Week 2 Test
A client admitted with acute stroke suddenly becomes lethargic. Which action does the nurse take next? 1- Notify the health care provider. 2- Keep the client NPO. 3- Assess for signs of infection. 4- Prepare the client for a CT scan.
1
A client with chronic kidney disease takes cinacalcet. Which laboratory test will the nurse monitor to determine the effectiveness of this medication? 1- Serum calcium. 2- Vitamin D level. 3- Serum magnesium. 4- Thromboplastin time.
1
The health care provider (HCP) prescribes epinephrine 1 mg IV STAT for treatment of a client who is experiencing asystole. The nurse is unable to establish peripheral IV access. Which action does the nurse anticipate the HCP implementing next? 1- Initiating intraosseous (IO) access. 2- Initiating a central venous line (CVL). 3- Administering subcutaneous epinephrine. 4- Performing emergent defibrillation.
1
The health care provider prescribes intramuscular pain medication for a child recovering from an appendectomy. Which is the most appropriate action for the nurse to take? 1- Advocate for the child to see if the medication can be given by an alternate route. 2- Disinfect the injection site and allow it to dry completely. 3- Administer a topical anesthetic at the intended injection site. 4- Administer the medication by the intravenous route.
1
The nurse assists the health care provider with cardioversion for a client with uncontrolled atrial fibrillation. Which step does the nurse take during cardioversion that is omitted during defibrillation? 1- Ensure the defibrillator is set in the synchronized mode when delivering the charge. 2- Use a conduction medium between the paddles and the client's skin if paddles are used. 3- Apply 20 to 25 pounds of pressure when using paddles to deliver the charge. 4- Record the delivered energy and resulting rhythm.
1
The nurse documents that a pregnant client is prescribed a medication that is a pregnancy category A drug. Which action will the nurse take next? 1- Administer the medication as prescribed. 2- Notify the health care provider. 3- Talk to the pharmacist about a medication substitute. 4- Ask if the client wants the nurse to hold the medication.
1
The nurse is teaching a group of nursing assistive personnel (NAP) about infection control practices. Which statement by a NAP indicates that the teaching is effective? 1- "I'll be sure to clean the least soiled areas first." 2- "I'll place soiled bed linens on the floor." 3- "I'll discard liquids by pouring them over the sink." 4- "I'll carry soiled items close to me to prevent them from dropping."
1
The nurse plans to ambulate a client who is 1-day postoperative for open-reduction internal fixation (ORIF) for a hip fracture. Which action will the nurse implement first? 1- Administer the prescribed analgesic before activity. 2- Teach the client about the benefits of exercising. 3- Ensure the incisional drain has been discontinued. 4- Change dressing and inspect suture before exercising.
1
The nurse prepares a medication in a prefilled syringe and notes that the syringe does not have a label with the client's name. What action will the nurse take? 1- Notify the pharmacy. 2- Call the health care provider. 3-Label the syringe. 4- Administer the medication.
1
The nurse prepares an educational session on stress and coping in older adults for a group of nursing students. The nurse includes teaching on sources of stress in older adults. Which information is most appropriate for the nurse to include in the teaching session? 1- Stressors include loss of autonomy and mastery resulting from frailty. 2- Stressors are related to self-esteem issues and changing family structure. 3- Stressors center around major life changes, such as career and family. 4- Stressors are related to the search for identity and asserting independence.
1
The nurse provides care for a client diagnosed with a severe ankle sprain. The client needs to be fitted with crutches. Which finding indicates to the nurse that the crutches are adjusted correctly? 1- Two fingers fit between the client's axillae and the top of the crutches. 2- The client's axillae are resting on the axillary bars on the top of the crutches. 3- The nurse can slide a pencil between the client's axillae and the top of the crutches. 4- The client keeps the arms straight when standing with crutches.
1
The nurse provides care for a client in the post-operative anesthesia care unit (PACU). The client's vital signs are respirations 16 breaths per minute, pulse 90 beats per minute, and blood pressure 110/68 mm Hg. The pulse oximeter shows 87% with 2 L of oxygen per nasal cannula. Which nursing diagnosis is a priority? 1- Impaired gas exchange. 2- Ineffective airway clearance. 3- Ineffective peripheral tissue perfusion. 4- Ineffective breathing pattern.
1
The nurse provides care for a client with a serum sodium level of 120 mEq/L. Which nursing action is a priority? 1- Monitor for neurological changes. 2- Check the client's serum creatinine level. 3- Assess the client's functional status. 4- Obtain a prescription for intravenous dextrose 5%.
1
The nurse provides care to a client diagnosed with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which goal is most appropriate to include in the nursing care plan? 1- Improve gas exchange. 2- Perform activities of daily living without dyspnea. 3- Obtain flu and pneumonia vaccinations. 4- Sleep for 8 hours without interruption.
1
The nurse provides care to a client with an appendectomy who just arrived in the postanesthesia care unit (PACU). Which medication will the nurse give intravenously for pain? 1- Hydromorphone. 2- Hydrocodone. 3- Oxycodone. 4- Codeine.
1
The nurse receives a notice to discharge all medically stable clients to prepare for the admission of victims of a major train derailment. Which client does the nurse recommend to stay hospitalized? 1- The client with an elevated troponin level and occasional chest pain. 2- The client recovering from melena and receiving treatment for H. pylori. 3- The client with type 1 diabetes mellitus being treated for an infected leg wound. 4- The client with chronic lung disease receiving breathing treatments and oxygen.
1
The nurse teaches a group of parents about infant car safety. Which information does the nurse include? 1- Do not transport the infant in a car without proper restraint. 2- It is safe to place the infant in the front passenger seat if there is no airbag. 3- Position the car seat in a rear seat with the infant facing the front of the car. 4- Secure the car seat tightly on the passenger side of the back seat.
1
The nurse works in a clinic located in a community where the population is primarily Hispanic. Which strategy will the nurse implement to decrease health care disparities for these clients? 1- Educate the clinic staff about Hispanic health practices. 2- Procure low-cost medications for clinic clients. 3- Update equipment at the clinic. 4- Improve public transportation to the clinic.
1
The nurse is screening a client diagnosed with atrial fibrillation for the risk of having a cerebrovascular accident. Which condition increases the client's risk? (Select all that apply.) 1- Congestive heart failure. 2- Hypertension. 3- Diabetes. 4- Myocardial infarction. 5- Transient ischemic attack.
1,2,3,5
The nurse performs wound care for a client with a deep stage 3 pressure injury with moderate exudate. Which actions by the nurse are appropriate? (Select all that apply.) 1- Perform hand hygiene before and after the procedure. 2- Pack the wound with calcium alginate if available. 3- Cover wound with a secondary dressing and secure it with tape. 4- Use hydrogen peroxide to rinse and clean the wound bed. 5- Apply wound packing to the level of the wound surface.
1,2,3,5
The nurse overhears an argument between a client and the nursing assistive personnel (NAP). Which action will the nurse take to resolve this conflict? (Select all that apply.) 1- Listen to the NAP's issue. 2- Listen to the client's issue. 3- Change the NAP's assignment. 4- Offer approaches to eliminate the issue. 5- Reprimand the NAP for aggressive behavior.
1,2,4
The nurse provides care for a client diagnosed with head trauma. The client experiences a seizure. Which actions will the nurse implement? (Select all that apply.) 1- Keep the client in a side-lying position. 2- Monitor the client's ability to maintain a patent airway. 3- Arouse the client frequently to assess neurological status. 4- Provide environmental stimuli to help the client awaken. 5- Place suction equipment and an oral airway at the client's bedside.
1,2,5
The nurse teaches a group of nursing students about health restoration activities. What is the best example for the nurse to include in the teaching? (Select all that apply.) 1- Administering an antibiotic every day. 2- Changing a dressing on a surgical incision. 3- Teaching the importance of handwashing 4- Advising a client to get an annual mammogram. 5- Administering intravenous fluids to client with dehydration.
1,2,5
The nurse provides care to a client who is diagnosed with new-onset tonic-clonic seizures. Which information does the nurse include when teaching the client about phenytoin therapy? (Select all that apply.) 1- Avoid switching between generic and trade brands. 2- Take the medication 2 hours after meals. 3- Avoid alcohol while taking the medication. 4- Report redness or swelling of gums. 5- Notify the health care provider if a rash appears.
1,3,4,5
The nurse provides care to a client with hearing aids. Which observation indicates to the nurse that additional teaching is required? (Select all that apply.) 1- Client removes devices from the ear and places in storage. 2- Client washes the ear mold with soap and water. 3- Client cleans and dries their ear canal thoroughly. 4- Client switches the device off when grandchildren visit. 5- Client soaks the ear molds in peroxide overnight.
1,5
A nurse is preparing to move a client, who weighs 220 lbs, up in bed. The client able to provide minimal assistance. Which action is essential for the nurse to take to prevent injury? 1- Position the bed waist high. 2- Use a friction-reducing device. 3- Ask another nurse to assist. 4- Place the bed in a Trendelenburg's position.
2
The nurse identifies a prolonged PR interval on the electrocardiogram of a client with acute kidney injury. The client reports fatigue and muscle weakness. Which action will the nurse take first? 1- Call the rapid response team. 2- Check the recent potassium level. 3- Establish client responsiveness. 4- Assess hourly urinary output.
2
The nurse manager expects each staff nurse to act as a leader. Which definition of leadership is the nurse manager using? 1- Leadership is being in a position with authority to exert power and control over subordinates. 2- Leadership is a process of interaction in which the leader influences others toward goal achievement. 3- Leadership is managing complex client care situations. 4- Leadership is being self-confident and democratic.
2
The nurse notes the client's electrocardiogram (ECG) tracing shows a prolonged PR interval, a wide QRS complex, and tall peaked T waves. Which action does the nurse take next? 1 Palpate the peripheral pulses. 2 Check the serum potassium. 3 Raise the head of the bed. 4 Obtain serum troponin level.
2
The nurse provides care for an adolescent client following a traumatic amputation of the left leg. The client states to the nurse, "My life is over now." Which response by the nurse is best? 1- "Your life is not really that bad." 2- "You feel like you have nothing to live for." 3- "Once you start physical therapy, you will feel better." 4- "Why do you feel that way?"
2
The nurse provides care to a client who fell. Which assessment finding indicates to the nurse that the client fractured the hip as a result of the fall? 1- Lengthened and externally rotated leg. 2- Shortened and externally rotated leg. 3- Unchanged leg length with internal rotation. 4- Bilateral leg shortening and internal rotation.
2
The nurse teaches a client who is prescribed sublingual nitroglycerin tablets 0.4 mg PRN. Which client statement suggests further instruction is needed? 1- "I will sit down and rest if I take the medication." 2- "I will place the medication in my pillbox organizer." 3- "I will not drink anything until after the pill dissolves." 4- "I will take the medication at 5-minute intervals."
2
The nurse teaches a parent actions for home safety during the second half of infancy. Which parent statement causes the nurse to be most concerned? 1- "I avoid giving my baby carrot sticks." 2- "My baby loves to be in the walker." 3- "I keep the bathroom door closed." 4- "I lay my baby on the back to sleep."
2
The nurse teaches a parent who is discontinuing breast-feeding a 5- month-old infant. Which food does the nurse advise the mother to include in the infant's diet? 1- Whole milk only. 2- Iron-rich formula only. 3- Strained meats and iron-rich formula. 4- Strained vegetables and low fat milk.
2
The nurse provides care for a client diagnosed with an acute stroke. Which intervention does the nurse delegate to the nursing assistive personnel (NAP)? (Select all that apply.) 1- Screen the client for thrombolytic therapy. 2- Take vital signs based on stroke protocol. 3- Measure and record urinary output. 4- Assist with positioning the client as needed. 5- Evaluate the client's motor strength every hour.
2,3,4
The nurse teaches a group of students about measures to reduce the risk for medical device-related accidents. Which point does the nurse include in the teaching? (Select all that apply.) 1- Bend electric cords for storage. 2- Be alert for wet surfaces near electric cords. 3- Handle medical equipment with care. 4- Avoid using equipment that is unfamiliar. 5- Use two-prong electrical plugs when possible.
2,3,4
The nurse prepares an injection for an infant. Which intervention will the nurse implement to promote comfort to the infant during the injection? (Select all that apply.) 1- Ask the parent of the infant to leave the room during injection. 2- Place a pacifier in the infant's mouth during the injection. 3- Have the parent rock the infant after the injection. 4- Administer the infant's injection slowly. 5- Ask the parent to cuddle the infant after the injection.
2,3,5
The client states to the nurse, "I am a lacto-vegetarian." Which food will the nurse expect the client to eat? (Select all that apply.) 1- Fish. 2- Milk. 3- Eggs. 4- Cheese. 5- Yogurt.
2,4,5
The nurse prepares the room for a client after an appendectomy. Which action will the nurse take when making a surgical bed? (Select all that apply.) 1- Place the pillow at the head of the bed. 2- Leave the bed in the high position when finished. 3- Tuck the top sheet and blanket under the foot of the bed. 4- Place the top linens on the bed without pouching them. 5- Fanfold the linens to the side opposite from where the client will enter.
2,4,5
A nurse working the night shift provides care for a client who appears restless, irritable, and worried. The client states to the nurse, "I cannot sleep." Which action by the night nurse is appropriate? 1- Administer the prescribed hypnotic. 2- Comfort the client by use of touch. 3- Ask the client to discuss feelings. 4-Allow the client to have time alone.
3
At 0700 hours, the nurse measures a client's temperature as being 97.2°F (36.1°C) while the remaining vital signs are all within normal limits. Which action will the nurse take next? 1- Document the temperature; it is within normal range. 2- Remeasure the temperature in 30 minutes. 3- Check to see what the temperature was the last time it was measured. 4- Remeasure the temperature with a different thermometer.
3
The nurse administers a new medication to a client. Which statement is most appropriate for the nurse to make? 1- "Is your name John Jones?" 2- "Can you tell me your birth date?" 3- "State your name for me while I check your wristband." 4- "Your health care provider has prescribed a new medicine."
3
The nurse assesses a client 8 hours after having a total abdominal hysterectomy. Which finding will the nurse identify as an early sign of shock? 1- Urine output of 30 mL/hour. 2- Heart rate of 110 beats/minute. 3- Restlessness. 4- Pale, warm, dry, skin.
3
The nurse attends a conference on neonatal health problems. Which statement by the nurse indicates a correct understanding of neonatal jaundice? 1- "Jaundice initially appears in the extremities and gradually progresses to the head." 2- "The conjunctival sacs and buccal mucosa appear yellow for the first month of life." 3- "Feeding, especially breastfeeding, is important in reducing serum bilirubin." 4- "Visual assessment of jaundice gives an accurate assessment of the serum bilirubin level."
3
The nurse discusses mood disorders with a group of nursing students. Which factor will the nurse include as being most closely related to depression? 1- The developmental stage of life. 2- Dysfunctional interpersonal relationships. 3- Experiencing a sense of loss. 4- Memories of a traumatic childhood.
3
The nurse learns that a client with heart failure has an ejection fraction of 28%. Which outcome will the nurse identify as being the most appropriate for this client? 1- Decreased episodes of nocturia. 2- Increased exercise tolerance. 3- Reduced preload and afterload. 4- Restored fluid volume.
3
The nurse notes that a client who follows Judaism has roast beef and whole milk on the dinner tray. Which action will the nurse take first? 1- Ask the nutrition department to replace the roast beef with pork. 2- Deliver the food tray to the client. 3- Ask the nutrition department for a new tray. 4- Replace the whole milk with skim milk.
3
The nurse notes that a client's laboratory values are blood urea nitrogen (BUN) 55 mg/dL (19.64 mmol/L) and creatinine 3.5 mg/dL (309.4 μmol/L). For which acid-base imbalance will the nurse assess the client? 1- Respiratory acidosis. 2- Respiratory alkalosis. 3- Metabolic acidosis. 4- Metabolic alkalosis
3
The nurse performs a follow-up assessment of a newborn. Which finding will the nurse report to the health care provider (HCP)? 1- The urethral opening is at the tip of the penis. 2- The newborn is having frequent hiccups. 3- The newborn has a pulse rate of 95 beats per minute. 4- A white cheesy substance is found under the foreskin.
3
The nurse prepares teaching about peak flow meter monitoring for a client with asthma. Which information does the nurse include in this teaching? 1- One peak flow reading a month is usually sufficient. 2- A bronchodilator should be used right before testing. 3- Peak flow monitoring can indicate airway changes before any symptoms occur. 4- After the meter is placed in the mouth, it is best to slowly exhale as long as possible.
3
The nurse provides care for a client diagnosed with congestive heart failure and acute pulmonary edema. Which diuretic is the health care provider most likely to prescribe? 1- Mannitol. 2- Spironolactone. 3- Furosemide. 4- Hydrochlorothiazide
3
The nurse provides care for a pediatric client diagnosed with otitis media. Which statement by the parent will cause the nurse to immediately intervene? 1- "I will continue giving my child antibiotics, even after symptoms resolve." 2- "I clean drainage from my child's outer ear canal with cotton swabs." 3- "I will encourage forceful nose blowing." 4-"I have been giving my child ibuprofen."
3
The nurse provides discharge teaching to the parents of an infant recovering from gastroenteritis and dehydration who is approaching the first birthday. After instructing on dietary and fluid requirements, which topic will the nurse teach the parents next? 1- Toilet training. 2- Introduction to solid foods. 3- Safety guidelines. 4- Glucose testing.
3
The nurse provides teaching for a client who has a medication delivered via the use of a transdermal patch. Which client statement requires the nurse to provide additional teaching? 1- "I will remove the old patch before applying the new patch." 2- "I will avoid putting the patch on any sites that have bruises." 3- "I will shave the skin area before applying the patch." 4- "I will place the patch on areas that are hairless."
3
The nurse provides teaching for an older adult client diagnosed with osteoporosis. Which instruction regarding exercise is most important for the nurse to provide to the client? 1- Avoid any exercise activities because they increase the risk of fracture. 2- Increase the intensity of exercise to lose weight. 3- Include weight-bearing activities in the exercise plan. 4- Exercise to strengthen muscles and improve muscle tone.
3
The school nurse has a group of children who need to be assessed. Which child does the nurse assess first? 1- Child experiencing a sore throat, vomiting, and fever. 2- Child with hemophilia who fell off the slide and has a headache. 3- Child with a bee sting who has trouble swallowing. 4- Child with diabetes who has been playing outside and is sweaty and pale.
3
The nurse reviews arterial blood gas (ABG) results for several clients. Which client does the nurse delegate to an LPN/LVN to provide care? (Select all that apply.) 1- PaCO2 31 mm Hg, HCO3 26 mEq/L (26 mmol/L), pH 7.50. 2- PaCO2 35 mm Hg, HCO3 30 mEq/L (30 mmol/L), pH 7.55. 3- PaCO2 37 mm Hg, HCO3 22 mEq/L (22 mmol/L), pH 7.40. 4- PaCO2 40 mm Hg, HCO3 24 mEq/L (24 mmol/L), pH 7.35. 5- PaCO2 43 mm Hg, HCO3 20 mEq/L (20 mmol/L), pH 7.30.
3,4
The nurse provides care for a postsurgical client unable to urinate. Which nursing intervention promotes urination? (Select all that apply.) 1- Encourage the client to lie back when trying to void. 2- Pour cool water over the thigh. 3- Turn on water in the sink. 4- Encourage relaxation when trying to void. 5- Provide for privacy.
3,4,5
A client diagnosed with a terminal disease questions the nurse about the purpose of diagnostic tests. Which action should the nurse take next? 1- Encourage the client to have the testing performed to validate the diagnosis. 2- Contact the radiology department to reschedule the diagnostic tests. 3- Inform the health care provider that the client is refusing diagnostic tests. 4- Ask the health care provider to discuss the diagnostic tests with the client.
4
A newly admitted client experiences a cardiac arrest and does not have a "do not resuscitate" order. Nursing assistive personnel (NAP) relate that the client stated to family earlier the desire to not be resuscitated. Which action will the nurse perform next? 1- Respect the client's wishes and do not perform cardiopulmonary resuscitation. 2- Tell the health care provider the client asked to be have a "do not resuscitate" order. 3- Determine who has the durable medical power of attorney. 4- Start cardiopulmonary resuscitation.
4
A nurse assesses a client's pain. Which question tells the nurse about the quality of the client's pain? 1- "What activities make the pain worse?" 2- "How frequently do you experience pain?" 3- "How would you rate your pain on a scale of 0 to 10?" 4- "What can you tell me about how the pain feels?"
4
Prior to delegating a client's surgical dressing change to an LPN/LVN, the nurse notes the dressing is saturated with blood. What action will the nurse take next? 1- Instruct the LPN/ LVN to complete the dressing change. 2- Reinforce the dressing. 3- Remove the dressing to assess the incision. 4- Notify the health care provider.
4
The charge nurse in a mental health facility overhears a staff nurse's conversation with a client. Which statement by the staff nurse requires follow-up by the charge nurse? 1- "The football game will be blacked out from television this Sunday." 2- "Tell me more about the abuse you endured as a child." 3- "What are your thoughts about using alcohol and drugs after you are discharged?" 4- "Any conversation we have regarding your personal life will not be discussed with anyone else."
4
The nurse finds a client with heart failure unresponsive with labored, gasping respirations. Which action does the nurse take first? 1- Obtain a defibrillator. 2- Deliver two rescue breaths. 3- Begin chest compressions. 4- Activate the emergency response system.
4
The nurse instructs a client on advance directives. Which client statement indicates to the nurse a need for further education? 1- "Advance directives should be completed long before a medical crisis develops." 2- "I decide who will make health care decisions for me if I chose a Health Care Proxy." 3- "A living will means my family will know what life-sustaining measures I want taken." 4- "A power of attorney for health care prevents my children from selling my home."
4
The nurse learns that a client at 10 weeks' gestation has a nonimmune rubella titer. Which information about vaccination will the nurse provide to this client? 1- Must be given immediately. 2- Will be given in the second trimester. 3- Will be given in the third trimester. 4- Will be given in the immediate postpartum period.
4
The nurse notes that a 4-hour-old newborn has blue hands and feet. Which action does the nurse implement next? 1- Place the neonate in a warmer. 2- Swaddle the neonate in double blankets. 3- Notify the health care provider. 4- Proceed with the assessment.
4
The nurse on a surgical unit receives report on a group of assigned clients. Which client does the nurse assess first? 1- Client 5 hours post-hysterectomy who is reporting nausea. 2- Client with a gastric ulcer reporting mid-epigastric pain and nausea. 3- Client 1 day post-thoracotomy who is reporting incision discomfort. 4- Client with a chest tube who reports that the transporter clamped the tubing.
4
The nurse performs a nitrazine test on a client at 38 weeks' gestation. Which color change indicates that membranes have likely ruptured? 1- Yellow. 2- Olive-green. 3- Olive-yellow. 4- Blue-green.
4
The nurse provides care for a client diagnosed with a stage 2 pressure injury. The nurse assigns the client a Braden scale score of 9. Which action does the nurse take next? 1- Reassess the Braden scale within 12 hours. 2- Increase the client's daily oral fluid intake. 3- Obtain a prescription for an indwelling catheter. 4- Consult with health team on the care plan.
4
The nurse provides care for a client on a cardiac progressive care unit. The nurse gives the change of shift report to the oncoming nurse. Which information is essential to include in the report? 1- Vital signs for the shift, laboratory results, and medications that are due. 2- The name of the health care provider and the client's birth date. 3- Items on the client's care plan that still need to be addressed. 4- Activity tolerance, heart rhythm variations, and respiratory status.
4
The nurse provides care for a client with a nasogastric (NG) tube. The X-ray determined the NG tube is in proper position. Which method does the nurse use to determine proper placement of the NG tube for each subsequent use? 1- Observe the contents in the suction canister. 2- Request a prescription for an X-ray. 3- Push air into the NG tube while auscultating the abdomen. 4- Measure the pH of the aspirate.
4
The nurse receives a prescription to give aspirin to a client with acute coronary syndrome (ACS). Which action will the nurse take first? 1- Administer enteric coated aspirin 650 mg via the nasogastric tube. 2- Request that the health care provider prescribe a metabolic profile. 3- Ask if the client has a history of peptic ulcer. 4- Administer the aspirin after collecting a specimen for urinalysis.
4
The nurse teaches a client with stomatitis about foods to help improve the health problem. Which menu selection by the client indicates to the nurse that teaching has been effective? 1- Hot tea. 2- Oranges. 3- Spicy nuts. 4- Bananas.
4
While changing a client's bed linen, the nurse sustains a needlestick injury from a syringe left in the bed. After washing the injury with soap and water, which action does the nurse take next? 1- Send the needle to the laboratory for testing. 2- Interview the client about infection status. 3- File an incident report according to protocol. 4- Notify the nurse manager as soon as possible.
4