Saunders Silvestri Questions
The nurse is caring for a child with heart failure (HF). The nurse provides instructions to the mother regarding the procedure for administration of the prescribed digoxin. Which statement by the mother indicates a need for further teaching? 1. "I will make sure to mix the medication with food." 2. "I need to take my child's pulse before administering the medication." 3. "If more than 1 dose is missed, I need to call the health care provider." 4. "If my child vomits after being given the medication, I should not repeat the dose."
1
The nurse is developing a nursing care plan for a client with a circumferential burn injury of the right arm. What is the nurse's priority action? 1. Monitor the radial pulse every hour. 2. Keep the extremity in a dependent position. 3. Document any changes that occur in the pulse. 4. Place pressure dressings and wraps around the burn sites.
1
The nurse is preparing the client's morning insulin isophane dose. The nurse notices a clumpy precipitate inside the insulin vial. What is the most appropriate nursing action related to this finding? 1. Draw the dose from a new vial. 2. Draw up and administer the dose. 3. Shake the vial in an attempt to disperse the clump. 4. Warm the bottle under running water to dissolve the clump.
1
A 3-year-old child is seen in the health care clinic, and a diagnosis of encopresis is made. The nurse expects to provide teaching about which client problem? 1. Odor 2. Nausea 3. Malaise 4. Diarrhea
1
A child is suspected of suffering from intussusception. The nurse should be alert to which clinical manifestation of this condition? 1. Tender, distended abdomen 2. Presence of fecal incontinence 3. Incomplete development of the anus 4. Infrequent and difficult passage of dry stools
1
The nurse reviews the laboratory results for a child with rheumatic fever and would expect to note which findings? Select all that apply. 1. Elevated C-reactive protein 2. Elevated antistreptolysin O titer 3. Presence of Reed-Sternberg cell 4. Decreased erythrocyte sedimentation rate 5. Presence of group A beta-hemolytic strep
1, 2, 5
The nurse instructs a client who is at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse determines that the client understands the food sources of potassium if the client states that which food items are lowest in potassium, providing less than 200 mg per serving? Select all that apply. 1. Grapes 2. Carrots 3. Spinach 4. Asparagus 5. Avocados 6. Applesauce
1, 4, 6
The nurse plans care for a client postoperatively following creation of a colostomy. Which potential client problem should the nurse include in the plan of care? 1. Fear 2. Anxiety 3. Sexual dysfunction 4. Upset about appearance
4
The nurse is caring for a child who was brought to the clinic complaining of severe abdominal pain and is suspected of having acute appendicitis. The child is lying on the examining table, with the knees pulled up toward the chest. What is the priority nursing action? 1. Collect urine sample for urinalysis 2. Perform a pain assessment using the FACES scale 3. Prepare the child for magnetic resonance imaging 4. Notify health care provider of white blood cell count above 10,000 mm3 (10 × 109/L)
2
The nurse is caring for a client after insertion of an implanted insulin pump. Which statement by the client indicates a need for further instruction? 1. "I should expect to gain less weight with this pump." 2. "I need to make sure I still give my insulin before I eat." 3. "This will help me to have better control of my blood sugar." 4. "This pump delivers a continuous infusion of insulin throughout the day."
2
The nurse is caring for a client experiencing an exacerbation of Crohn's disease. Which intervention should the nurse anticipate the health care provider prescribing? 1. Enteral feedings 2. Fluid restrictions 3. Oral corticosteroids 4. Activity restrictions
3
The nurse is performing an assessment on a client admitted to the nursing unit who has sustained an extensive burn injury involving 45% of total body surface area. When planning for fluid resuscitation, the nurse should consider that fluid shifting to the interstitial spaces is greatest during which time period? 1. Immediately after the injury 2. Within 12 hours after the injury 3. Between 18 and 24 hours after the injury 4. Between 42 and 72 hours after the injury
3
