Post Test(basic adult)

A nurse is caring for a client who is using a PCA pump for post-op pain management. The nurse enters the room to find the client asleep and his wife pressing the button to dispense another dose. Which of the following responses should the nurse make? a. Only your husband should decide when more medication is needed. b. If you feel he needs more medication, you can call me and I will assess him. c. Why do you think your needs more medication when he is asleep? d. it's important to medicate during sleep tot maintain better pain control.

a. Only your husband should decide when more medication is needed.

The nurse assesses the client's stoma during the initial post-op period. Which of the following observations should be reported immediately to the physician? a. The stoma is dark red to purple b. the stoma oozes a small amount of blood c. The stoma doesn't expel stool d. The stoma is slightly edematous

a. The stoma is dark red to purple

The client in the medical unit begins to experience a severe anaphylactic reaction after an initial dose of IV penicillin, an antibiotic. Which intervention would least likely be implemented as an immediate response to this development? a. Administer Epinephrine, an adrenergic blocker, SQ then IV continuous b. Prepare to administer Solu-Medrol, a glucocorticoid, IV c. Request and obtain a routine chest x-ray d. initiate the rapid response team

A. Administer Epinephrine SQ then IV continuous

The nurse is administering a transfusion of packed RBC to a client. Which interventions should the nurse implement? List in order of performance. 1. start the transfusion slowly 2. Verify the client has signed consent 3. Assess the IV site for size and patency 4. Check the blood with another nurse at the bedside 5. Obtain the blood from the laboratory

ANS: 2,3,5,4,1

Which of the following interventions may prevent a urinary tract infection? a. consume cranberry juice b. wear leather pants c. restrict fluid intake d. take a bath instead of a shower

a. consume cranberry juice

A client undergoing assessment of cranial nerve VIII is likely to have which of the following included in his examination? a. Weber, Rinne, and Romberg test b. deep tendon reflexes c. cardinal gaze examination d. snellen chart

a. weber, rinne, and romberg test

Which of the following clients is most at risk for developing a deep-vein thrombosis? a. A 63-year old client post-CVA on anticoagulant therapy b. A 40-year old client who smokes and uses oral contraceptives c. A 41-year old client who underwent laparoscopic cholecystectomy d. A 30-year old client who is 1 week postpartum

b. A 40-year old client who smokes and uses oral contraceptives

Which of the following statements is true regarding the difference between DKA and HHS? a. DKA occurs more often in client with type 2 diabetes b. HHS develops over the course of days while DKA has a rapid onset c. Arterial pH levels during HHS can drop below 7.3 d. Ketones are present in the urine for both conditions

b. HHS develops over the course of days while DKA has a rapid onset

A client on an inpatient psychiatric unit angrily says to a nurse "Peter is not cleaning up after himself in the community bathroom. You need to address this problem." Which is the appropriate nursing response? a. I will talk to Peter and present your concerns. b. I can see that you are angry. Let's discuss ways to approach Peter with your concerns. c. Why are you overreacting to this issue? d. You should bring this to the attention of your treatment team.

b. I can see that you are angry. Let's discuss ways to approach Peter with your concerns.

A client has a nasogastric tube following a subtotal gastrectomy. The nurse should: a. reposition the tube if it is not draining well b. Monitor the client for nausea, vomiting, and abdominal distention c. irrigate the tube with 30 mL d. Turn the machine to high suction if the drainage is sluggish on low suction

b. Monitor the client for nausea, vomiting, and abdominal distention

A nurse is caring for a client who has emphysema. Which of the following findings would the nurse no expect to assess in this client? a. Dyspnea b. deep respirations c. barrel chest d. clubbing of the fingers

b. deep respirations

A nurse discovers a client's suicide note that details the time, place, and means to commit suicide. What should be the priority nursing intervention and the rationale for this action? a. establishing room restrictions, because the client's threat is an attempt to manipulate the staff b. placing the client on one-on-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide c. administering lorazepam prn, because the client is angry about the discovery of the note

b. placing the client on one-on-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide

A nurse is admitting an adult client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is a priority action for the nurse to take? a. apply an ice pack to the casted leg b. elevate the extremity c. perform a neurovascular assessment d. administer analgesics

c. perform a neurovascular assessment

A nurse is admitting a client who has influenza accompanied by severe nausea and vomiting. Client reports numbness and tingling of the toes and fingers. The nurse should recognize the client is experiencing which of the following acid-base imbalances? a. Respiratory Alkalosis b. Metabolic alkalosis c. Respiratory acidosis d. Metabolic acidosis

d. Metabolic acidosis

A nurse's forearm is splattered with blood while inserting an intravenous catheter. What action should the nurse take? a. Wipe the blood away with a tissue b. Flush the forearm with hot water, letting the water flow from the elbow toward the fingers c. Wipe the blood away with an alcohol swab d. Wash the forearm with soap and water

d. Wash the forearm with soap and water

A nurse is caring for a client recently diagnosed with hypothyroidism. The client noticed thinning hair and a change in bowel movements from everyday to every other day. She also reports a new preference for warmer environments and a profound decrease to her energy levels. Which of the following nursing diagnoses would be priority for this client? a. body image disturbed related to physical changes b. constipation related to diminished gastrointestinal peristalsis c. risk for imbalanced body temperature related to potential hypothermia d. activity intolerance related to insufficient physiologic energy

d. activity intolerance related to insufficient physiologic energy

A client with a history of angina pectoris is admitted to the medical surgical unit for treatment of peptic ulceration. After lunch, the client calls nurse and reports an 8/10 crushing pain in his chest. The nurse's first action is: a. administer an antacid b. call the pcp c. ask the client what he had for lunch d. administer nitrates and aspirin as prescribed

d. administer nitrates and aspirin as prescribed

A nurse is assessing a client who has developed atelectasis post-op. Which of the followin findings should the nurse expect? a. facial flushing b. decreased respiratory rate c. pleural friction rub d. increasing dyspnea

d. increasing dyspnea

A client was admitted following a motor vehicle accident. The nurse notes the client has a glasgow coma scale of 3. What should be the nurse's primary concern? a. document the client has a fall risk and implementing appropriate prevention strategies b. performing a swallow evaluation due to increased aspiration risk c. there is no concern, as 3 is the highest score one can get on a GCS d. protecting the airway and respiratory function due to the decreased LOC

d. protecting the airway and respiratory function due to the decreased LOC

A client has a complaint of incontinent episodes when sneezing, coughing, laughing, or changing body position. Which type of incontinence should the nurse document in the EMR? a. neurogenic b. functional c. latrogenic d. stress

d. stress