breaths/min B. Pulse oximetry of 88% C. Pulse rate of 110 beats/min D. Productive cough with rapid breathing.
A
The nurse is planning care for a client scheduled for esophagogastroduodenoscopy (EGD) and a barium swallow. What will the nursing care plan include? A. Anticipating the client will receive a a clear liquid diet in the evening and then receive nothing by mouth (NPO) 8 hours before the test. B. Discussing with the client the NG tube and the importance of gastric drainage for 24 hours after the test. C. Explaining to the client that he will receive nothing by mouth (NPO) for 24 hours after the test to make sure his stomach can tolerate food. D. Discussing the general anesthesia and expelling to the client that he will wake up in the recovery room.
A
What is the priority nursing action for the client who is complaint of nausea in the recovery room after gastric resection? A. Evaluate the NG tube for patency. B. Call the physician for an antiemetic order. C. Place client in semi-fowler's position so that he will not aspirate. D. Medicate the client with a narcotic analgesic.
A
What symptoms would the nurse expect to observe in a 19-month-old client with a diagnosis of laryngotracheobronchitis (LBT)? A. Stridor on inspiration B. Expiratory wheezing C. Paroxysmal coughing D. Hemoptysis
A
The nurse is caring for a client who is experiencing an acute asthma attack. He is dyspneic and experiencing orthopnea; his pulse rate is 120 beats/min. In what order will the nurse provide care to this client? Number the following options in the order in which they will be performed, with 1 being the first action and 4 being the last action. A. Administer humidified oxygen B. Place in semi-fowler's position. C. Provide nebulizer treatment with bronchodilator. D. Discuss factors that precipitate attack.
A = 2 B = 1 C = 3 D = 4
The nurse is monitoring a client after thrombolytic therapy has been initiated. Shortly after the infusion is started, the client becomes confused, disoriented, cool, clammy. The heart rate progressively increases to 120 and blood pressure drops to 60/40. What actions should the nurse take? Select all that apply. A. Stop the thrombolytic. B. Apply oxygen C. Raise the head of the bed. D. Call for assistance E. Reorient the client.
A, B, D
The nurse received handoff for a client returning from a cardiac angiogram and begins the initial assessment. The right femoral groin dressing has a dime-sized area of blood. What additional actions should the nurse perform? Select all that apply. A. Assess peripheral pulses in both legs and feet B. Mark the dressing with a pen, circling the bloody drainage. C. Hold pressure on the dressing site for 20 minutes. D. Assess blood pressure E. Place the client in a high-fowler position.
A, B, D,
The nurse is caring for a client with a history of heart failure. Which statements by the client require additional inquiry? Select all that apply. A. "I've noticed that I've gained 3 lbs. this week" B. "I sleep best in my recliner chair" C. "I've noticed that the swelling in my feet seems less" D. "I cannot make it through the grocery store without resting". E. "I often have to use the restroom at night".
A, B, D, E
The nurse has been assigned a group of cardiac clients. What would be the most important information for the nurse to assess during the initial visit? Select all that apply. A. Presence of cardiac discomfort. B. Medications taken before hospitalization. C. Presence of jugular vein distention D. Heart sounds and apical rate E. Presence of diaphoresis F. History of difficulty breathing
A, C, D, E
The nurse is caring for a client with venous blooding in the lower extremities caused by chronic venous insufficiency. The nurse would identify what assessment data that would correlate with this diagnosis? Select all that apply. A. Statis dermatitis B. Diminished peripheral pulses. C. Peripheral edema. D. Gangrenous wounds E. Venous stasis ulcers F. Skin hyperpigmentation
A, C, E, F
In planning discharge teaching for the client who has undergone a gastrectomy, the nurse includes what information regarding dumping syndrome? select all that apply. A. Symptoms may include nausea, vomiting, weakness, and abdominal cramping. B. The client should eat three to four small meals per day. C. Consumption of fluids should be very limited with the meal. D. The client should increase the amount of complex carbohydrates and fiber in the diet. E. Activity will decrease the problem; it should be scheduled about 1 hour after meals. F. You may need to take a multivitamin with calcium and iron supplements.
A, C, F
Six hours after gastric resection, the client' NG aspirate is continuing to drain bright red fluid. What is the best nursing action? A. Continue to monitor the amount of drainage and correlate it with any change in vital signs, B. Reposition the NG tube and irrigate the tube with normal saline solution. C. Call the physician immediately and notify of the continued bright red aspirate. D. Irrigate the NG tube with iced saline solution and attach the tube
A.
The vital signs of a client with cardiac disease are as follows; blood pressure of 102/76 mmHg, pulse of 52 beats/min, and respiratory rate of 16 breaths/min. Atropine sulfate is administered IV push. What nursing assessment indicates a therapeutic response to the medication? A. Pulse rate has increased to 70 beats/min. B. Systolic blood pressure has increased by 20 mmHg. C. Pupils are dilated. D. Oral secretions have decreased.
A.
A client is experiencing a sickle cell crisis during labor and delivery. What is the best nursing action? A. Maintain IV fluid infusion and assess adequacy of hydration. B. Administer a high concentration of oxygen. C. Insert a foley catheter and monitor hourly urine output. D. Provide continuous sedation for pain relief.
A
The client returns to his room after thoracotomy. What will the nursing assessment reveal if hypoxemia from excessive blood loss is present? A. CVP of 3 cm H20 and urine output of 20 ml/hr B. Jugular vein distention with the head elevated 45 degrees. C. Chest tube drainage of 50 ml/hr in the first 2 hours D. Increased BP and increased pulse pressure.
A
The nurse practitioner orders an enteral formula at a rate of 50 ml/hr. A can hold 250 ml. How many cans would the nurse need for the next 24 hours?
5 cans
A client has been diagnosed with pernicious anemia. What will the nurse teach this client regarding the medication he will need to take after he goes home? A. Monthly vitamin B12 injections will be necessary. B. Daily ferrous sulfate (in oral form) will be prescribed. C. Coagulation studies are important to monitor the effect of medications. D. He should reduce his intake of leafy, green vegetables to decrease vitamin K.
A
A client has had her blood pressure evaluated weekly for month. At the end of the month, the nurse averages out the weekly blood pressure at 150/96 mmHg. The client is 20 pounds (9.1 kg) overweight, and her cholesterol is 240 mg/dL (6.22 mmol/L). What is important information for the nurse to include in the teaching plan for this client? A. Refer her to the doctor for further follow-up and medications. B. Increase the fiber in her diet and begin a daily 30-minute workout. C. Reduce her sodium intake and decrease the dietary calories that come from fat. D. Reduce her cholesterol intake for 1 month and check her BP 3 time a week.
A
The nurse is assessing a client who is on a ventilator and has an endotracheal tube in place. What information confirms that the tube has migrated to far into the trachea? A. Decreased breath sounds are heard over the left side of the chest B. Increased rhonci are present at the lung bases C. Client is able to speak and coughs excessively D. Ventilator pressure alarm continues to sound
A
The nurse is caring for a client who has been diagnosed with a bleeding duodenal ulcer. Which data identified on a nursing assessment would indicate a possible intestinal perforation and require immediate nursing action? A. Increasing abdominal distention, with increased pain and vomiting. B. Decreasing hemoglobin and hematocrit with bloody stools. C. Diarrhea with increased bowel sounds and hypovolemia. D. Decreasing blood pressure with tachycardia and disorientation.
A
The nurse is providing preoperative care for client who is scheduled for cardiac surgery. During the preoperative preparation, what is an important nursing action? A. Perform a thorough nursing assessment to provide an accurate baseline for evaluation after surgery. B. Discuss with the client the steps of myocardial cellular metabolism and the anticipated surgical response. C. Provide preoperative education regarding the mechanics of the cardiopulmonary bypass machine. D. Discuss with the client and family the anticipated amount of postoperative chest tube drainage.
A
The nurse is taking the history of a client wit heart failure caused by chronic hypertension. Which statement by the client is most concerning/ A. "I get short of breath after walking about half a block" B. "My weight has dropped 15 pounds over the the past 3 months". C. "My legs get swollen in the evening". D. "Sometimes I get dizziness when I get up too quickly".
A
What finding on the nursing assessment would be associated with a diagnosis of pneumonia in the older adult? A. Acute confusion B. Hypertension C. Hematemesis in the morning. D. Dry hacking cough at night.
A
What will be important for the nurse to do when collecting a stool specimen for an occult blood (hemoccult) test? A. Samples should be taken from two areas of the stool. B. Three separate stool samples will be required for accuracy of test. C. The nurse should collect about 20 ml of stool sample. D. Any red color on or near the specimen is considered positive.
A
A young adult comes to the clinic complaining of dizziness, weakness, and palpitations. What will be important for the nurse to evaluate initially when obtaining the health history: A. Activity and exercise B. Nutritional patterns C. Family health status D. Coping and stress tolerance
B
For a client with COPD, what is the main risk factors for pulmonary infection? A. Fluid imbalance with pitting edema. B. Pooling of respiratory secretions. C. Decreased fluid intake and loss of body weight D. Decreased anterior-posterior diameter of the chest.
B
The nurse is caring for an infant who is experiencing respiratory distress and being treated with continuous positive airway pressure (CPAP). The nurse knows that for this treatment to be most effective, the infant must be: A. Intubated with respiration maintained by controlled ventilation B. Able to breath spontaneously C. Frequent stimulated to maintain respiratory rate. D. Suctioned frequently to maintain alveolar ventilation
B
The nurse would identify which if the following clients to be at an increased risk for the development of a fecal impaction? Select all that apply. A. Post barium enema B. Obese client in traction. C. Poorly hydrated older adult. D. Client receiving opioid medications. E. Three days after colostomy F. Acute appendicitis.
A, B, C, D
The nurse is preparing discharge teaching for a client with a diagnosis of gastesophageal reflux disease (GERD). What would be important for the nurse to include in the teaching plan? Select all that apply? A. Elevate the head of the bed. B. Decrease intake of caffeine products C. Discuss strategies for weight loss if overweight. D. Increase fluid intake with meals. E. Take omeprazole at bedtime. F. Eat a bedtime snack of milk and protein
A, B, C, E
The nurse is preparing a teaching plan for a family with a child who has been diagnosed with sickle cell anemia and crisis. What will the nurse include in the teaching regarding the pathophysiology of sickle cell crisis? A. It results from altered metabolism and dehydration B. Tissue hypoxia and vascular occlusion cause the primary problems. C. Increased bilirubin levels will cause hypertension. D. There are decreased clotting factors with an increase in white blood cells.
B
The nurse is assessing a child with a tentative diagnosis of appendicitis. The nursing assessment is most likely to reveal what characteristics concerning the pain? Select all that apply. A. Colicky, cramping abdominal pain located around the umbilicus. B. Tenderness in the left lower quadrant, associated with decreased bowel sounds. C. Nausea, vomiting, and anorexia, after onset of pain. D. Gnawing pain radiating through to the lower back, with severe abdominal distention E. Sharp pain with severe gastric distention, frequently associated with hemoptysis F. Tenderness at McBurney's point
A, C, F
What are the best nursing action in caring for a young client with appendicitis before surgery? select all that apply. A. Maintain bed rest. B. Offer full liquids to maintain hydration. C. Keep patient still and position with right leg flexed. D. Position on left side, apply a warm K-pad to the abdomen. E. Administer morphine intravenously to relieve pain. F. Keep the client NPO and maintain a peripheral IV for fluid replacement
A, C, F
Which of the following would be appropriate discharge instructions for the client that has been diagnosed with polycythemia vera? Select all that apply A. "You can expect to have repeated phlebotomies" B. "Take an iron supplement daily" C. "low-dose aspirin may be prescribed by your health care provider". D. "A warm bath may be used to decrease generalized pruritus" E. "Avoid crowds due to increased risk of infection secondary to your low white blood cell (WBC) count" F. "Try to keep well hydrated by drinking at least 2 liters of fluid per day"
A, C, F
The nurse is preparing a client for a cardiac catherization. Which nursing interventions are necessary in preparing the client for this procedure? Select all that apply. A. Verify consent form has been signed. B. Explain procedure to client. C. Provide clear liquids, no caffeine diet. D. Evaluate peripheral pules. E. Obtain a 12-lead ECG F. Obtain history for shellfish allergy.
A, D, F
The nurse is caring for a client who is 6 hours postpartum. What nursing actions are directed towards the prevention of postpartum thrombophlebitis? A. Encourage early ambulation and increased fluid intake. B. Allow bathroom privileges only and elevate the lower extremities. C. Administer anticoagulants and evaluate the clotting factors. D. Encourage the client to breastfeed the infant as soon as possible.
A.
The nurse is preparing to administer spironolactone to a client. After assessing the client, what data indicate the need to withhold the medication? A. Potassium level to 5.8 mEq/L (mmol/L). B. Apical pulse rate of 58 beat/min C. BP of 130/90 mmhg D. Urine output of 30 mL/hr
A.
The nurse is teaching a client with hypertension about his antihypertensive medications, hydrochlorothiazide (HCTZ) and enalapril. What is important to include in this teaching? A. "Stand up slowly to decrease problem with dizziness". B. "Increase fluid intake because of increased loss of body fluids". C. "When you begin to feel better, the doctor will decrease your medications". D. "Stay out of the sunshine, and make sure you have adequate sodium intake".
A.
The parents of a client with hemophilia are taking their child home. Which statement indicates a need for further education regarding hemophilia? A. "We should ensure that our child has regular dental appointments" B. " We need to wrap our child's limbs daily to prevent bleeding" C. "We should help our child select activities that minimize the risk of injury" D. "We should not give our child aspirin"
B
What nursing observation indicates that an unplanned extubation of an endotracheal tube has occurred? A. The high-pressure ventilator alarm activates. B. Client is able to speak C. Increased swallowing efforts by client D. Increased crackles (rales) over left lung field
B
A chid with leukemia is being discharged after beginning chemotherapy. What instructions will the nurse include on the teaching plan for the parents of this child? A. Provide a diet low in protein and high in carbohydrates. B. Avoid unwashed fruits and vegetables. C. Notify the doctor if the child's temperature exceeds 102 degrees F (39 degree C) D. Increase the use of humidifiers throughout the house.
B
A client has a diagnosis of right-sided empyema. Thoracentesis is to be performed in the client' room. The nurse will place the client in what position for this procedure? A. Prone position with feet elevated. B. Sitting with upper torso over bedside table. C. Lying on left side with right knee bent. D. Semi-fowler's position with lower torso flat
B
A client has an order for one unit of packed cells. What is a correct nursing action? A. Initiate the IV with 5% dextrose in water (D5W) to maintain a patent access site. B. Initiate the transfusion within 30 minutes of receiving that blood C. Monitor the client's vital signs for the first 5 minutes. D. Monitor the client's vital signs every 3 hours during the transfusion.
B
A client has been diagnosed with disseminated intravascular coagulopathy (DIC). The nurse will anticipate administering which of the following fluids? A. Packed red blood cells (PRBCs) B. Fresh Frozen Plasma (FFP) C. Volume expanders, such as D10W D. Whole blood
B
A nurse is caring for a client who is receiving a blood transfusion. The transfusion was started 30 minutes ago at a rate of 100ml/hr. The client begins to complain of low back pain and headache and is increasingly restless. What is the first nursing action. A. Slow the infusion and evaluate the vital signs and the client's history of transfusion reactions. B. Stop the transfusion, disconnect the blood tubing, and begin a primary infusion of normal saline solution. C. Stop the infusion of blood and begin infusion of normal saline solution for the Y connector. D. Recheck the unit of blood for correct identification numbers and cross match information.
B
Which client is most likely to have iron deficiency anemia? A. A client with cancer receiving radiation therapy twice a week. B. A toddler whose primary nutritional intake is milk. C. A client with a peptic ulcer who had surgery 6 weeks ago. D. A 15-year-old client in sickle cell crisis.
B
The nurse applies a nitroglycerin patch on a client who has undergone cardiac surgery. What nursing observation indicates that a nitroglycerin patch is achieving the desired effect? A. Chest pain is completely relieved. B. Client performs activities of daily living without chest pain. C. Pain is controlled with frequent changes of patch. D. Client tolerates increased activity without pain.
B.
The nurse is teaching a client about home care and treatment of venous stasis ulcers on his leg. What should be included in the nurse's instructions? Select all that apply. A. Dressings do not need to be changed frequently because there is minimal drainage. B. Healing will be facilitated by wearing leg compression devices. C. When the client is in the sitting position, he should keep his legs elevated. D. Avoid standing for prolonged periods of time. E. Cool packs can be applied to the ulcers to decrease inflammation. F. Soak the affected extremity in warm water every evening.
B, C, D
The nurse is administering propranolol to a client who is being treated for hypertension. What is the desired response to this medication? A. Vasodilation occurs, resulting in a decrease in the cardiac afterload. B. The cardiac rate is decreased, with a resulting decrease in the cardiac output. C. Cardiac output is decreased, and the arterial BP rises. D. Pericardial fluid is decreased, thus decreasing the cardiac workload.
B.
The nurse is conducting discharge dietary teaching for a client with diverticulosis who is recovering from an acute episode of diverticulitis. Which statement by the client would indicate to the nurse that the client understood his dietary teaching? A. "I will need to increase my intake of protein and complex carbohydrates to increase healing" B. "I need to progress my diet from liquids to soft, low-fiber foods until the diverticulitis is completely resolved". C. "I will not put any added salt on my food, and I will decrease intake of foods that are high in saturated fat". D. "Milk and milk products can cause a lactose intolerance. If this occurs, I need to decrease my intake of these products".
B.
A client with hypertension asks the nurse what type of exercise she should do each day. What is the nurse's best response? A. "Exercise for an hour, but only three times a week". B. "Walk on the treadmill for 45 minutes every morning" C. "Begin walking and increase your distance as you can tolerate it". D. "Exercise only in the morning and stop when you get tired".
C
Four hours after aortic-femoral bypass graft surgery, the nurse assesses the client and is unable to palpate in the operative leg. This client complains of pain in the leg. What is the first nursing action? A. Massage the leg and apply warm towels. B. Elevate the leg and recheck the pulse. C. Call the physician immediately D. Help the client ambulate
C
On auscultation, the nurse hears wheezing in a client with asthma. Considering the pathophysiology of asthma, what would the nurse identify as the primary cause of this type of lung sound? A. Increased inspiratory pressure on the upper airway. B. Dilation of the respiratory bronchioles and increased mucus. C. Movement of air through narrowed airways. D. Increased pulmonary compliance.
C
One the first postoperative day after a right lower lobe (RLL) lobectomy, the client deep breathes and coughs but has difficulty raising mucus. What nursing observation would indicate the client is not adequately clearing secretions? A. Chest x-ray film showing right-sided pleural fluid. B. A few scattered crackles on RLL on auscultation C. Increase in Paco2 from 35 to 45 mmHg D. Decrease in forced vital capacity
C
The nurse is administering nitroglycerin intravenously to a client experiencing chest pain of an 8 on a 1 to 10 scale. What assessment changes would cause the nurse to decrease the infusion rate? A. Pain drops from a 8 to a 4. B. Heart Rate increases from 110 to 115 beats per minute. C. Blood pressure drops from 110/65 (80) to 89/44 (59) mmHg. D. Client verbalizes his head is pounding
C
The nurse is providing teaching to a family whose child has been recently diagnosed with hemophilia. Which of the following would the nurse include in this discussion? A. Hemophilia is a genetic disease that is more common in females. B. Hemophilia is correctable through transfusions and bone marrow transplantation. C. Hemophilia is most often a sex-linked congenital disorder. D. Hemophilia is preventable through genetic counseling
C
While discussing her diagnosis of hypertension, a client asks the nurse how long she is going to have to take all of the medications that have been prescribed. On what principle is the nurse's response based? A. The client will be scheduled for an appointment in 2 months; the doctor will decrease her medications at that time. B. As soon as her blood pressure (BP) returns to normal levels, the client will be able to stop taking her medications. C. To maintain stable control of her BP, the client will have to take the medication indefinitely. D. The nurse cannot discuss the medications with the client; the client will need to talk with the doctor
C
A client is admitted with duodenal ulcers. What will the nurse anticipate the client's history to include? A. Recent weight loss B. Frequent acetaminophen use. C. Burning pain 2 to 5 hours after a meal. D. Episodes of vomiting.
C.
During the night, a client with a diagnosis of acute coronary syndrome is found to be restless and diaphoretic. What is the best nursing action? A. Check his temperature and determine his serum blood glucose level. B. Turn the alarm low and promote sleep by decreasing the number of interruptions. C. Check the monitor to determine his cardiac rhythm. D. Call the physician to obtain an order for sedation.
C.
During the shift handoff report, the nurse learns that one of the assigned clients is in first-degree heat block. What actions should the nurse take? A. Count the radial pulse for 1 full minute. B. Determine the cardiac rate at the point of maximum impulse. C. Evaluate an ECG or monitor strip. D. Take hourly pulse checks and correlate with blood pressure.
C.
The nurse is assessing a client whose condition is being stabilized after experiencing a ST-segment-elevation myocardial infarction. Which assessment is most indicative of inadequate renal perfusion? A. Increasing serum blood urea nitrogen (BUN) level B. Urine specific gravity of less than 1.010 C. Urine output of less than 30 ml/hr. D. Low urine creatinine clearance
C.
A client and her husband are positive for the sickle cell trait. The client asks the nurse about the chances of her children having sickle cell disease. The nurse understands that this genetic problem will reflect what pattern in the client's children? A. One of her children will have sickle cell disease. B. Only the male child will have sickle cell disease. C. Each pregnancy carries a 25% chance of the child being affected. D. If she has four children, one of them will have the disease.
C. Each pregnancy carries a 25% chance of the child being affected.
A client with hemophilia comes to the emergency department after bumping his knee. The knee is rapidly swelling. What is the first nursing action. A. Initiate an IV site to begin administration of cryoprecipitate. B. Perform a type and cross-match for possible transfusion. C. Draw blood for determination of hemoglobin and hematocrit values. D. Apply an ice pack and compression dressing to the knee.
D
A school age child with a diagnosis of celiac disease asks the nurse. "Which foods will make me sick?" Which food items would the nurse teach the child to avoid? A. Rices, cereal, milk and tapioca B. Corn, cereals, milk, and fruit. C. Corn or potato bread and peanut butter D. Malted milk, white bread, and spaghetti.
D
The client with COPD is to be discharged home while receiving continuous oxygen at a rate of 2 L/min via cannula. What information does the nurse provide to the client and his wife regarding the use of oxygen at home? A. Because of his need for oxygen, the client will have to limit activity at home. B. The use of oxygen will eliminate the client's shortness of breath C. Precautions are necessary because oxygen can spontaneously ignite and explode D. Use oxygen during activity to relieve the strain on the client's heart
D
The nurse is caring for a client who is scheduled for a gastric endoscopy. Which of the following actions must the nurse perform before the client is able to eat or drink after the endoscopy? A. Check oxygen saturation. B. Give small sips of water. C. Check all vital signs. D. Assess the client' gag reflex.
D
The wife of a client with COPD is worried about caring for her husband at home. Which statement by the nurse provides the most valid information? A. "You should avoid emotional situation that increase his shortness of breath". B. "Help your husband arrange activities so that he does as little walking as possible". C. "Arrange a schedule so your husband does all necessary activities before noon; then he can rest during the afternoon and evening". D. "Your husband will be more short of breath when he walks, but that will not hurt him"
D
Which nursing action would be most effective in preventing venous stasis in the postoperative surgical client? A. Raise the foot of the bed for 1 hour, then lower it to stimulate blood flow. B. Massage the lower extremities every 6 hours. C. Facilitate active range of motion of the upper body to stimulate cardiac output. D. Help the client walk as soon as permitted and as often as possible.
D
Which statement correctly describes suctioning through an endotracheal tube? A. The catheter is inserted into the endotracheal tube; intermittent suction is applied until no further secretions are retrieved; the catheter is then withdrawn. B. The catheter is inserted through the nose and the upper airway is suctioned; the catheter is then removed from the upper airway and inserted into the endotracheal tube to suction the lower airway. C. With suction applied, the catheter is inserted into the endotracheal tube; when resistances met, the catheters slowly withdrawn. D. The catheter is inserted into the endotracheal tube to a point of resistance, and intermittent suction is applied during withdrawal.
D
A 6-year-old client is admitted to the postoperative recovery area after a tonsillectomy. In what position will the nurse place the client? A. Semi-fowler's position, with the head turned to the side. B. Prone position, with the head of the bed slightly elevated. C. On the back, with the head turned to the right. D. On the abdomen, with the head turned to the side.
D.
A client is admitted for evaluation of his permanent pacemaker. Which assessment is most concerning? A. Pulse rate of 96 beats/min with regular rate and rhythm. B. Irregular pulse rate with with premature ventricular beats. C. Atrial premature beats shown on the monitor. D. Pulse rate of 48 beats/min with premature ventricular beats.
D.
The nurse is preparing discharge teaching for a client with hypertension who is being treated with furosemide and clonidine. The nurse would caution the client about which over-the-counter medications? A. Antihistamines B. Acetaminophen C. Topical corticosteroid cream D. Decongestant cough preparation
D.
What is an important nursing action in the safe administration of heparin? A. Check the prothrombin time (PT) and administer the medication if it is less than 20 second. B. Use a 20-gauge, 1-inch (2.5cm) needle and inject into the deltoid muscle and gently massage the area. C. Dilute in 50 ml 5% dextrose in water (D5W) and infuse by intravenous piggyback (IVPB) over 15 minutes. D. Use a 25-gauge, 1/2 inch (1.25 cm) needle and inject the medication into the subcutaneous tissue of the abdomen.
D.