B GUIDE Flashcards
The nurse is preparing to administer prescribed medications to the following clients. It is most important for the nurse to follow up with the PCP for the client who has m Exam3
a. A prosthetic mitral valve, an INR of 3.0 and is currently taking a prescribed dose of warfarin
b. Constipation predominant IBS and has been prescribed loperamide
c. Diabetes mellitus, is scheduled to have a computer tomography scan with IV contrast,
and has been prescribed to withhold metformin
d. A methicillin-resistant staphylococcus aureus wound infection, an allergy to
sulfonamide, and has been prescribed vancomycin
b. Constipation predominant IBS and has been prescribed loperamide
The nurse is preparing to administer an intramuscular injection to an adult client. Which of the following actions is appropriate for the nurse to take?
a. Limit the amount of medication to 4ml when injecting into the deltoid muscle
b. Use the deltoid site if the client is an adult who requires 3ml of medication
c. Draw up an air bubble into the syringe after the medications has been prepared
d. Hold the skin taut when using the z-track method
d. Hold the skin taut when using the z-track method
The nurse is discussing health screening guidelines with a group of men. It is appropriate for the nurse to state that men should:
a. Perform a monthly testicular self-examination immediately after a bath or shower
b. Begin having a sigmoidoscopy once every 10 years beginning at age 50 (every 5 years once year are 45)
c. Begin having an annual prostate examination beginning at age 40 (50 years old every 2
- years)
d. Be tested annually for sexually transmitted diseases upon becoming sexually activ
a. Perform a monthly testicular self-examination immediately after a bath or shower
The nurse manager is observing a staff nurse care for a client who has a sealed radiation implant. Which of the following would require the nurse to intervene?
a. Keeping the door to the client’s room closed
b. Keeping dedicated equipment in the clients until the implant is removed
c. Wearing a lead shield when providing client care
d. Placing bed linens in a receptable kept inside the client’s room.
b. Keeping dedicated equipment in the clients until the implant is removed
The nurse is reviewing prescriptions for the following assigned clients. The nurse should clarify the prescription for the client who:
a. Presented with clinical manifestations of an ischemic stroke that started 2 hours ago and is to receive alteplase intravenously
b. Has creatinine level of 2.8 mg/dl and is scheduled to have a cardiac catheterization in the morning
c. Had a myocardial infraction 3 hours ago and is to have troponin levels drawn in 3 hours
d. Had a permanent pacemaker inserted 6 months ago and is scheduled for a radiography
(x-ray) of the chest.
b. Has creatinine level of 2.8 mg/dl and is scheduled to have a cardiac catheterization in the morning
The nurse preceptor has discussed appropriate dietary intake for various ages of pediatric clients with a newly hired nurse. Which of the following statements by the newly hired nurse indicated a need for further teaching?
a. Sliced banana is an appropriate snack for a toddler-aged child
b. Milk is introduced as 12 months of age in an infant which has been breastfed since birth
c. Honey can be introduced to an infant at 9 months of age (needs to be 1 year)
d. 4oz fruit juice can be given in a cup to a 13-month-old infant pe
c. Honey can be introduced to an infant at 9 months of age (needs to be 1 year)
The nurse is assessing a client at the scene of a mass casualty disaster and prioritizing care
des based on the disaster triage tag system. The client who should be transported to the healthcare facility first is the one:
a. Patient who is confused and has an open wound on the right lower leg
b. Patient who has multiple compound fracture and is reporting chest pain
c. Patient who reports an abdominal pain and has facial lacerations
d. Patient who has burns to 75% of the posterior trunk and lower body
b. Patient who has multiple compound fracture and is reporting chest pain
The nurse is caring for a pediatric client who is postoperative following ventriculoperitoneal -
shunt placement. The nurse notes the client has been difficult to arouse. Which of the following actions should the nurse take immediately?
a. Prepare the client for endotracheal tube insertion
b. Measure the clients head circumference
c. Turn the client to the operative side (positioned on nonoperative side to prevent pressure on shunt valve)
d. Elevate the client’s head of bed to 30 degrees
d. Elevate the client’s head of bed to 30 degrees
The nurse is caring for a client who has hypovolemic shock and has a pulse of 116. The nurse has intravenous 0.9% sodium chloride. Which of the following actions should the nurse perform next?
a. Initiate oxygen at 2 L/min via nasal cannula
b. Document and continue to monitor the client
c. Insert and indwelling urethral catheter
d. Obtain a prescription for a vasodilator
a. Initiate oxygen at 2 L/min via nasal cannula
The nurse is caring for a client receiving mechanical ventilation with high-pressure alarm sounds. The nurses assess for problems causing the alarm and is unable to determine. Which of the following actions should the nurse take?
a. Ventilate the client with a bag-mask valve devise
b. Notify respiratory therapy to check the ventilator settings
c. Turn off and call a code
d. Assess client’s lung sounds and breathing pattern
a. Ventilate the client with a bag-mask valve devise
The nurse is assisting with discharge planning for assigned clients. Which of the following referrals is appropriate for the nurse to make?
a. A speech therapist referral for a client who will be discharged with intermittent tube feedings.
b. An occupation therapist referral for a client who has Parkinson’s disease and experiencing difficult performing activities of daily living.
c. A physical therapist referral for a client who has rheumatoid arthritis and requires instructions in the use of an assistive device for eating
d. A social worker referral for a client who will be discharged with a prescription for a benzodiazepine.
b. An occupation therapist referral for a client who has Parkinson’s disease and experiencing difficult performing activities of daily living.
The nurse has attended a continuing education program on legal issues in nursing practice. Which of the following statement by the nurse indicates a correct understanding of the conference?
a. Threatening to touch a client without the client’s consent is an example of assault
b. Giving clients false assurance about a health care condition expected outcome is an
example of libel
c. Posting information about a client on social media without the client’s permission is
slander
d. Failure to communicate concerns about an elderly client who is confused is being
discharged home is an example of defamation
a. Threatening to touch a client without the client’s consent is an example of assault
The nurse working in a medical surgical unit is caring for assigned clients. Which of the following tasks is appropriate to delegate?
a. Asking a licensed practical nurse to obtain a capillary blood glucose reading on a client who has become diaphoretic
b. Asking an UAP to turn off the tube feeding for a client who is receiving continuous tube feedings and is vomiting
c. Asking an UAP to flush the Jackson-Pratt drain of a client who is 7 days postoperative from an open appendectomy
d. Asking an LPN to teach a client who has a newly created ileostomy how to change the appliance.
a. Asking a licensed practical nurse to obtain a capillary blood glucose reading on a client who has become diaphoretic
The nurse is caring for the following pediatric clients. It is most appropriate for the nurse to initiate an interdisciplinary conference for the client who is
a. 3 days old, has been readmitted with rhinorrhea, and report that the mother has a history of substance abuse during pregnancy
b. 6 months old, has acute otitis media with purulent drainage, a red bulging tympanic membrane and is crying
c. 5 years old, has a fractured arm from falling on the school playground, and is being discharged with a fiberglass cast
d. 2 months old, has developmental dysplasia of the hip, unequal leg lengths, limited abduction of the left hip, and asymmetry of the gluteal folds
a. 3 days old, has been readmitted with rhinorrhea, and report that the mother has a history of substance abuse during pregnancy
The nurse working in the labor and delivery unit is caring for a client in labor whose membranes just spontaneously ruptured. Which of the following finding is a priority for the nurse to report to the primary health care provider?
a. A maternal temperature of 99.5
b. Four contractions in a 10-minute period (5 or more contractions in 10 minutes)
c. Appearance of bloody fluid from the vagina
d. Contractions lasting 60 seconds (contraction duration 2 minutes or longer)
c. Appearance of bloody fluid from the vagina
The nurse is caring for a client who weighs 150lb (68kg) and has developed hepatic encephalopathy. It is a priority for the nurse to notify the PCP if the client develops
a. An increase in alanine aminotransferase (ALT) levels
b. A decrease in urine output to 450 ml/day (hepatorenal syndrome → sudden decrease in
urinary flow <500ml/24hr→cause of death in patients)
c. The development of a musty odor to the breath
d. A change in pupil size from 7 to 5 mm
b. A decrease in urine output to 450 ml/day (hepatorenal syndrome → sudden decrease in
urinary flow <500ml/24hr→cause of death in patients)
The nurse has received report for the following clients. The nurse should first assess the client who:
a. Has meningitis and reports a headache and photosensitivity
b. Had a stroke 24 hours ago and has become restless and irritable
c. Has an abdominal aneurysm and reports mild lower back pain
d. Had epilepsy and remains drowsy 30 minutes after having a seizure
b. Had a stroke 24 hours ago and has become restless and irritable
The nurse is caring for assigned clients. It is a priority for the nurse to follow up with a client
who:
a. Is receiving intravenous fluid at a prescribed rate at 100ml/hr and has received 400ml after 2 hours
b. Has end stage renal disease, a history, and is drinking orange juice brought in by a visitor
c. Is receiving continuous heparin infusion and received the first dose of warfarin 1 hour
ago
d. Has a closed-chest drainage system attached to 20 cm of suction and has 3 cm of water
in the water seal chamber
a. Is receiving intravenous fluid at a prescribed rate at 100ml/hr and has received 400ml after 2 hours
The nurse working in the ED is precepting a newly hired nurse. It indicates a correct care if the newly hired nurse:
a. Raises the HOB to 30 degrees for a client who has a BP of 95/58 mmHg
b. Prepares to give lorazepam to a client who is anxious and needs to sign a consent form
c. Rewarms the trunk before the extremities of client who had moderate hypothermia
d. Removes the pants of a client who has chemical burns by soaking them off with water
c. Rewarms the trunk before the extremities of client who had moderate hypothermia
The nurse is participating in the development of a staff education program about ethical responsibilities in nursing practice. Which of the following should the nurse include in an ethical dilemma that requires follow-up by a nurse?
a. A 16-year-old who needs to sign a surgical consent for their 6-month-old infant
b. A family member who is talking with a client about the client’s diagnosis while the
roommate is present
c. A nurse is preparing for organ procurement and donation of a deceased client who
followed the Catholic faith
d. A PCP is placing a percutaneous intravenous central catheter line for antibiotic therapy
into a client who is receiving hospice care
d. A PCP is placing a percutaneous intravenous central catheter line for antibiotic therapy
into a client who is receiving hospice care
