Set 1

A nurse is caring for a client who has protein malnutrition. Which of the following foods should the nurse identify as a source of complete protein? A. Eggs B. Cereal C. Peanut butter D. Pasta

A. Eggs Complete proteins contain all the essential amino acids to support growth and homeostasis. Examples of complete protein include eggs, meat, poultry, seafood, milk, yogurt, cheese, soy beans, and soy bean products.

As a nurse is preparing to administer liquid medication from a bottle to a client. Which of the following actions should the nurse take? A. Hold the medication bottle with the label against the palm of the hand when pouring B. Place the cap with the inside facing down on a hard surface C. Fill the cup until the medication is even with the edge of the dosage scale D. Pour any excess liquid back into the bottle after measuring

A. Hold the medication bottle with the label against the palm of the hand when pouring The nurse should hold a multidose bottle with the label against the palm of the hand when pouring to prevent contaminating the label with spilled medication that could cause information on the label to fade or become illegible

A nurse in a providers office is measuring a client and not a loss in height from the previous year. the nurse should identify this finding as a manifestation of which of the following musculoskeletal system disorders? A. Osteoporosis B. Scoliosis C. Kyphosis D. Lordosis

A. Osteoporosis A loss of height is often an early indication of osteoporosis. this occurs due to loss of calcium in the vertebrae, which can cause them to fracture and collapse. B. Scoliosis does not precipitate a decrease in the height of the client. it is an abnormal lateral curve of the spine. C. Kyphosis does not precipitate a decrease in the height of the client. It is an exaggerated posterior curvature of the thoracic spine (I.e. hunchback) D. Lordosis does not precipitate a decrease in the height of the client. it is an exaggerated lumbar curvature (I.e. swayback)

A nurse on a medical surgical unit is caring for a client who is at risk of experiencing seizures. Which of the following pieces of equipment must be available at the client's bedside at all times? A. Suction equipment B. Clean gloves C. Blankets D. Oxygen

A. Suction equipment The greatest risk to a client who is having a seizure is an injury from aspirating secretions or emesis; therefore, the nurse must have suction equipment available for clearing the mouth of secretions or emesis to reduce this risk. B. The nurse should have clean gloves available to check the clients mouth for injuries to the mucous membranes or teeth; however other equipment is the nurse's priority C. The nurse should have blankets and linens available to pad the side rails if a seizure begins while the client is in bed to help prevent injury; however, other equipment is the nurse's priority D. During and after a seizure, some clients require supplemental oxygen to maintain oxygen saturation; therefore, the nurse should have oxygen ready to administer period however, other equipment is the nurse's priority.

A nurse is teaching a client about the use of a straight leg cane. Which of the following client actions indicates an understanding of the teaching? A. The client hold the cane on the unaffected side B. The client walks by stepping with the unaffected leg before the affected leg C. The client hold the cane directly next to the foot D. The client hold of the cane with a straight elbow

A. The client hold the cane on the unaffected side The nurse should instruct the client to hold a cane on the unaffected side to provide a wide base of support and stability

A nurse is caring for an older adult client who has been in the canal hearing aid cup. The client states that the hearing aid is making a whistling sound. The nurse should identify which of the following factors as a source for this sound? A. Low battery power B. Excessive wax in the ear canal C. A volume setting that is too low D. A crack in the ear tube

B. Excessive wax in the ear canal Factors that can make a hearing aid whistle include a poor seal with the ear mold, an ear infection, excessive wax in the ear canal, an improper fit, or a malfunction.

A nurse is teaching a client who is postoperative following a knee arthroplasty about the muscles he will need to strengthen in physical therapy. Which of the following muscle groups is responsible for movement at the knee joint? A. Antigravity B. Antagonistic C. Synergistic D. Skeletal

B. Antagonistic The nurse should teach the client that the antagonistic muscle group is responsible for movement of the knee joint by contracting while other muscles relax

A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings as an indication of infiltration? A. Redness at the infusion site B. Edema at the infusion site C. Warmth at the infusion site D. Using of blood at the infusion site

B. Edema at the infusion site Edema due to fluid entering subcutaneous tissue is an indication of infiltration

A nurse is assessing a client who is experiencing an obstruction of the flow of the vitreous humor in the eye. This manifestation is consistent with which of the following eye disorders? A. Retinopathy B. Glaucoma C. Cataracts D. Macular degeneration

B. Glaucoma The nurse should identify that an obsturction of the flow of the vitreous humor of the eye is a manifestation of glaucoma. This obstruction leads to an increase in intraocular pressure, resulting in damage to the eye. A. Manifestations of retinopathy include changes in the blood vessles of the retina that can lead to blindness. C. Manifestations of cataracts include an increase in the opacity of the lens, blocking rays of light from entering the eye D. Manifestations of macular degeneration include changes in sharp and central vision and are often associated with aging

A nurse is caring for a client who has a cuffed endotracheal tube in place. The nurse should identify that the purpose of inflating the cuff includes which of the following? Select all that apply A. Allowing the client to speak B. Stabilizing the position of the tube C. Preventing aspiration of secretions D. Preventing air leaks E. Preventing tracheal injury

B. Stabilizing the position of the tube C. Preventing aspiration of secretions D. Preventing air leaks And inflated cuff helps prevent movement of the endotracheal tube, reduces the risk of aspiration of oral pharyngeal secretions, and keeps air from leaking around the outer portion of the endotracheal tube

A nurse is providing teaching to another adult client who has constipation period which of the following statements should the nurse include in the teaching? A. Drink a minimum of 1000 mL of fluid daily B. Increase your intake of refined-fiber foods C. Sit on the toilet 30 minutes after eating a meal D. Take a laxative every day to maintain regularity

C. Sit on the toilet 30 minutes after eating a meal Increase peristalsis occurs after food enters the stomach. Sitting on the toilet 30 minutes after eating a meal, regardless of feeling the urge to defecate, is a recommended method of bowel retraining to treat constipation. A. The nurse should instruct the client to consume a minimum of 1500 mL of fluid to prevent constipation. B. The nurse should instruct the client to increase consumption of course fiber and whole grains, rather than refined fiber foods. C. The nurse should not recommend intake of daily laxatives because consistent use hinders natural defecation have it and can cause constipation.

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider? A. Tenderness when touched B. Pink, shiny tissue with a granular appearance C. Serosanguineous drainage D. Halo of erythema on the surrounding skin

D. Halo of erythema on the surrounding skin The nurse should report to the provider when the client has a ring of erythema on the surrounding skin, which might indicate underlying infection. This and any other manifestation of infection (purulent drainage, swelling, warmth, or a strong odor) should be reported to the provider.

A nurse is teaching a client who is using a patient controlled analgesia pump to deliver morphine for pain management. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. I'll limit pushing the button so I don't get an overdose B. If I push the button and still have pain after two minutes, I'll push it again C. I'll ask my niece to push the button when I am sleeping D. I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button

D. I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button The nurse should encourage the client to utilize nonpharmacological methods of pain management such as transcutaneous electrical nerve stimulation while using a PCA pump to reduce the amount of opioid dosing the client needs