PRE EXIT 01/23

C

Cranial nerves supplying eyes are: Select one: a. 4, 5, 6 b. 4, 6, 7 c. 3, 4, 6 d. 3, 4, 5

A

A postoperative client with deep-vein thrombosis is at risk for pulmonary embolism. For which characteristic sign or symptom of this complication does the nurse monitor the client? Select one: a. Pleuritic chest pain b. Chills and a high fever c. Slowed heart rate d. Decreased respiratory rate

A

A trauma survivor is requesting sleep medication because of "bad dreams." Concerned about posttraumatic stress disorder, the nurse asks Select one: a. "Can you describe your phobias?" b. "Are you having chest pain?" c. "Are you reliving your trauma?" ` d. "Can you tell me when you wake up?"

C

Horizontal nystagmus is more consistent with toxicity of: Select one: a. Digoxin b. Lithium c. Phenytoin d. Theophylline

D

If a nurse applies a restraint vest without the patient's permission or a physician's order, the nurse may be charged with: Select one: a.Invasion of privacy b. Neglect c.Assault d.Battery

A

If the pump of total parenteral nutrition (TPN) has problem and stop working in a patient that is receiving IV infusion at 60ml/hr. Which of the following actions should the nurse take while waiting for a new infusion pump? Select one: a. Provide dextrose 10% in water solution using manual drip tubing at 60 mL/hr. b. O"er the client oral $uids in place of the TPN solution. c. Administer the TPN solution at the same rate using manual drip tubing. d. Infuse 0.9% sodium chloride solution using manual drip tubing at 30 mL/hr.

B

In Leopold's maneuver step #1, you palpated a soft broad mass that moves with the rest of the mass. The correct interpretation of this !nding is: Select one: a. The mass palpated is the back b. The mass palpated is the buttocks. c. The presentation is breech. d. The mass palpated at the fundal part is the head part.

A

In the event of a !re in a client's home, your !rst action is to _______. Select one: a. move the client to a safe place. b.get the !re extinguisher. c.turn on the !re alarm. d.report the !re to your agency.

B,C,E

Right heart failure include which of the followings: Select all that apply Select one or more: a. confusion b. ascities c. hepatomegaly d. crackles e. jugular veins distention

A

Sulfa allergy is a concern in a patient taking: Select one: a. Chlortalidone b. Triamterene c. Verapamil " d. Amiloride

D>E>C>B>A

The correct order to Mix Insulin is A-Recap the needle using the one-hand scoop technique...if not using immediately. B-Insert syringe into Humulin-N and turn bottle upside down and remove the units that you need. C-Inject units of air into the Humulin-R vial & turn bottle upside down and then withdraw units of clear insulin and REMOVE SYRINGE. D-Check the doctor's order and that you have the correct medication E-Inject units of air into the Humulin-N vial & then remove syringe from vial.

C

nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse assess for as the expected therapeutic response? Select one: a. Hypertensive crisis b. Decreased intraocular pressure c. Short period of asystole d. Increased heart rate

D

A client with emphysema is receiving theophylline (Theo-24). While providing dietary instructions, the nurse tells the client that it is acceptable to consume: Select one: a. Cola b. Coffee c. Hot cocoa d. Apple juice

A

A client with human immunode!ciency virus (HIV) infection has white lesions in the oral cavity that resemble milk curds. Nystatin preparation is prescribed as a swish and swallow. Which information is most important for the nurse to provide the client? Select one: a. Oral hygiene should be performed before the medication. b. Antifungal medications are available in tablet, suppository, and liquid forms. c. Candida albicans is the organism that causes the white lesions in the mouth. " d. The dietary intake of dairy and spicy foods should be limited.

D

A client with non-Hodgkin lymphoma has been prescribed cyclophosphamide IV for therapy. Which assessment finding would need to be reported immediately to the oncologist? Select one: a. Sores on the mouth or tongue b. Changes in color of !ngernails or toenails c. Loss of appetite or weight with diarrhea d. Chills, fever, and sore throat

B

A client being seen in the clinic complains of fatigue and weakness. Laboratory studies are performed because thephysician suspects iron-de!ciency anemia. Which finding indicative of this type of anemia does the nurse expect to find on reviewing the laboratory results? Select one: a. An increased hematocrit level b. Microcytic red blood cells (RBCs) c. An increased RBC count d. An increased hemoglobin level

B

A client diagnosed with lung cancer is told that the client only has about 6 months to live. The spouse tells the nurse, "I pray every night that God will give me more time with my loved one." Which Kübler-Ross stage of grief does the nurse recognize the spouse to be exhibiting? Select one: a. Acceptance b. Bargaining # c. Anger d. Depression

D

A client is prescribed diazepam. The nurse provides additional teaching when the client makes which statement? Select one: a. this medication will relax my muscles b. this medication can be used to treat seizures c. this medication reduces feelings of anxiety d. this medication prevents high blood pressure

D

A patient with lung cancer is developing a SIADH (Inappropriate ADH secretion). The nurse should plan to monitor which of the following complications. Select one: a. Cardiac Arrythmias b. Polyuria and Polydipsia c. Diarrhea d. Hyponatremia

D

A pediatric nurse is caring for a hospitalized toddler. Which of the following activities does the nurse deem the most appropriate for the toddler? Select one: a. Singing games b. Watching videos c. Simple board games d. Large building blocks

D

Following a lumbar puncture, the client reports a headache on a pain scale of 8 out of 10. What priority action should the nurse perform? Select one: a. Close room blinds to darken the environment. b. Instruct the client to drink at least 8 ounces of water. c. Notify primary healthcare provider of client's complaints. d. Assist the client into a supine position in bed.

A, D

A nurse is performing an assessment of a newborn with a diagnosis of esophageal atresia (EA) and tracheoesophageal fistula (TEF). Which !ndings does the nurse expect to note in the infant? Select all that apply. Select one or more: a. Excessive oral secretions b. Bowel sounds over the chest c. Wheezing d. Drooling e. Short periods of apnea

B

A nurse is preparing for the admission of a child with a diagnosis of acute-stage Kawasaki disease. On assessment of the child, the nurse expects to note which clinical manifestation of the acute stage of the disease? Select one: a. a normal appearance b. conjunctivitis c. desquamation of the skin d. cracked lips

D

A male client with Parkinson disease is prescribed the antiparkinsonian agent amantadine HCl. Which action should the nurse take? Select one: a. Notify client that development of a rash is a common side e"ect. b.Encourage foods high in vitamin B such as meat or liver. c. Instruct client to take at the same time as prescribed beta blocker. d. Teach client to change positions slowly.

D

A male patient with a history of type 1 diabetes is two days post-op following cholecystectomy. He has complained of nausea and can't tolerate solid foods. The nurse finds the patient confused and shaky. Which of the following most likely explains the patient's symptoms? Select one: a.Hyperglycemia b. Diabetic ketoacidosis " c.Respiratory acidosis d.Hypoglycemia

A

A nurse is providing dietary instructions to the mother of a child with celiac disease. The nurse tells the mother that it is acceptable to give the child: Select one: a. Boiled rice b. Cooked pasta c. Warm oatmeal d. Baked macaroni and cheese

C

A medical nurse is providing palliative care to a patient with a diagnosis of end-stage chronic obstructive pulmonary disease (COPD). What is the primary goal of this nurse's care? Select one: a. To provide physical support for the patient b. To support aggressive and innovative treatments for cure c. To improve the patient's and family's quality of life d. To help the patient develop a separate plan with each discipline of the health care team.

B

A nurse administers nitroglycerin sublingually to a client with angina pectoris who complains of chest pain. The medication is ine"ective, so the nurse prepares to administer a second dose. Before administering the nitroglycerin, which action does the nurse make a priority? Select one: a. Asking the client whether he has a headache b. Checking the client's blood pressure c. Obtaining blood levels of cardiac enzymes " d. Obtaining a 12-lead electrocardiogram (ECG)

D

A nurse admitting a newborn to the nursery notes that the physician has documented that the newborn has a gastroschisis. The nurse performs an assessment, expecting to note that the viscera are: Select one: a. Inside the abdominal cavity and under the skin b. Inside the abdominal cavity and under the dermis c. Outside the abdominal cavity but inside a translucent sac covered with peritoneum and amniotic membrane d. Outside the abdominal cavity, not covered with a sac

B

A nurse arrives late to work smelling strongly of breath mints. The nurse displays inattentiveness. As a nurse manager, what is the best action? Select one: a. Terminate the employee as soon as possible. b. Speak with the nurse about the matter. # c. Call security to escort the patient out of the building. d. Record the observations in the employee's !le

A

A nurse cares for a client with a prescription for irrigation of an indwelling urinary catheter. The nurse knows this task can be delegated to which personnel? Select one: a. A practical nurse b. An unlicensed assistive personnel c. A radiology technician d. The on-call urologist

A,C,D,E

The patient asked the nurse what laboratory values are healthy for a low density lipoprotein test. Which of the following values did the nurse say are healthy for those not at risk for heart disease? check all answers that apply Select one or more: a. 85 mg/dL b. 135 mg/dL c. 105 mg/dL d. 115 mg/dL e. 95 mg/dL

D

Which information should the nurse plan to teach family members of a client diagnosed with hepatitis B? Select one: a. Wash dishes separately from the rest of the family's. b. Wear a surgical mask when in close proximity to the client. c. Use a separate bathroom from the client. d. Do not share personal items with the client, such as razors or toothbrushes.

C

A nurse caring for a client 24 hours after a radical neck dissection notes the presence of serosanguineous drainage in the portable wound suction device attached to the surgical site. On the basis of this !nding, the nurse should: Select one: a. Increase the pressure on the wound suction device b. Ask the physician to remove the drains " c. Document the findings d. Contact the physician

3>1>4>2

A nurse developing a plan of care for a client with HIV infection identi!es several concerns. List them in order of priority, from highest to lowest. 1-Decreased nutrition 2-Despair 3-Possible infection 4-Fatigue

D

A nurse discovers that a client receiving heparin sodium by way of continuous intravenous (IV) infusion has removed the IV tubing from the infusion pump to change his hospital gown. After assessing the client and placing the tubing back in the infusion pump, which medication does the nurse check for in the medication room in case a heparin overdose has occurred? Select one: a. Phytonadione (vitamin K) b. Aminocaproic acid (Amicar) c. Enoxaparin (Lovenox) d. Protamine sulfate

B

Which interpretation is correct about these values ( pH:7.30; PO2: 56 mmHg; PCO2: 54 mmHg; HCO3: 26 ? Select one: a. Uncompensated metabolic acidosis b. Uncompensated respiratory acidosis c. Compensated metabolic acidosis d. Compensated respiratory acidosis

C

A nurse in a physician's o#ce is talking to a client who underwent mastectomy of the right breast 2 weeks ago. The client says to the nurse, "I hate looking at this incision. I feel that I'm not even myself anymore." The nurse interprets this statement to mean that the client is experiencing which problem? Select one: a. Inability to maintain health b. Inability to care for self c. Distorted body image d. Inability to cope

A

A nurse is caring a client who has thrombocytopenia. Which instructions should include in the plan of care? Select one: a.Avoid venipunctures when possible. b. Prohibit fresh $owers in the client's room c.Limit oral $uid intake to between meals d.Restrict visitors to family members.

D

A nurse is caring for a client who had terminal illness and require not receive saving live measure in case of cardiacarrest. Which statement should the nurse make? Select one: a. You will need to draft a health care proxy so a designee can make this decision for you. b. Your provider determines if you should have lifesaving measures if your heart stops. c. I will make sure that no one performs any lifesaving measures if your heart stops. d. I will provide you with information about medical treatment to include in your living will.

B

A nurse is caring for a client who has had a cast applied to the left leg and is at risk for acute compartment syndrome. For which early sign of this complication does the nurse monitor the client? Select one: a. Weak pedal pulse b. Paresthesia c. Cold, bluish toes d. Severe pain relieved by medication

A

A nurse is in care of a 4h postoperative patient of hysterectomy. Which of the following acton should the nurse take !rst. Select one: a.Measure the client's vital signs. b. Administer pain medication. c.Encourage the client to use an incentive spirometer. d.Reposition the client.

A

Captopril (Capoten) is prescribed for a hospitalized client with heart failure. Which action is a priority once the nurse has administered the !rst dose? Select one: a. Maintaining the client on bed rest for 3 hours b. Checking the client's apical heart rate c. Checking the client's breath sounds for decreased wheezing d. Monitoring the client for increased urine output

D

A child with a diagnosis of Wilms' tumor is being admitted to the pediatric unit. The nurse prepares the room for the child and places a sign at the child's bedside that tells staff to avoid: Select one: a. Taking temperatures rectally b. Turning the child to the right side c. Measuring blood pressure in the right arm d. Palpating the abdomen

C

A child with nephrotic syndrome is receiving prednisone. Which choice of breakfast foods at a fast food restaurant indicates that the mother understands the dietary guidelines necessary for her child? Select one: a. Canadian bacon slices and hot chocolate b. Sausage egg mu#n and grape juice c. Toasted oat cereal and low-fat milk d. French toast sticks and orange juice

C

Carbon monoxide poisoning treatment: Select one: a. Nitrites b. Nitrogen and Oxygen by facemask c. Oxygen 100% # d. Low pressure chamber

B

A nurse is monitoring a client who has undergone subtotal thyroidectomy for signs of postoperative complications. Which of the following !ndings would be a matter of concern for the nurse as an indication of hypocalcemia? Select one: a. The client's heart rate is 92 beats/min. b. The client complains of a tingling sensation around the mouth. c. The client's temperature is 100.6° F. d. The client's voice is hoarse and weak.

C

A client with tuberculosis will be taking pyrazinamide (Pyrazinamide), and the nurse provides instructions about the adverse effects of the medication. For which of the following occurrences does the nurse tell the client to contact the physician? Select one: a. Difficulty sleeping b. Headache c. Yellow skin d. Nasal congestion

A

Damage to _________________ cranial nerve results in inability to shrug and weak head movement. Select one: a. Accessory nerve b. Vagus nerve c. Glossopharyngeal nerve d. Facial nerve

C

A diabetic patient receives 10 units of Regular insulin and 20 units of NPH insulin each day after breakfast. After following normal preparation steps for administering insulin, what should the nurse do next? Select one: a.Either insulin can be drawn !rst, as long as 30 units are given b.Draw up NPH insulin !rst, because it is clear c. Draw up Regular insulin !rst, because it is clear # d.Administer each type of insulin separately for accuracy

B

A nurse is monitoring a client who was brought to the emergency department in an unresponsive state and is now being treated for hyperglycemic hyperosmolar nonketotic syndrome (HHNS). Which of the following !ndings indicates to the nurse that $uid replacement is inadequate? Select one: a. Potassium level of 3.6 mEq/L b. Level of consciousness remains unchanged c. Increased urine output d. Blood pressure of 128/80 mm Hg

B

A nurse is performing an assessment of a client with Ménière disease. Which question does the nurse ask to elicit data about the manifestations of this disease? Select one: a. "Do you have headaches?" b. "Do you have episodes of dizziness?" c. "Have you had any loss of appetite?" d. "Have you been having any diarrhea?"

A

A nurse is performing an assessment of a client with suspected pheochromocytoma. Which clinical manifestation does the nurse expect to note? Select one: a. A blood pressure higher than the normal range b. Flushed face c. Client complaint of diarrhea d. Weight gain

D

A !ve year old is in Bryant's traction for intervention for a fractured femur. Which !nding by the nurse would require intervention? Select one: a. The parents are at the bedside reading a book with the child. b. The child's hips are in 90-degree $exion. c. The child is consuming 120 mL of grape juice. d. The child's hips are gently resting on the bed.

C

A 55-year-old patient returns from open-heart surgery. Which nurse should care for this patient? Select one: a. A nurse with 5 years' experience on the general medical $oor b. A nurse with 15 years of experience on the telemetry floor. c. A nurse with 1 of experience in surgery. # d. A nurse with 10 year's experience in the emergency department.

A

A 63-year old male of Chinese descent complains of severe post-operative pain that does not respond to analgesics. He tells the nurse, "If I could get acupuncture, my pain would go away." The nurse understand that Asian cultures use acupuncture to Select one: a.Restore energy balance b.Promote serenity c.Expel evil spirits d.Block pain pathways

D

A child is being discharged home following a bone marrow transplant. When providing discharge instructions to the parents, what information is most important for the nurse to include? Select one: a. Clean toothbrush weekly with alcohol. b. Apply heating pad to bruised areas of the skin. c. Drink bottled water the day. d. Avoid eating raw fruits and vegetables.

B

A child was diagnosed with Duchenne's muscular dystrophy; which of the following usually is the !rst indication of the condition? Select one: a. Lateness in walking in the toddler b. Difficulty running in the preschooler c. Decreasing coordination in the school-age child d. Inability to suck in the newborn

D

A client has been admitted for evaluation of severe anxiety and new onset panic attacks following the loss of a spouse. Which client factor would the nurse consider most important in developing a plan of care? Select one: a. Desire to return to work b. Available support system c. Perception of the situation d. Coping mechanisms

D

A client has been receiving levo$oxacin, 500 mg IV piggyback q24h for 7 days. The UAP reports to the nurse that the client has had three loose foul-smelling stools this morning. Which intervention is most important for the nurse to implement? Select one: a. Administer a PRN dose of psyllium. b. Instruct the UAP to obtain incontinent pads for the client. c. Perform a digital evaluation for fecal impaction. d. Obtain a stool specimen for culture and sensitivity.

C

A client has been taking tranylcypromine for approximately two weeks. The client is visiting the nurse at the local mental health center for follow up and group therapy. Which client comment indicates a lack of understanding of the medication that could result in a medical emergency? Select one: a. I know that I must take this medication until my primary healthcare provider tells me to stop. b. I am going to have broccoli salad and roasted turkey for lunch today. c. I am getting a cold, and I am going to take some over the counter cold medicine. d. It is frustrating to have to follow dietary restrictions.

D

A client is seen at the clinic two weeks after starting amitriptyline. The client reports improved sleep patterns and appetite, but no change in feelings of sadness or depression. What comment by the nurse is most appropriate? Select one: a. "You might need to be changed to a di"erent medication." b. "Would you like me to ask the doctor to increase your dose?" c. "Tell me what type of situations make you feel depressed." " d. "Some medications take a little longer to improve moods."

C

A client receiving furosemide 20 mg every day reports an onset of cramping in the lower extremities. Based on this report, what current lab !nding would the nurse expect? Select one: a. Sodium level of 140 mEq/L (140 mmol/L) b. pH level of 7.40 c. Potassium level of 3.1 mEq/L (3.1 mmol/L) d. Calcium level of 11 mg/dL (2.75 mmol/L)

B

A client scheduled for an amniocentesis expresses concerns about the procedure to the nurse, despite having signed the consent form. What statement by the nurse would be most appropriate for the client? Select one: a."I will tell the doctor you need to talk more." b. "Can you tell me what most concerns you?" # c. "You have already signed the consent form." d. "Don't worry, it's a very simple procedure."

B

A client who has a history of major depression is in the emergency department. Which statement would demonstrate a risk for suicide or self-directed injury? Select one: a. "I am not sure what to do anymore." b. "I just cannot take this loneliness anymore." c. "I can't do anything right anymore." d. "No one cares about me."

C, E

A client with Addison Disease has a prescription of oral prednisone. Which instruction should the nurse provide? Select all that apply Select one or more: a. increase the intake of potatoes and green beans b. stop medication immediately if blurred vision or eye pain occur " c. take each dose with food d. increase the intake of bananas e. report weight gain of more than 5 pounds in a week.

A

A client with HIV infection who has been found to have histoplasmosis is being treated with intravenous amphotericin B(Fungizone). Which parameter does the nurse check to detect the most common adverse e"ect of this medication? Select one: a. Intake and output b. Peripheral pulses c. Blood pressure d. Temperature

C

A client with acute renal failure (ARF) starts to void 4 L/day 2 weeks after treatment is initiated. Which complication is important for the nurse to monitor the client for at this time? Select one: a. Hyperkalemia b. Uremia c. Hypotension d. Diabetes insipidus

A

A client with chronic back pain asks a nurse about the use of complementary and alternative therapies to treat the pain. The nurse would initially: Select one: a. Identify the client's treatment goals b. Tell the client that the physician does not believe in these therapies c. O"er options that may be bene!cial to the client d. Share current research outcomes with the client

D

A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide PO and 40 mg of furosemide PO daily. Today, at a routine clinic visit, the client's serum potassium level is 4 mEq/L. What is the most likely cause of this client's potassium level? Select one: a. The client recently consumed large quantities of pears or nuts. b. The client is noncompliant with his medications. c. The client needs to be started on a potassium supplement. d. The client's renal function has a"ected his potassium level.

C

A client with diabetes mellitus has a glycosylated hemoglobin A1C level of 9%. On the basis of this test result, the nurse plans to teach the client about the need for which measure. Select one: a. Preventing and recognizing hypoglycemia b. Taking adequate fluids c. Preventing and recognizing hyperglycemia d. Avoiding Infection

C

A client with psychosis, tells another client, "You are so adorabogalishus." Which form of thought process should the nurse document this client as having? Select one: a. Perseveration b. Magical thinking c. Neologism d. Tangentiality

C

A client with schizophrenia tells the nurse, "The world is coming to an end. All the violence in the Middle East is soon going to destroy the entire world!" How should the nurse respond? Select one: a. "The news makes you have upsetting thoughts." b. "Let's play some dominoes for a few minutes." c. "Listening to the news seems to be frightening you." d. "I don't think the violence means the world is ending."

C

A client with suspected HIV infection has positive results on enzyme-linked immunosorbent assay (ELISA) and Western blot tests. The plasma HIV RNA level is assessed, and the result is reported as 8000 copies/mL. The nurse interprets the results of the HIV RNA test as indicating that the client: Select one: a. Is at risk for HIV infection b. Requires further testing to con!rm the presence of HIV c.Is at low risk for AIDS d. Is at high risk for AIDS

D

A nurse is providing education to a client regarding the use of an inhaler for acute asthma symptoms. Which statement made by the client would indicate the need for further teaching? Select one: a. "I should hold my breath for approximately 8-10 seconds before exhaling slowly." b.I should shake the inhaler well before use." c. "I should breathe out slowly and completely through my mouth before placing the mouthpiece of the inhaler in mymouth." d. "I should administer the two pu"s that are ordered in rapid sequence."

C

A nurse on the neurology unit has the following patients. Which would be the most concerning and require the nurse to contact the physician? Select one: a. A patient recovering from a motor vehicle collision with intracranial monitoring and an ICP that has risen from 6 mmHg to 11 mmHg. " b. A patient who becomes dizzy and almost falls when standing from a seated position. c. A patient who states, "I have a headache and my balance has been off all day". d. A patient who states, "My vision becomes blurry when I get up in the morning".

B

A nurse provides home care instructions to a client with coronary artery disease (CAD) who is being discharged from the hospital. Which statement by the client indicates a need for further instruction? Select one: a. "I need to carry my nitroglycerin with me at all times." b. "I need to participate in aerobic and weightlifting exercise three times a week." c. "I need to avoid foods with saturated fats and foods high in cholesterol." d. "I need to check my pulse before, during, and after exercise."

B

A nurse provides information to a client who will be undergoing endoscopic retrograde cholangiopancreatography (ERCP). The nurse tells the client that: Select one: a. The procedure is performed speci!cally to visualize the esophagus, stomach, and duodenum b. Dye may be injected during the procedure to permit visualization of the pancreatic and biliary ducts # c. There is no need to fast (NPO status) before the procedure d. The gallbladder is easily removed during this procedure if gallstones are found

B

A nurse provides information to a client with chronic obstructive pulmonary disease (COPD) about methods of alleviating shortness of breath while the client is eating. Which statement by the client indicates a need for further instruction? Select one: a. "I should use my bronchodilator 30 minutes before I eat." b. "I should eat three meals a day, and the biggest meal should be at suppertime." c. "I should rest before I eat." d. "Pursed-lip breathing will help relieve my shortness of breath."

B

A nurse provides skin care instructions to a client with acne vulgaris. Which statement by the client indicates a need for further instruction? Select one: a. "I should avoid rubbing my face vigorously." b. "I should use oil-based cosmetics." c. "I should wash my face two or three times a day with a mild cleanser." d. "I shouldn't leave make-up on overnight."

A

A nurse receives a report at the beginning of a day shift. Which client does the nurse assess first? Select one: a. A client reporting shortness of breath and di#culty breathing # b. A client who reports di#culty sleeping through the night c. A client whose previous assessment included audible wheezing d. A client with a report of surgical incision pain of 4/10

D

A patient diagnosed with type 2 diabetes mellitus is admitted to the medical unit with pneumonia. The patient's oral antidiabetic medication has been discontinued and the patient is now receiving insulin for glucose control. Which of the following statements best explains the rationale for this change in medication? Select one: a. Infection has compromised beta cell function so the patient will need insulin from now on b.Acute illnesses like pneumonia will cause increased insulin resistance c.Insulin administration will help prevent hypoglycemia during the illness d.Stress-related states such as infections increase risk of hyperglycemia

D

A patient with a history of atrial !brillation for three days is admitted to the cardiac unit. Besides initiating an antidysrhythmia medication, which order should the nurse anticipate? Select one: a.Immediately give atropine by IV push b.Obtain consent for AV node ablation c. Set up for a cardioversion procedure d.Prepare a heparin infusion

25

A physician writes a prescription for 1000 mL of 0.9% normal saline solution to be administered intravenously (IV) to a client over 10 hours. The drop factor for the infusion set is 15 gtt/mL. At what drip rate does the nurse set the infusion? (gtt/min)Type answer in the box provided. Answer:

D

An electrocardiogram strip shows that the PR interval is 6 small boxes in length. The nurse knows this indicates: Select one: a.An impending myocardial infarction. b.The interval is within normal limits. c. Stress is causing sympathetic stimulation. d.A delay in the AV node conduction.

A

An emergency department nurse is monitoring a client who sustained a severe inhalation burn injury during a fire in which the client was trapped in an enclosed space. The nurse auscultates the client's trachea and notes that the previously heard wheezing sounds have disappeared. The nurse most appropriately: Select one: a. Notifies the emergency department physician b. Removes the oxygen mask and !ts the client with a nasal cannula c. Continues monitoring the client d. Documents the client's improvement in the medical record

D

An expectant HIV positive client asks why zidovudine (ZDV) must be continued throughout the pregnancy. What is the best explanation by the nurse? Select one: a. "This drug prevents transmission of HIV to your partner." b. "The medication permits safe breastfeeding after delivery." c. "It protects you against other infections during pregnancy." d. "ZDV decreases the chance the baby will contract HIV."

A

Myasthenic crisis is caused by: Select one: a. Omit dose of medication b. Over medication c. Excessive medication d. Excessive Cholinergic medication

B

Laboratory studies are performed on a client with suspected sickle cell disease, and electrophoresis reveals a large percentage of hemoglobin S (HbS). Which additional laboratory finding will the nurse expect to note that is a characteristic of this disease? Select one: a. Low reticulocyte count b. Increased white blood cell (WBC) count c. Increased hematocrit count d. Low total bilirubin level

B

Testing of the plasma theophylline level in a client who is receiving a continuous intravenous infusion of theophylline reveals a level of 20 mcg/mL. The nurse interprets this result as: Select one: a. Below the therapeutic range b. At the top of the therapeutic range c. In the middle of the therapeutic range d. In excess of the therapeutic range

350

The health care provider prescribed a three-way bladder irrigation to be infused at a rate of 250 mL per hour, which infused without problem. At the conclusion of the 12-hour shift, 3350 mL of fluid are in the collection receptacle. How much urine did the client pass? Fill in the blank.

D

The healthcare provider administers NPH insulin at 6:00 AM to a patient with diabetes. How soon will the patient show any signs hypoglycemia? Select one: a. 8:00 AM b. 9:00 AM c. 7:00 AM d. 10:00 AM

D

The healthcare provider is caring for a patient who has an implanted permanent pacemaker due to complete heart block and severe bradycardia. Which of the following should the healthcare provider assess !rst to determine pacemaker functioning? Select one: a.Apical pulse b. Pacemaker insertion site c.Blood pressure d.Electrocardiogram (EKG)

B,D,E

The healthcare provider is performing chest physiotherapy on a 8-year-old patient with cystic fibrosis. Which of the following are indications for chest physiotherapy? Select all that apply. Select one or more: a. SaO2 =95% b. Coarse pulmonary crackles c. Bronchoconstriction d. PaCO2 = 50 mmHg 50mmHg e. Productive cough

A

The healthcare provider is planning care for four patients. Which patient is MOST in need of interventions aimed at preventing anemia? The patient Select one: a. with renal failure on hemodialysis. b. with a Jackson-Pratt drain. c. who has been NPO for 3 days. d. who is a vegetarian.

D

The healthcare provider is preparing a patient on the medical-surgical unit for a thoracentesis. Which of the following is the most appropriate position for the patient during the procedure? Select one: a. The head of the bed flat with the patient lying on the unaffected side. b. The head of bed elevated 45 degrees with the patient lying on the a"ected side. c. Prone, with both arms extended above the head. d. Sitting up, leaning over a bedside table and feet supported on the ground or stool.

D

The nurse administers intravenous morphine sulfate to a client in pulmonary edema. For which intended e"ect of the medication does the nurse monitor the client? Select one: a. Increased blood pressure b. Decreased urine output c. Relief of pain d. Relief of anxiety

B,E

The nurse administers levothyroxine to a client with hypothyroidism. Which data indicate(s) that the drug is e"ective? (Select all that apply.) Select one or more: a. Decrease in heart rate b. Decrease in periorbital edema c. Increase in TSH d.Decrease in urine output e. Increase in T3 and T4

A

The nurse delegates tasks to the CNA. Which of the following could be safely performed by the CNA? Select one: a. Administer a fecal containment bag on an incontinent patient. b. Teach the patient how to use an insulin pen. c. Apply an ace wrap to the lower extremity of a patient su"ering from edema.

C

The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open ulcer without slough on the right heel of the patient. This pressure ulcer would be staged as stage Select one: a. I " b. III c. II d. IV

D

The nurse is assessing a client who has had a spinal cord injury. Which of the following assessment !ndings would suggest the complication of autonomic dysreflexia? Select one: a.Urinary bladder spasm pain. b.Severe hypotension. c.Tachycardia d.Severe pounding headache.

B

The nurse is caring for a client and the family at a time of impending death for the client. What comment by the nurse would best assist the family to cope with their grief during this time? Select one: a. "Things will be !ne. You just need to give yourself some time." b. "I'm so sorry. This must be very di#cult for you." # c. "Don't cry. Your family member would not want it this way." d. "Try not to be upset in front of your family member."

B

The nurse is caring for a client who develops ventricular !brillation. Which action should the nurse take !rst? Select one: a.Notify the health care provider b. Defibrillate immediately. c. Administer epinephrine. d. Give a bolus with isotonic fluid.

C

The nurse is caring for a client with myasthenia gravis who is vomiting and complaining of abdominal cramps and diarrhea. The nurse notes that the client is hypotensive and experiencing facial muscle twitching. Which possible situation does this assessment data support? Select one: a. A reaction to plasmapheresis b. Systemic infection c. Cholinergic crisis d. Myasthenic crisis

D

The nurse is caring for a postoperative client who has had an adrenalectomy. What should the nurse check for during the client's focused assessment? Select one: a. Bilateral exophthalmos b. Signs and symptoms of hypocalcemia c. Peripheral edema d. Signs and symptoms of hypovolemia

D

The nurse is correct in withholding an older adult client's dose of nifedipine if which assessment finding is obtained? Select one: a. Potassium level of 3.3 mEq/L b. Urine output of 200 mL in 4 hours c. Apical pulse rate of 68 beats/min d. Blood pressure of 90/56 mm Hg

A

The nurse is giving instructions to a client receiving Cholestyramine (Questran/Prevalite). Which statement made by the client indicates a required intervention? Select one: a. "I will take cholestyramine and atorvastatin at bedtime". b. "I will include a high !ber rich food in my diet". c. "I will continue taking my multivitamins". " d. "This medication will help lower my cholesterol".

5>4>3>1>2

The nurse is performing peritoneal dialysis on a client diagnosed with renal injury. In what order should the nurse perform this procedure? 1-Drain fluid for 30 minutes. 2-Turn client from side to side. 3-Provide 30 minute dwell time 4-Infuse dialysate through peritoneal catheter. 5-Warm dialysate.

A

The nurse is preparing to administer a tube feeding by way of a nasogastric tube. Which action does the nurse carry out as a priority before starting the flow of the solution? Select one: a. Checking for gastric residual volume and assessing tube placement b. Checking urine output in the previous 24 hours c. Scrubbing the port with povidone-iodine (Betadine) solution d. Flushing the tube with 30 mL of tap water

A

The nurse is providing instructions regarding home care measures to a client with diabetes mellitus and instructs the client about the causes of hypoglycemia. The nurse determines that additional instruction is needed if the client identifies which as a cause of hypoglycemia? Select one: a. Decreased daily insulin dosage b. Omitted meals c. Increased intensity of activity d. Inadequate amount of fluid intake

B

The nurse is unable to read an order written by the physician in the chart. What is the best action for the nurse to take? Select one: a. Call the pharmacy to ask for their interpretation of the order. b. Call the physician who wrote the order and ask for clari!cation. # c. Ask the nurse supervisor for help in reading the order. d. Ask the intern or resident to clarify the order.

A

The nurse knows which of the following would have the greatest impact on an elderly client's ability to complete activities of daily living (ADLs)? Select one: a. Apraxia. b.Mnemonic disturbance. c. Perseveration. d. Aphasia.

A

The nurse learns that a sta" member providing care to a client with cytomegalovirus is in early pregnancy. Which of the following actions, if taken by the nurse, is BEST? Select one: a.Ensure that the sta" member follows standard precautions. b.Ask the sta" member how she is feeling about her pregnancy. c.Instruct the sta" member to contact her physician. d.Reassign the pregnant sta" member to care for other patients.

A

The nurse manager has only one RN among many LPN's for tonight's shift. The nurse manager must place the RN with which of the following patients? Select one: a. A patient with CHF admitted for observation with fluid overload and shortness of breath. b. A patient with multiple sclerosis and a jejunostomy tube admitted 2 days ago requiring feedings. c. A patient with co"ee ground emesis admitted 2 days ago for observation and $uid replacement. d. A patient with a chronic pressure ulcer admitted 1 day ago requiring a wound vacuum system.

B

The nurse manager reviews recently admitted patients to the medical-surgical $oor. Which patient would be best suited for transfer to the acute care unit or intensive care unit? Select one: a. A 50-year-old with three fractured ribs and a fractured wrist. b. A 60-year-old with a Blakemore tube for esophageal varices. c. A 40-year-old asthmatic receiving chest physiotherapy. d. A 55-year-old reporting pain in his left leg while walking.

C

The nurse must decide which task to delegate to the LPN. Which task can the LPN safely perform? Select one: a. Teaching a patient newly diagnosed with COPD how to use an Advair inhaler. b. Flushing a central line with normal saline. c. Recording and interpreting the vital signs of a patient receiving a platelet transfusion. # d. Performing the initial assessment on a patient admitted from the emergency department with dehydration.

A

The nurse performs chart reviews. Which documentation should the nurse question? Select one: a. "Patient refused nebulizer treatment. Patient displaying hopelessness." b. "Patient states, "I am tired of this pain." 2 mg Morphine Sulfate administered IV. Pain 2/10 30 minutes later." c. "50 mL sanguineous drainage noted from Jackson-Pratt drain." d. "Hematocrit of 27% reported to Dr. Smith. No orders received."

C

The nurse prepares to administer digoxin, 0.125 mg PO, to an adult client with heart failure and notes that the digoxin serum level in the laboratory report is 1 ng/mL. Which action should the nurse take? Select one: a. Discontinue the digoxin. b. Notify the health care provider c. Administer the digoxin. d. Reverify the digoxin level.

A

The nurse supervises the staff caring for clients on the medical/surgical unit. The nurse observes the student nurse enter wearing a gown, gloves, and a mask. The nurse determines that the precautions are correct if the student nurse is caring for which client? Select one: a. A teenager diagnosed with rubella (German measles). b. A young child with a wound infected with S. aureus. " c. A teenager diagnosed with toxic shock syndrome. d. An infant diagnosed with respiratory syncytial virus.

D

The parents of a child with hemophilia want to know the cause of the disease. Which of the following would be the BEST response by the nurse? Select one: a."The father transmits the gene to his son." b."Both the mother and the father carry a recessive trait." c."There is a 50% chance that the mother will pass the trait to each of her daughters." d."The mother transmits the gene to her son."

B

The school nurse has been observing a 13 year-old student during the past few months as the student has steadily lost weight. Which assessment !nding would be the best indication of the beginning of an eating disorder? Select one: a. Student eats most meals with peers. b. Client reports a fear of gaining weight. c. Diet consists mostly of fruit or raw vegetables. d. Clothing size has decreased by 2 sizes.

B

There has been a mass casualty shooting at a nearby school. A nurse is working in the emergency department and is asked to triage patients as they arrive at the hospital. Which of these is the correct order for the nurse to use when conducting her exam? Select one: a. major external wounds, airway, pulse, respiration and quality of respiration, neurological status, and blood pressure b. airway, respiration and quality of respiration, pulse, major external wounds, blood pressure, and neurological status c. airway, respiration, major external wounds, pulse, quality of respiration, blood pressure, and neurological status d. airway, pulse, respiration, major external wounds, neurological status, blood pressure, and quality of respiration

C

What is the priority action when a patient presents to the emergency room suffering from nausea, vomiting, and flank pain as a result of renal calculi? Select one: a. Educate the patient on the importance of fluid intake. b. Schedule a surgical consult. c. Administer morphine sulfate 2 mg IV. d. Reposition the client onto the side that is not experiencing flank pain.

A

When caring for a postpartum client, which intervention is best for the nurse to implement to promote increased peripheral vascular activity? Select one: a. Encourage the client to ambulate every 3 hours. b. Elevate the foot of the client's bed at least 6 inches. c. Teach the client how to perform leg exercises while in bed. " d. Encourage the client to turn from side to side every 2 hours.

A

When caring for a postsurgical client who has undergone multiple blood transfusions, which serum laboratory !nding is of most concern to the nurse? Select one: a. Potassium level, 5.5 mEq/L b. Blood urea nitrogen (BUN) level, 18 mg/dL c. Calcium level, 10 mEq/L d. Sodium level, 137 mEq/L

D

When evaluating the arterial blood gases (ABGs) of a patient with a 20 year history of chronic bronchitis, which of these would the healthcare provider expect? Select one: a.Metabolic acidosis, uncompensated b.Respiratory alkalosis, uncompensated c.Metabolic alkalosis, compensated d. Respiratory acidosis, compensated

B

When examining the tympanic membrane of a toddler by otoscope, the nurse should move the child's pinna in which direction? Select one: a.Down and forward b.Down and back c.Up and back d. Up and forward

D

When reviewing laboratory results, the nurse should immediately notify the health care provider about which !nding? Select one: a. Protein level of 2 mg/100 mL b. pH of 6.4 " c. Urine output of 80 mL/hr d. Glomerular !ltration rate of 20 mL/min

B

When the home health nurse reviews her daily schedule, which client is most at risk for abuse? Select one: a. A 88-year old male with newly diagnosed bilateral cataracts. " b.An 84-year old woman with advanced diabetes complications. c.A 74-year old man with poorly controlled hypertension. d.A 76-year old woman recovering from a broken hip.

B

When the nurse realizes that a patient has received the wrong medication, what is the nurse's !rst action? Select one: a.Initiate an incident report b. Assess the patient's condition c.Report the error to the unit manager d.Notify the physician of the error

D

Which !nding is expected in patients with macular degeneration? Select one: a. Floating dark spots b. Increased intraocular pressure c. Double vision d. Decreased central vision

C

Which action by the nurse $oating to a medical-surgical unit is considered professionally negligent? Select one: a. The nurse asks the name and date of birth of the patient before administering medications. b. The nurse brings a computer on wheels into the patient's room to chart while providing care. c. The nurse assesses the patient on non-violent restraints every 4 hours. d. The nurse asks the CNA to apply barrier cream to an incontinent patient's sacral area.

C

Which action by the student nurse, if observed by the RN, would require further teaching? Select one: a. The student nurse applies 120 mmHg suction to the tracheostomy tube. b. The student nurse changes the disposable inner cannula of the tracheostomy tube with sterile gloves. c. Prior to tracheal suctioning, the student nurse instills 5 mL of sterile saline into the tracheostomy. d. The student nurse elicits a strong cough and grimace while suctioning the patient.

D

Which action should the nurse take to assess the infant rooting reflex? Select one: a. Depress the infant's tongue. b. Tap on the bridge of the infant's nose. c. Turn the infant's head to one side. d. Stroke the infant's cheek.

C

Which action we can delegate to de Assistive personnel (UAP)? Select one: a. Review the client's medication administration record. b. Request a dietary referral. c. Obtain blood pressure before and after medication administration. d. Teach the client to use salt substitutes.

D

Which client is best to assign to a graduate PN who is being oriented to a renal unit? Select one: a. A client with continuous bladder irrigation for hematuria b. A client who is receiving continuous ambulatory peritoneal dialysis c. A client who is 1 day postoperative after placement of an arteriovenous (AV) shunt d. A client with renal calculi whose urine needs to be strained

A

Which finding should the nurse expect to see when assessing a client with diverticulitis.? Select one: a. cramping in the left lower quadrant, diarrhea, low grade fever and increase WBC. # b. absent bowel sounds and high fever c. abdominal pain relieved with defecation and non bloody diarrhea d. cramping abdominal pain, non bloody diarrhea and weight loss

A

Which observation in a patient with being prostatic hyperplasia indicate a complication? Select one: a. elevated serum potassium level b. Increase post void residual volume c. urine specific gravity 1.015 " d. decreased urine peak flow rate

D

Which of the following !ndings is a priority to report to the HCP in a patient with cystic !brosis? Select one: a.Weight loss 2.3 kg (5 lb) b.Decreased activity c.Fever d.Hemoptysis 275 mL/ 24hr

B

Which of the following action is the most appropriate intervention in a patient with polymophic ventricular tachycardia? Select one: a. Document b. IV magnesium sulfate c. Amiodarone d. Atropine

B

Which of the following finding indicate that the client has the ability to sign the informed consent. Select one: a. The nurse witnesses the provider's explanation of the procedure. " b. The client is able to accurately describe the upcoming procedure. c. The client's partner tells the nurse that the client understands the procedure. d. The nurse locates the provider's prescription for the surgical procedure.

D

Which of the following is accurate with Diabetes Insipidus? Select one: a. Urine speci!c gravity of 1.033 b. Increase urine osmolarity c. Increase urine speci!c gravity d. Increase serum osmolarity

D

Which of the following is identi!ed as a contraindication in a patient taking clozapine? Select one: a.BP 150/87 mm Hg b.Auditory hallucinations c. Nausea d. WBC 2,800/mm

B

Which of the following patient in triage you can tag as BLACK. Select one: a. A client who is alert and has a 2.5 cm (1 in) laceration on the forehead b. A client who has signi!cant head trauma and agonal respirations # c. A client who is unconscious and has a rapid, thready radial pulse d. A client who has an open fracture of the right forearm

C

Which of the following patients the nurse should assess as a priority Select one: a. The client who has an oxygen saturation percentage of 95% b. The client who has a blood pressure of 110/70 mm Hg c. The client who has an irregular apical pulse of 120 beats per minute.

B

Which of the following task should the nurse delegate to the LPN in a team of 1 RN, 1LPN and 1 UAP? Select one: a.Preparation of a client's postoperative bed b.Insertion of a nasogastric tube c.Administration of a unit of packed RBCs d.Collection of a stool specimen

B

Which of the following teaching should be provided in patients with hepatitis A? Select one: a. Wear a surgical mask when in public. b. Use a chlorine bleach solution to clean kitchen surfaces. c. Seal non-washable items in a plastic bag for 2 weeks. d. Limit family visits to 30 min periods.

C

Which of these is the correct order of events a nurse should follow when applying personal protective equipment (PPE)? Select one: a. gown, mask, eye protection, handwashing, and gloves b. mask, eye protection, handwashing, gloves, and gown c. handwashing, gown, mask, eye protection, and gloves d. handwashing, gloves, gown, eye protection, and mask

B

Which pathophysiologic response supports the contraindication for opioids, such as morphine, in clients with increased intracranial pressure (ICP)? Select one: a. Higher doses of opioids are required when cerebral blood $ow is reduced by an elevated ICP. b. Opioids suppress respirations, which increases PCO and contributes to an elevated ICP. c. Dysphoria from opioids contributes to altered levels of consciousness with an elevated ICP. d. Sedation produced by opioids is a result of a prolonged half-life when the ICP is elevated.

C

Which patient should the nurse see !rst? Select one: a. A 25-year-old recovering from an appendectomy. b. A 30-year-old diabetic with a blood sugar of 120. " c. A 65-year-old with congestive heart failure. d. A 45-year-old with Cushing's disease.