CHING Flashcards
A nurse is reviewing the laboratory results of a lumbar puncture (LP) for a client who has manifestations of bacterial meningitis. Which of the following findings should the nurse expect?
A.Elevated protein
B. Elevated glucose
C. Decreased potassium
D. Elevated sodium
A.Elevated protein
A nurse is caring for a client who has diabetes insipidus. Which of the following medications
should the nurse plan to administer?
a. Desmopressin
b. Regular insulin
c. Furosemide
d. Lithium carbonate
a. Desmopressin
A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several
times daily for 3 years.Which of the following test should the nurse monitor?
a. Fasting blood glucose
b. Stool for occult blood - GI bleed
c. Urine for white blood cells
d. Serum calcium
b. Stool for occult blood - GI bleed
A nurse is assessing a client who is 12hr postoperative following a colon resection. Which of the
following findings should the nurse report to the surgeon?
a. Heart rate 90/min
b. Absent bowel sounds
c. Hgb 8.2 g/dl
d. Gastric pH of 3.0
c. Hgb 8.2 g/dl
A nurse is contacting the provider for a client who has cancer and is experiencing
breakthrough pain. Which of the following prescriptions should the nurse anticipate?
a. Transmucosal fentanyl
b. Intramuscular meperidine
c. Oral acetaminophen
d. Intravenous dexamethasone
a. Transmucosal fentanyl
A nurse is teaching a client who has ovarian cancer about skin care following radiation
treatment. Which of thefollowing instructions should the nurse include?
a. Pat the skin on the radiation site to dry it
b. Apply OTC moisturizer to the radiation site
c. Cover the radiation site loosely with a gauze wrap before dressing
d. Use a soft washcloth to clean the area around the radiation site
a. Pat the skin on the radiation site to dry it
A nurse is admitting a client who reports chest pain and has been placed on a telemetry monitor. Which of thefollowing should the nurse analyze to determine whether the client is experiencing a myocardial infarction?
a. PR interval
b. QRS duration
c. T wave
d. ST segment
d. ST segment
A nurse is assessing a client who is receiving magnesium sulfate IV for the treatment of hypomagnesemia. Which of the following findings indicates the effectiveness of the medication?
a. Lungs clear
b. Apical pulse 82/min
c. Hyperactive bowel sounds
d. Blood pressure 90/50 mm Hg
b. Apical pulse 82/min
A nurse is reviewing a client’s ABG results pH 7.42, PaC02 30 mm Hg, and HCO3 21 mEq/L. The nurse should recognize these findings as an indication of which of the following conditions?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Compensated respiratory alkalosis
d. Uncompensated respiratory acidosis
c. Compensated respiratory alkalosis
A nurse is caring for a client who has a deep partial thickness burns over 15% of her body which of the following labs should the nurse expect during the first 24 hours
A. Decreased BUN (elevated due to fluid loss)
B. Hypoglycemia (High due to stress)
C. Hypoalbuminemia (Low due to fluid loss)
D. Decreased Hematocrit
C. Hypoalbuminemia (Low due to fluid loss)
A nurse is caring for a client who has dumping syndrome following a gastrectomy, which of the following actions should the nurse takes?
a. Offer the client high carbohydrate meal options (High fat, high protein, low fiber
b. Provide the client with four full meals a day (Small frequent meals)
c. Encourage the client to drink at least 360 ml of fluids with meals (Eliminate liquids with meals for 1 hr. prior and following a meal)
d. Have the client lie down for 30 minutes after meals (Lying down after a meal slows the movement of food within the intestines)
d. Have the client lie down for 30 minutes after meals (Lying down after a meal slows the movement of food within the intestines)
A nurse is preparing to administer fresh frozen plasma to a client. Which of the following actions should the nurse take?
a. Administer the plasma immediately after thawing
b. Transfuse the plasma over 4 hours (20-30 mins for this)
c. Hold the transfusion if the client is actively bleeding
d. Administer the transfusion through a 24-gauge saline lock
a. Administer the plasma immediately after thawing
A nurse is assessing a client who reports numbness and tingling of his toes and exhibits a positive TROUSSEAU. Which of the following electrolyte imbal- ance should the nurse suspect?
a. Hyponatremia
b. Hyperchloremia
c. Hypermagnesemia
d. Hypocalcemia
d. Hypocalcemia
A nurse is caring for a client who has a central venous access device. Which of the following
assessment findings should thenurse report to the provider?
a. RBC count of 4.7 million/mm (
b. BUN 22-mg/ dl - (5-25 mg/dl) 10-20
c. WBC count of 16,000/ mm
d. Blood glucose of 120 mg/dl (70-110)
c. WBC count of 16,000/ mm
A nurse is providing dietary teaching to a client who has chronic kidney disease and a decreased glomerular filtration rate. Which of the following statements by the client indicates an understanding of the teaching?
a. I will spread my protein allowances over the entire day
b. I should increase my intake of canned salmon to three times per week
c. I will season my food with lemon pepper rather than salt
d. I should limit my intake of hard cheese to 3 ounces each day
a. I will spread my protein allowances over the entire day
A nurse is caring for a client who has a peripherally inserted central catheter. The client is receiving an antibiotic via intermittent IV bolus. Which of the following actions should the nurse take?
a. Administer 20 ml of 0.9 sodium chloride after each dose of medication
b. Flush the catheter using a 5-ml syringe à you use a 10mL syringe to flush
c. Verify the placement with an x-ray prior to the initial dose
d. Change the transparent membranes dressing daily (dressing can last
for up to 7 days
c. Verify the placement with an x-ray prior to the initial dose
A nurse is assessing the pain status of a group of clients. Which of the following findings indicate a client is experiencing referred pain?
a. A client who has angina reports substernal chest pain
b. A client who has pancreatitis reports pain in the left shoulder
c. A client who is postoperative reports incisional pain
d. A client who has peritonitis reports generalized abdominal pain
b. A client who has pancreatitis reports pain in the left shoulder
A nurse is assessing a client who has acute pancreatitis and has been receiving total parenteral nutrition for the past 72hours. Which of the following findings requires the nurse to intervene?
a. Right upper quadrant pain
b. Capillary blood glucose level of 164 mg/dl - glucose not significantly high
c. WBC counts 13,000/mm3 (Infection is one complication of TPN administration
d. Crackle in bilateral lower lobes
d. Crackle in bilateral lower lobes
A nurse is planning care for a client who is 12 hr. postoperative following a kidney transplant. Which of the following actions should the nurse include in the plan of care?
a.) Check the client’s blood pressures every 8 hr.
b.) Administer opioids PO
c.) Assess urine output hourly
d.) Monitor for hypokalemia
c.) Assess urine output hourly
A nurse is obtaining a medication history from a client who is to start therapy with naproxen for rheumatoid arthritis. Which of the following medications places the client at risk for bleeding?
a.) Captopril
b.) Ibuprofen
c.) Digoxin
d.)Phenytoin-seizure
b.) Ibuprofen
A nurse is assessing the extremities of a client who has Raynaud’s disease. Which of the following
findings should the nurse expect?
a.) Blanching of the hands
b.) Hyperactive reflexes
c.) Calf pain with foot dorsiflexion
d.) Vitiligo on affected extremities
a.) Blanching of the hands
A nurse is caring for a group of clients. The nurse should obtain a blood pressure reading using only the left extremity from which of the following clients?
a. A client who has a peripherally inserted central catheter in the left arm
b. A client who has left-sided Bell’s palsy
c. A client who has a right upper extremity arteriovenous fistula
d. A client who has right-sided weakness due to Parkin- son’s disease
c. A client who has a right upper extremity arteriovenous fistula
A nurse is caring for client who has Cushing’s disease. Which of the following actions should the nurse take first?
a. Check the client’s medication administration record for antihypertensive medication.
b. Verify the client’s understanding of sodium restriction.
c. Auscultate the client’s lung sound - due to fluid retention
d. Determine the need for further glucose monitoring.
c. Auscultate the client’s lung sound - due to fluid retention
A nurse is assessing a client who has nephrotic syndrome. Which of the findings should the nurse expect?
a. Proteinuria
b. Flank pain
c. Hyperalbuminemia
d. Hypotension
a. Proteinuria
A nurse is assessing a client who has right-sided heart failure. Which of the following assessment findings should the nurse expect to find?
a. Oliguria
b. S3/S4 galloping heart sounds
c. Poor skin turgor
d. Pitting edema
d. Pitting edema
A nurse is caring for a client who has newly inserted chest tube. The nurse should clarify
which of the following prescriptions with the provider?
a. Notify the provider when tidaling ceases.
b. Assisting the client out of bed three times daily.
c. Vigorously strip the chest tube twice daily.
d. Administer morphine 2 mg IV bolus every 3 hr.
c. Vigorously strip the chest tube twice daily.
A nurse is teaching a client who is taking an ACE inhibitor for heart failure. Which of the following instructions should the nurse include for home management of heart failure?
a. Obtain daily weight.
b. Use of salt substitute.
c. Monitor Intake and Output
d. Limit daily activity.
a. Obtain daily weight.
A nurse is providing discharge teaching to a client who has a permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching?
a. I need to maintain pressure over the pacemaker site with an elastic bandage.
b. I need to check my pulse rate every day for a full minute.
c. The pacemaker will deliver shock if I develop a dysrhythmia-
d. When a microwave oven is in use, I need to stay out of the room.
b. I need to check my pulse rate every day for a full minute.
A nurse is assessing a client who is 4hr postoperative following arterial re-vascularization of the left femoral artery. Which of the following findings should the nurse report immediately?
a. Bruising around the incision site
b. Pallor in the affected extremity
c. Urine output 150mL over 4hr
d. Temperature of 37.9 (100.2)
b. Pallor in the affected extremity
A nurse is preparing to discharge a client who has a halo traction device and is reviewing new prescriptions from the provider. The nurses should clarify which of the following prescriptions with the provider?
a. Increase intake of fiber rich foods
b. May operate a motor vehicle when no longer taking analgesics
c. Take tub baths instead of showers
d. May place a small pillow under the head
b. May operate a motor vehicle when no longer taking analgesics
A nurse is assessing for elderly signs of compartment syndrome for a client who has a short leg fiberglass cast. Which of the following findings should the nurse expect?
a. Bounding distal pulses
b. Capillary refill less than 2 seconds
c. Erythema of the toes
d. Intense pain with movement
d. Intense pain with movement
A nurse is caring for a client who is taking furosemide. The client has a potassium level of 3.1 mEq/L. Which of the following should the nurse assess first?
a. Urine output
b. Level of orientation
c. Cardiovascular status
d. Muscle weakness
c. Cardiovascular status
A nurse is caring for a client who is 6 hours postoperatively following a thyroidectomy. The client reports tingling and numbness in the hands. The nurse should identify this as a sign of which of following electrolyte imbalances?
a. Hypernatremia
b. Hypermagnesemia
c. Hypokalemia
d. Hypocalcemia
d. Hypocalcemia
A nurse is assessing a client 15 min after the start of a transfusion of 1 unit of packed RBC’s. Which of the following findings is an indication of a hemolytic transfusion reaction?
a. Hypotension
b. Bradypnea
c. Bradycardia
d. Hypothermia
a. Hypotension
A nurse in an emergency department is caring for a client who has sinus bradycardia. Which of the following actions should thenurse take first?
a. Prepare the client for temporary pacing.
b. Initiate IV fluid therapy for the client
c. Measure the client’s blood pressure
d. Administer atropine to the client
c. Measure the client’s blood pressure
A nurse is caring for a client who has a prescription to discontinue a peripherally inserted central catheter. Which of the following actions should the nurse take?
a. Apply slight pressure when resistance is met
b. Measure the catheter after removal
c. Remove the catheter with one continuous motion
d. Place a dry sterile dressing to the site after removal
d. Place a dry sterile dressing to the site after removal
A nurse is caring for a client in the emergency department who experienced a full-thickness burn injury to the lower torso 1 hr. ago. Which of the following findings should the nurse expect?
a. Decreased respiratory rate
b. Hypotension
c. Bradycardia
d. Urinary diuresis
b. Hypotension
A nurse is teaching a group of newly licensed nurses about acute respiratory failure. Which of the
following manifestations should the nurse include in the teaching?
a. Hypoxemia
b. Hyperventilation
c. Hypocarbia
d. Hypervolemia
a. Hypoxemia
A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take?
a. Obtain the client’s vital signs
b. Clear items from the client’s surrounding area
c. Loosen the client’s restrictive clothing
d. Lower the client to the floor
d. Lower the client to the floor
A nurse is teaching a client who is receiving total parenteral nutrition at home through a central venous access device about transparent dressing changes. Which of the following instructions should the nurse in- clude in the teaching?
a. Change the dressing every 48 hr.
b. Replace the extension tubing with each dressing change
c. Use clean technique when changing the dressing
d. Wear a mask during dressing change
d. Wear a mask during dressing change
A nurse is providing instructions about foot care for a client who has a peripheral arterial disease. The nurse should identify which of the following statements by the client indicates an understanding of the
teaching?
a. “I apply a lubricating lotion to the cracked areas on the soles of my feet every morning”
b. “I use my heating pad on a low setting to keep my feet warm.” (Minimal sensation)
c. “I soak my feet in hot water before trimming my toenails” (Minimal sensation for PAD)
d. I rest in my recliner with my feet elevated for about an hour every afternoon”
d. I rest in my recliner with my feet elevated for about an hour every afternoon”
A nurse is teaching a client who has a new prescription for alendronate to treat osteoporosis. Which of
the following instructionsshould the nurse include in the teaching?
a. Swallow the medication with 120mL
b. Take the medication with a vitamin E supplement
c. Sit upright for 30 min after taking the medication
d. Take the medication with lunch
c. Sit upright for 30 min after taking the medication
A nurse is providing teaching to a client who is post-operative following a partial glossectomy. Which of the following statements by the client indicates an under- standing of the teaching?
a. I will consume can soup whenever sores appear in my mouth
b. I will drink orange juice to increase my vitamin C intake
c. I will rinse my toothbrush with hydrogen peroxide and water after each use
d. I will inspect my mouth once each week for sores.
c. I will rinse my toothbrush with hydrogen peroxide and water after each use
A nurse is providing teaching for a client who has diabetes mellitus about the self-administration of insulin. The client has prescriptions for regular and NPH insulin. Which of the following statements by the
client indicates an understanding of the teaching?
a.I will draw up regular insulin into the syringe first
b.I will insert the needle at a 15-degree angle
c.I will store prefilled syringes in the refrigerator with the needle pointing downward
d.I will shake the NPH vial vigorously before drawing up the insulin
a.I will draw up regular insulin into the syringe first
A nurse is caring for a client in diabetic ketoacidosis DKA. Which of the following is the priority intervention by the nurse?
a. Check potassium levels
b. Administer 0.9% sodium chloride
c. Begin bicarbonate continuous IV infusion
d. Initiate continuous IV insulin infusion
b. Administer 0.9% sodium chloride
A nurse is reviewing the laboratory results of a female client who asked about acupuncture treatment for chemotherapy-induced nausea and vomiting. Which of the following laboratory results contraindication
to receiving acupuncture?
a. Absolute neutrophil count 500/mm3
b. C-reactive protein 0.7 mg/dl
c. Platelets 160,000/mm3
d. Hemoglobin 12g
a. Absolute neutrophil count 500/mm3
A nurse at a long-term care facility is assessing an older adult client. Which of the following findings should the nurse identify as an indication that the client has recall memory impairment?
a. Inability to state what he has for dinner last night
b. Inability to Name the members of his family
c. Inability to count backwards from 10
d. Inability to state his current age
a. Inability to state what he has for dinner last night
A nurse on an intensive care unit is planning care for a client who has increased intracranial pressure following a head injury.Which of the following IV medica- tions should the nurse plan to administer?
a. Chlorpromazine
b. Dobutamine
c. Mannitol
d. Propanol
c. Mannitol
A nurse is teaching a client who is to begin chemother- apy about peripherally inserted central catheter. Which of the following statements should the nurse include in the teaching?
a. We will replace the PICC every month (Not every month)
b. We can draw blood samples from the PICC for diagnostic test
c. We will change the dressing daily (not daily)
d. We can measure your blood pressure in either arm
b. We can draw blood samples from the PICC for diagnostic test
A nurse is assessing a client who has Pyelonephritis and reports flank pain. Which of the following actions should the nurse take?
a. Assist the client to a sitting position
b. Percuss the side of tenderness first
c. Auscultate for a bruit over the coastal vertebral area
d. Thump the area of tenderness directly with a closed fist
a. Assist the client to a sitting position
A nurse working in the emergency department is caring for a client who has a burn injury. After securing the
client’s Airway which of the following interventions should the nurse take first?
a. Cleanse the client wound
b. Administer Analgesic medication
c.Increase the room temperature
d. Start an IV with a large bore needle
d. Start an IV with a large bore needle
A nurse is assessing a client who has acute kidney failure. Which of the following findings should the nurse report to the provider?
a. Peripheral pulses 2 + bilaterally
b. Weight gain 1.1 kilogram to 2.4 pound in 24-hour
c. Urine specific gravity 1.045
d. Creatinine 0.8 milliliter (0.5-1.1 mg/dl)
b. Weight gain 1.1 kilogram to 2.4 pound in 24-hour
A nurse is caring for an older adult client who is 72 hours postoperative following a total hip arthroplasty. The client requires a PRN medication before ambulation. Which of the following medications should the nurse anticipate administering?
a. Indomethacin
b. Meperidine
c. Naproxen
d. Oxycodone Oxycontin Opioids agent.
d. Oxycodone Oxycontin Opioids agent.
A nurse is providing discharge teaching to a client who has pulmonary tuberculosis. Which of the following findings should thenurse include, as an indication the client is no longer infectious?
a. Mantoux skin test reveals and induration of less than 1mm
b. Client no longer coughing up blood tinged sputum
c. Positive Quantiferon TB gold test
d. Negative sputum culture for acid fast bacillus
d. Negative sputum culture for acid fast bacillus
A nurse is caring for a client who has a central venous access device and notes the tubing has become disconnected. The client develops dyspnea and tachycardia- dia. Which of the following actions should the nurse
take first?
a. Obtain ABG values
b. Perform an ECG
c. Turn the client to his left side
d. Clamp the catheter
d. Clamp the catheter
A nurse is caring for a client who has admitted with nausea, vomiting, and a possible bowel
obstruction. An NG tube is placedand set to low intermit- tent suction. Which of the following findings should the nurse report to the provider?
a. The client reports being extremely thirsty with a sore throat
b. The amount of drainage is gradually decreasing
c. The client’s abdomen becomes distended and firm
d. The drainage is bright green in color with brown
c. The client’s abdomen becomes distended and firm
A nurse is caring for a client who has an endotracheal tube. Which of the following actions should the
nurse take to verify tube placement?
a. Deflate the cuff to check the tube placement
b. Place the client’s head and neck in a flexed position
c. Observe for symmetry of chest expansion
d. Document the tube length where it passes the chin
c. Observe for symmetry of chest expansion
A nurse is providing discharge teaching to a client who has chronic urinary tract infections. The client has a prescription for ciprofloxacin 250 mg PO twice daily. Which of the following instructions should the nurse include in the teaching?
a. Take a laxative to prevent constipations
b. Take an antacid 30 min before taking the medication
c. Monitor heart rate once daily
d. Drink 2 to 3 L of fluid daily
d. Drink 2 to 3 L of fluid daily
A nurse is presenting an in-service program about Parkinson’s disease (PD). Which of the following statements should thenurse include in the teaching?
a. PD cause clients to have an increased sympathetic nervous system response
b. PD results in the development of neurofibrillary tangles within the client’s brain
c. PD results from a decreased amount of dopamine in the client’s brain
d. PD manifestations worse due to the clients decreased production of
acetylcholine.
c. PD results from a decreased amount of dopamine in the client’s brain
A nurse is caring for a client who presents to the emergency department after experiencing a heat stroke. Which of the following actions should the nurse take?
a. Apply a cooling blanket.
b. Assess axillary temperature every 15 min.
c. Administer an antipyretic
d. Administer lactated ringers
a. Apply a cooling blanket.
.A nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the following findings should the nurse report to the provider as a contraindication to receiving heparin?
a. Thrombocytopenia
b. Thalassemia
c. Rheumatoid arthritis
d. COPD
a. Thrombocytopenia
.A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes that the weights are touching on the floor. Which of the following actions should the nurse take?
a. Pull the client up in bed
b. Tie knots in the ropes near the pulleys to shorten them
c. Increase the elevation of the affected extremity
d. Remove one of the weights
a. Pull the client up in bed
A nurse is reviewing a medical record of a client who has acute gout. The nurse expects an increase in
which of the following laboratory results?
a. Intrinsic factor
b. Chloride level
c. Uric acid
d. Creatinine kinase
c. Uric acid
A nurse is providing teaching to a client who is to start furosemide therapy for heart failure. Which of the following statements indicates that the client understands a potential adverse effect of this medication?
a. “I will check my pulse before I take this medication.”
b. “I’ll check my blood pressure so it doesn’t get too high.”
c. “I’m going to include more cantaloupe in my diet.”
d. “I will try to limit foods that contain salt.”
c. “I’m going to include more cantaloupe in my diet.”
A nurse is assessing a client who has a diagnosis on colon cancer which
of the following should the nurse expect?
a) Statorrhea
b) Elevated hemoglobin
c) Hematochezia blood in stool
d) Weight gain
c) Hematochezia blood in stool
A nurse is assessing a client admitted with peripheral vascular disease,.Which of the following findings indicates a venous vascular disorder?
a) An ulcer at the tip of a toe
b) Hair loss distal to the clients calves
c) Leg pain at rest
d) Edema of the ankle
d) Edema of the ankle
A community health nurse is reviewing home care instructions with an older adult client who has a new diagnosis of heart failure. Which of the following
is the priority topic for the nurse to review with the client?
a) Daily sodium restriction
b) Daily exercise routine
c) Changes in weight
d) Fluid intake record
c) Changes in weight
A nurse is teaching a client about the use of a transcutaneous electrical
nerve stimulation (TENS) unit. Which of the following statements should the
nurse include?
a) “Apply lotion to the site prior to attaching the electrodes”
b) “ this device requires access to a 220 volt outlet”
c) ‘ this device delivers heat via electrodes that are at- attached to the effected
area”
d) “adjust the dial until you feel a ‘pins and needles’ sensation”
d) “adjust the dial until you feel a ‘pins and needles’ sensation”
A nurse finds a client in bed, unresponsive and breathing. Which of the following action should the nurse take first?
a) Establish IV access
b) Apply blood pressure cuff
c) Palpate for the client’s carotid pulse
d) Initiate cardiac monitoring for the client
c) Palpate for the client’s carotid pulse
A nurse is caring who is experiencing a hypertensive crisis. Which of the following actions should the nurse take?
a) Initiate IV dopamine infusion
b) Perform neurological assessments
c) Place the client supine
d) Begin an IV bolus of lacted ringer’s
b) Perform neurological assessments
A nurse is providing discharge teaching about blood sugar monitoring for a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should
instruct the client to obtain which of the following supplies?
a) Sterile lancets
b) Compression stockings
c) Hand mirror
d) Toenail clippers
a) Sterile lancets
A nurse is completing discharge teaching who has a peripherally inserted central catheter ( PICC) line in the left arm. Which of the following instructions should the nurse include in the teaching?
a) Do not elevate the arm above the level of the heart
b) Change the catheter dressing daily
c) Use 10- mL syringe to flush line
d) Clean the insertion site using 20- mL of hydrogen peroxide
c) Use 10- mL syringe to flush line
A nurse is caring for a client who is receiving a blood transfusion. The nurse observes that the client has bounding peripheral pulses, hypertension, and distended jugular veins. The nurse should anticipate administering which of the following prescribed medications?
a) Pantoprazole
b) Acetaminophen
c) Furosemide
d) Diphenhydramine
c) Furosemide
A nurse is planning care for a client who has upper gastrointestinal bleeding due to a peptic ulcer. Which of the following actions should the nurse plan to take?
a) Provide ketorolac for abdominal pain
b) Administer nitroprusside IV based on the client’s weight
c) Insert a large bore nasogastric tube
d) Ensure that the client has a 22- gauge iv line in place
c) Insert a large bore nasogastric tube
A nurse is caring for a client who has bladder cancer and a WBC count of 900/mm3 . which of the following actions should the nurse take?
a) Instruct client to avoid eating raw fruit
b) Move the client to a negative pressure room
c) Use contact isolation while providing care
d) Apply pressure to venipuncture sites for 10 min
a) Instruct client to avoid eating raw fruit
A nurse is reviewing a cardiac Rhythm strip of a client who has atrial flutter. Which of the
following findings should the nurse expect?
a) Progressively longer PR durations
b) undetectable p waves
c) absent PR intervals with ventricular rate of 40 to 60 / minutes
d) Sawtooth pattern with atrial rate of 252 400 / minutes
d) Sawtooth pattern with atrial rate of 252 400 / minutes
A Nurse is completing an assessment of an older adult client and notes reddened areas
over the bony prominences, but the client’s skin is intact. Which of the following interventions
should the nurse include in the plan of care?
a) Apply an occlusive dressing
b) turn and reposition the client every 4 hours
c) support bony prominences with pillows
d) massage Tourette in areas three times daily
c) support bony prominences with pillows
A nurse is caring for a client who is scheduled for an abdominal paracentesis. The nurse
should plan to take which of the following actions?
a) Administer a stool softener following the procedure
b) ask the client to empty his bladder prior to the procedure
c) instruct the client to take deep breaths and hold them during the procedure
d) assist the client into the left lateral position during the procedure
b) ask the client to empty his bladder prior to the procedure
A nurse is assessing a client following the insertion of a central venous catheter. Which of the following findings indicates a pneumothorax?
a) diminished breath sounds
b) itching over the incision
c) distended neck veins
d) irregular heart rate
a) diminished breath sounds
A nurse is providing teaching to a client who is receiving opioids for pain management.
Which of the following information should the nurse in- clude in the teaching?
a) Monitor urinary output for retention
b) avoid taking anti emetics with the medication
c) restrict fluid intake If you experience constipation
d) itching Indicates you are having an allergic reaction to the medication
a) Monitor urinary output for retention
A nurse is providing preoperative teaching for a client who is having left-sided cardiac
catheterization. Which of the following information should the nurse include in the teaching?
a) You should plan to remain in bed for 18 hours after the procedure
b) you will have blood pressure measurement every 5 minutes for the first two hours after
the procedure
c) You will receive a general anesthetic during the procedure
d) you should expect warm sensation after the injection of the contrast dye during the procedure
d) you should expect warm sensation after the injection of the contrast dye during the procedure
A nurse is caring for a client who has anemia. Which of the following assessment findings should the nurse anticipate with the client’s condition?
a) Bradycardia
b) Headache
c) heat intolerance
d) flushed skin color
b) Headache
● Fatigue, somnolence, and headache
A nurse is teaching a client who has a new prescription for Warfarin about foods that affect the INR. The nurse should include in the teaching which of the following Foods interact with this medication?
a) Kale
b) beef stew
c)Yogurt
d) orange juice
a) Kale
A nurse is providing discharge teaching for a client who is receiving treatment for genital
herpes. Which of the following statements by the client indicates effectiveness of the teaching?
a) I should expect to take my medication for three weeks
b) I should apply antibiotic ointment to the lesions
c) I should expect my lesions to resolve in 6 weeks
d) I should use natural skin condoms during sexual intercourse
c) I should expect my lesions to resolve in 6 weeks
A nurse in an emergency department is preparing a client for emergency surgery. The
client’s blood alcohol level is 180 mg / DL which of the following action is the nurses priority?
a) Insert an NG Tube
b) obtain consent
c) apply anti-embolic stockings
d) Institute bleeding precautions
a) Insert an NG Tube
A nurse suspects that a client who has diabetes mellitus is experiencing hypoglycemia. Which of the following assessment findings supports this suspicion?
a) Cool, clammy skin
b) kussmaul respirations
c) acetone breath
d) increased urine output
a) Cool, clammy skin
A nurse is caring for a client who is receiving radiation. The client reports nausea since the
therapy was initiated. Which of the following considera- tions should the nurse include when finding the clients meals?
a) Offer hot beverages with meals
b) offer a snack prior to radiation therapy
c) offer highly seasoned Foods
d) offer frequent High carbohydrate meals
d) offer frequent High carbohydrate meals
A charge nurse receives a call from the house super- visor requesting room assignments for
four new clients. Based on the information diagnosis which of the following clients requires a private room?
a) A client service port reports having fever, night sweats, and call for 2 days
b) an older adult client who was admitted with aspiration pneumonia
c) a client who has diabetes mellitus and is presenting with acute ketoacidosis
d) a client who has a compound fracture of the right femur
a) A client service port reports having fever, night sweats, and call for 2 days
A nurse in an emergency department is assessing a client who has diabetic ketoacidosis. Which of the following findings should the nurse expect?’
(select all the apply)
a) Tremors
b) reports of nausea and vomiting
c) Serum glucose 380 mg / DL
d) serum pH 7.6
e) fruity smelling breath
b) reports of nausea and vomiting
c) Serum glucose 380 mg / DL
e) fruity smelling breath
A nurse is planning a staff education session about hepatitis A. Which of the following
information should the nurse include?
a) Immunization for Hepatitis A is recommended prior to travel to high-risk areas
b) the incubation. Of hepatitis A is 5 to 10 days
c) hepatitis A is transmitted is Through Blood to blood exposure
d) clients who have Hepatitis A require a broad-spectrum antibiotic
a) Immunization for Hepatitis A is recommended prior to travel to high-risk areas
food and water contamination
A nurse is caring for a client who has advanced liver disease. Which of the following
laboratory results should the nurse monitor when assessing this client?
a) Phosphate level
b) glucose level
c) serum troponin
d) Serum ammonia
d) Serum ammonia
A nurse is planning care for a client who has status epilepticus. Which of the following
interventions is the nurses priority to include?
a) Administer phenytoin IV bolus to the client
b) provide the client oxygen at 6 L / min using a nasal cannula
c) turn the client to the lateral position during seizure activity
d) administer diazepam intravenously to the client
c) turn the client to the lateral position during seizure activity
A nurse is caring for a client who had a total hip arthroplasty. Which of the following actions should the nurse take to prevent hip dislocation?
a) Elevate the knees higher than the hips when sitting
b) remove the wedge device when turning
c) encourage the client to lean forward when attempting to stand
d) place two bed pillows between the legs when in bed
d) place two bed pillows between the legs when in bed
A nurse is caring for a client who is 6 hours postoper- ative following application of an
external fixator for a tibial fracture. Which of the following actions should the nurse take?
a) Adjust the clamps on the fixator frame
b) maintain the affected extremity in a dependent position
c) palpate the dorsalis pedis pulse
d) wrap sterile gauze on the sharp point of the pins
c) palpate the dorsalis pedis pulse
A nurse is caring for a client in the emergency department who experienced a full thickness burn injury to the lower torso 1 hour ago. Which of the following findings should the nurse expect?
a) Hypotension
b) Bradycardia
c) decrease respiratory
d) hypothermia
a) Hypotension
A nurse is completing discharge teaching with a client who has a new diagnosis of AIDS.
Which of the following statements by the client indicates an understanding of the teaching?
a) I will need to take my clothes to the dry cleaners to sterilize them
b) I will wipe up areas soiled with body fluids with alcohol and immediately disposed of the
trash (should be cleaned with bleach not alcohol )
c) I will be sure to wear gloves and wash my hands when I change my cat’s litter box
d) I will increase the amount of fresh fruits and vegetables I consume
c) I will be sure to wear gloves and wash my hands when I change my cat’s litter box
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take when performing a close intermittent irrigation?
a) Use a 3ml syringe to perform the catheter irrigation
b) Clamp the catheter above the specimen port
c) place the client in Trendelenburg position
d) inject the irrigation solution slowly into the catheter
d) inject the irrigation solution slowly into the catheter
A nurse is caring for a client admitted with a skull fracture. Which of the following assessment findings should be of greatest concern to the nurse?
a) Pulse pressure changes from 30 to 20 mmhg
b) bilateral pupil diameter changes from 4 to 2 mm
c) WBC count changes from 9,000 to 16,000 / mm 3
d) Glasgow Coma Scale score changes from 14 to 9
d) Glasgow Coma Scale score changes from 14 to 9
A nurse is caring for an older adult client who is sus- pected of having septicemia. Which of the following actions is the nurses priority?
a) Obtain a history to determine recent injuries
b) obtain a broad-spectrum antibiotic for Rapid Adminis- tration
c) obtain a WBC count with differential
d) obtain a blood specimen for culture and sensitivity testing
d) obtain a blood specimen for culture and sensitivity testing
A nurse is caring for a client who has just undergone a total laryngectomy. Which of the following findings is the nurse’s priority for immediate intervention?
a) Blood-tinged secretions
b) tachypnea
c) Fever
d) IV infiltration
b) tachypnea
A nurse is admitting a client to the emergency department after a gunshot wound to the abdomen. Which of the following actions should the nurse take to help prevent the onset of
acute kidney failure?
a) Administer IV fluids to the client
b) insert a urinary catheter
c) initiate beta-blocker therapy
d) prepare the client for an intravenous pyelogram
a) Administer IV fluids to the client
A nurse is an emergency department is reviewing a client’s ECG reading. Which of the following findings should the nurse identify as an indication that the client has a first degree heart block?
a) more p waves than QRS complexes
b) prolonged PR intervals
c) non discernible P waves
d) no correlation between P and QRS waves
b) prolonged PR intervals
A nurse is reviewing the medication list of a client who is being admitted with diabetes
insipidus. Which of the following medication places the client at an increased risk for developing
diabetes insipidus?
a) Ranitidine
b) Atorvastatin
c) Propranolol
d) lithium
d) lithium
A nurse is planning care for a client who has left-sided hemiplegia following a stroke which
of the following actions should the nurse include in the plan of care?
a) Place a plate guard on the clients meal tray
b) position the bedside table on the client’s left side
c) remind the client to use a cane on his left side while ambulating
d) provide the client with a short handled Reacher
a) Place a plate guard on the clients meal tray
A nurse is administering potassium chloride via IV infusion to a client who has severe hypokalemia. Which of the following actions should the nurse take?
a) Start the infusion at 30 meq /hr
b) assess the client for a positive chvostek’s sign
c) Monitor the client for adequate urine output
d) check the infusion site at least every 4 hours
a) Start the infusion at 30 meq /hr
A nurse in the PACU is caring for a client. Which of the following assessment is the nurses priority?
a) Surgical site
b) level of consciousness
c) respiratory status
d) pain level
c) respiratory status
A nurse is reviewing the medical record of a client who is scheduled for a CT scan with contrast media. Which of the following medication should the nurse instruct the client to withhold for 48 hours following the procedure?
a) Carvedilol
b) Furosemide
c) Metformin
d) Clopidrogel
c) Metformin
The nurse is caring for a client who has pancreatitis and has been receiving Total parenteral Nutrition. Which of the following Laboratory test should the nurse monitor for overall nutritional
status?
a) creatinine
b) Prealbumin
c) Lipase
d) C-reactive protein
b) Prealbumin
A nurse is teaching a client who has endometriosis about the adverse effects of leuprolide. Which of the following manifestations should the nurse include in the teaching?
a) Pallor
b) increased appetite
c) bone loss
d) hypoglycemia
c) bone loss
A nurse is planning the discharge of a client who had an ischemic stroke. The nurse should ensure that the client is discharged with which of the following types of pharmacologic therapy?
a) Opioid analgesic
b) Anticonvulsant
c) anti thrombotic
d) diuretic
c) anti thrombotic
A nurse is caring for a client who has a new colostomy the nurse notes that the client appears withdrawn and looks away during ostomy care. Which of the following actions should the nurse take?
a) Ask the client how they feel about the stoma
b) make a referral for the client to see an ostomy nurse
c) include the clients partner in stoma care education
d) educate the client about expected stoma appearance
a) Ask the client how they feel about the stoma
A nurse is preparing to perform ocular irrigation for a client following a chemical Splash to the eye. Which of the following actions should the nurse plan to take first?
a) Administer proparacaine eye drops into the affected eye
b) Place strip of pH paper on to the cul-de-sac of the affected eye
c) collect information about the irritant that caused an injury
d) instill 0.9% sodium chloride solution into the affected eye
d) instill 0.9% sodium chloride solution into the affected eye
A nurse is teaching a client who has AIDS and wishes to continue self care at home despite living alone. Which of the following actions by the nurse demonstrates client advocacy?
a) Remind the client of the importance of the medication adherence
b) Initiate a referral for the client to a home health agency
c) instruct the client to avoid eating raw vegetables
d) tell the client to avoid places where there are a large crowds of people
b) Initiate a referral for the client to a home health agency
A nurse is assessing a client who has cirrhosis. Which of the following findings is the priority for the nurse to report?
a) Alkaline phosphate 125 units /L
b) clay-colored stools
c) platelets 70,000 / mm3
d) distended abdomen
c) platelets 70,000 / mm3
A home health nurse is providing nutrition education for a client who has trigeminal neuralgia. Which of the following foods should the nurse recommend?
a) Graham crackers
b) iced coffee
c) vanilla pudding
d) vegetable soup
c) vanilla pudding
A nurse is caring for a client who has cancer. The client tells the nurse, “I would prefer to try vitamins and minerals instead of chemotherapy” which of the following responses should the nurse make?
a) I have never heard of any holistic treatment that is effective
b) you should ask your provider about your plan
c) the best way to treat your cancer is chemotherapy
d) tell me what you know about chemotherapy
d) tell me what you know about chemotherapy
A nurse is caring for a client following a total knee arthroplasty. The client reports a pain level on a pain scale of 0 to 10. Which of the following interventions should the nurse take?
A. Place pillows under the client’s knee
B. Gently massage the area around the client’s incision
C. Apply an ice pack to the client’s knee
D. Perform range-of-motion exercises to the client’s knee
C. Apply an ice pack to the client’s knee
Avoid knee gatch and pillows placed behind the knee.
Apply ice or cold therapy to the incisional area to reduce postoperative swelling.
a nurse is planning to teach a client whose provider has prescribed a low purine diet. The nurse should plan to instruct the client that he can include which of the following Foods in his diet ( select all that apply)
a) Sardines
b) Nuts
c) Apricots
d) liver
e) scallops
b) Nuts
c) Apricots
A nurse is assessing a client who is preoperative and reports an allergy to bananas. The nurse should recognize that the client is at risk for an allergic cross-reactivity to which of the following substances
A. Povidone-iodine
B. Adhesive tape
C. Latex
D. Anesthetics
C. Latex
Latex: allergy
Kiwi
Stawberry
Banana
A nurse on a medical unit is planning care for a group of clients. Which of the following clients should the nurse attend to First?
a) A client who has chronic obstructive pulmonary dis- ease in oxygen saturation of 89%
b) a client who has left-sided paralysis and slurred speech from a prior stroke
c) a client who has thrombocytopenia and reports a nose- bleed
d) a client who has multiple sclerosis and reports Ataxia and vertigo
c) a client who has thrombocytopenia and reports a nose- bleed
- A nurse is monitoring a client who is receiving two units packed RBC’s. Which of the following manifestation indicates a hemolytic transfusion reaction?
a) back pain
b) Hypertension
c) Chills
d) bradycardia
c) Chills
A nurse is teaching a client who has diabetes mellitus about foot care. Which of the following instruction should the nurse include?
a) Use a heating pad to keep your feet warm at night
b) wear loose-fitting slippers around the house
c) where cotton rather than nylon socks
d) wash your face twice per day with antibacterial soap and hot water
c) where cotton rather than nylon socks
A nurse is providing teaching to a client who has a deep vein thrombosis (DVT) . Which of the following findings should the nurse identify as a risk factor for the development of the DVTs?
a) NSAID use
b) hypertension
c) oral contraceptive use
d) cirrhosis
c) oral contraceptive use
A nurse is administering furosemide 80 mg PO twice-daily to a client who has pulmonary edema. Which of the following assessment findings indicates to the nurse that the medication is effective?
a) Respiratory rate of 24 / min
b) adventitious breath sounds
c) weight loss of 1.8 kg (4 lb) in the past 24 hours
d) elevation in blood pressure
c) weight loss of 1.8 kg (4 lb) in the past 24 hours
A nurse is preparing to administer furosemide to a client who has acute heart failure. Which of the following laboratory results should the nurse identify as a contradiction for receiving the medication?
a) Creatinine 0.8 mg / DL
b) sodium 136 meq / L
c) potassium 3.2 meq / L
d) bun 18 mg / DL
c) potassium 3.2 meq / L
A nurse on an oncology unit is caring for a client who is receiving internal radiation therapy. Which of the following actions should the nurse take?
a) Place the dosimeter film badge on a client’s door
b) wear a lead apron when providing client care
c) leave the door to the clients room open
d) allow visitors to hold the clients hand
b) wear a lead apron when providing client care
A nurse is caring for a client who has diabetes mellitus and has been following a treatment plan for 3 months which of the following results should the nurse monitor to determine long-term glycemic control?
a) Glycosylated hemoglobin level
b) fasting blood glucose level
c) oral glucose tolerance test results
d) post-prandial blood glucose level
a) Glycosylated hemoglobin level
A nurse is reviewing the plan of care for a client who has a seizure disorder. Which of the following interventions should the nurse anticipate including in the plan? (click on the exhibit button for additional information about the client)
a) place the client in a private room
b) Hold the client’s phenytoin
c) check the client’s stool for occult blood
d) administer regular insulin to the client
b) Hold the client’s phenytoin
LIVER TOXIC (ANTICONVULSANTS)
-PHENYTOIN THERAPEUTIC LEVEL MAY BE HIGH
THERAPUTIC RANGE IS (10-20MCG
TOXIC IS 30MCG
A nurse is preparing to administer two units of packed rbc’s to a client. Which of the following actions should the nurse take?
a) Transfuse each unit of blood over five hours
b) change the IV tubing after each unit of blood is trans- fused
c) administer the blood through a 22 gauge intravenous catheter
d) Prime the tubing with 0.9% sodium chloride
d) Prime the tubing with 0.9% sodium chloride
A nurse is caring for a client who has chronic renal failure. The client displays the following ABG results: pH: 7.24 paCO2: 44 mm Hg, paO2 : 84 mmHg, HCO3 : 18 meq/ L base excess - 2 and O2 saturation 95% The nurse should include that the client has which of the following acid-base balances ?
a) Metabolic alkalosis
b) respiratory acidosis
c) respiratory alkalosis
d) metabolic acidosis
d) metabolic acidosis
A nurse is assessing a client who has heart failure which of the following client statements should indicate to the nurse that the client needs a referral for cardiac rehabilitation?
a) I hate how I feel all the time
b) I am too tired to brush my teeth
c) I Will Weight myself daily
d) I need to start eating a low sodium diet
b) I am too tired to brush my teeth
A nurse is caring for a client who is receiving contin- uous bladder irrigation following a transurethral resection of the prostate.The client reports bladder spasms and the nurse observes decreased urinary output. Which of the following actions should the nurse take?
a) Remove the indwelling urinary catheter
b) decrease transaction of the catheter
c) flush the catheter manually with 0.9% sodium chloride
d) administer ibuprofen 400 mg for pain relief
c) flush the catheter manually with 0.9% sodium chloride
A nurse is discussing nutrition options with a client who has a new diagnosis of COPD. Which of the following statements should the nurse take?
a) Plan to include high-protein foods in each of your meals
b) increase your intake of vegetables such as broccoli and brussel sprouts
c) drink a glass of milk with each meal
d) consume three large meals throughout the day
a) Plan to include high-protein foods in each of your meals
A nurse is caring for a client who has bounding pulses, crackles on auscultation, and pink frothy secretions when receiving suction. The nurse should recognize these as- sessment findings us indicating which of the following?
a) Aspiration
b) increased cardiac output
c) pleural effusion
d) fluid volume excess
d) fluid volume excess
A nurse in a clinic is providing for preventive teaching to an older client during a Well Visit. The nurse should in- struct the client that which of the following immunizations are recommended for healthy adults after age 60 (select all that apply)
a) human papillomavirus
b) pneumococcal polysaccharide
c) Meningococcal
d) Influenza
e) herpes zoster
a) human papillomavirus
d) Influenza
e) herpes zoster
A nurse is caring for a client who has a traumatic brain injury. The client, who has been quiet and Cooperative, becomes agitated and Restless. Which of the following assessments should the nurse perform first?
a) Blood pressure (assess for increased intracranial pressure)
b) blood glucose
c) urinary output motor responses
d) constipation
a) Blood pressure (assess for increased intracranial pressure)
Nurse in the emergency department is caring for a client who was involved in an explosion. Which of the following actions should the nurse plan to take first question (click on the exhibit button for additional information about the client)
a) initiate peripheral IV access
b) obtain an ECG
c) notify the rapid response team
d) calculate the extent of burns using the rule of nines
a) initiate peripheral IV access
A nurse is assessing a client who has right-sided heart failure. Which of the following assessment findings should the nurse expect to find?
a) Oliguria
b) poor skin turgor
c) pitting edema
d) S3 - S4 Galloping heart sounds
c) pitting edema
nurse is providing a discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching?
A. “I will keep my left arm flexed at the elbow as much as possible” ?
B. “ I should expect less than 25 mL of secretions per day in the drainage devices
C. “I will perform strength building arm exercises using a 15 pound weight”
D. “ I will have to wait 2 months before additional saltine can be added to my breast
B. “ I should expect less than 25 mL of secretions per day in the drainage devices
A nurse is teaching the family of a client who has Alzheimer’s disease about caring for the client at home. Which of the following instructions should the nurse include?
A. Cover electrical outlets in the client’s home with tape.
B. Hang a monthly calendar in the client’s bedroom.
C. Keep the client’s bedroom dark at night.
D. Place a large-face clock in the client’s bedroom.
D. Place a large-face clock in the client’s bedroom.
A nurse is caring for a client who has a sealed radiation implant(BRACHYTHERAPY). Which of the following
actions should the nurse take?
a) Remove soiled linens from the room after each change
b) Give the dosimeter badge to the oncoming nurse at the end of the shift
c) Apply a second pair of gloves before touching the client’s implant if it dislodges
d) Limit family member visits to 30 min per day
d) Limit family member visits to 30 min per day
A nurse is caring for a client who is postoperative following a complete thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider?
a. Serosanguineous drainage
b. Muscle twitching
c. Client report of nausea
d. Client report incisional pain
b. Muscle twitching
A nurse is caring for a client who has cervical cancer and is receiving brachytherapy. Which of the following actions should the nurse take?
a. Keep the soiled bed linens in the client’s room
b. Instruct visitors to remain 3 feet from the client
c. Discard the radioactive device in the client’s trash can
d. Limit time for visitors to 2 hour per day
a. Keep the soiled bed linens in the client’s room
A nurse is caring for a client who has cervical cancer and a sealed radiation implant.
Which of the following actions should the nurse take?
a. Place long-handled forceps at the client’s bedside
b. Attach a dosimeter badge to the client’s gown
c. Leave unused equipment in the client’s room until discharge
d. Move the client’s soiled linens to a designated container outside the room
a. Place long-handled forceps at the client’s bedside
A nurse is caring for a client who is receiving epidural analgesics. Which of the following
assessment findings in the nurse’s priority?
a. Bladder distention
b. Hypoactive bowel sounds
c. Hypotension
d. Weakness to lower extremities
c. Hypotension
A nurse is planning care for a client who has status epilepticus. Which of the following
interventions is the nurse’s priority to include?
a. Turn the client to the lateral position during seizure activity
b. Provide the client oxygen at 6 l/min using a nasal cannula
c. Administer phenytoin IV bolus to the client
d. Administer diazepam intravenously to the client
c) turn the client to the lateral position during seizure activity
A nurse is caring for a client following a below-the knee amputation. The client states.
“my life is over.” Which of the following responses should the nurse make?
a. “you are upset. We can talk about this later?”
b. “would you like to meet with another client who is an amputee?”
c. “why do you think your life is over?”
d. “most people can adjust following this surgery”
b. “would you like to meet with another client who is an amputee?”
A nurse is assessing a client who has a new diagnosis of type 1 diabetes mellitus.
Which of the following findings indicates that the client is experiencing hypoglycemia?
a. Abdominal cramping
b. Increased perspiration
c. Dehydration
d. Fruity odor to breath
b. Increased perspiration
A nurse in the PACU is assessing a client who is postoperative following general
anesthesia. Which of the following findings is the priority to address?
a. Vomiting upon arousal
b. Decreased body temperature
c. Indistinct, rambling speech
d. Piloerection of the skin
a. Vomiting upon arousal
A nurse is caring for a client who has hypervolemia. Which of the following is an
expected assessment finding?
a. Bradycardia
b. weight gain
c. Increased perspiration
d. Hypotension
b. weight gain
A nurse is caring for a client following a cardiac catheterization who has hives and urticaria following administration of IV contrast dye. Which of the following medications should the nurse plan to administer?
a. Spironolactone
b. Desmopressin
c. Metoclopramide
d. Diphenhydramine
d. Diphenhydramine
A home care nurse is planning to use nonpharmacological pain relief measures for an older adult client who has severe chronic back pain. Which of the following guidelines
should the nurse use?
a. Discontinue opioids before trying nonpharmaco- logical methods of pain relief
b. Use imagery with clients who have difficulty with focus and concentration
c. Distraction changes the client’s perception of pain, but does not affect the cause
d. Pain relief from the use of heat and cold continues for several hours after removal of the stimulus
c. Distraction changes the client’s perception of pain, but does not affect the cause
A nurse is caring for a female client who is receiving a. Crackles in total parental nutrition without fat for the bilateral lung emulsion. Which of the following findings should the bases nurse report?
a. Crackles in the bilateral lung bases
b. Weight gain of 1.3 kg (3lb) over the past 7 days
c. Triglyceride 110 mg/dl
d. Bowel sounds absent in lower quadrants
a. Crackles in the bilateral lung bases
A nurse is caring for an older adult client who has dementia. Which of the following
questions should the nurse ask to assess the client’s abstract thinking?
a. “can you count backwards from 100 intervals of 7?”
b. “what is meant by the saying, don’t beat around the brush?
c. “what do you understand about your condition?”
d. “can you tell me the state where you were born?”
b. “what is meant by the saying, don’t beat around the brush?
A nurse is planning care for a client who has devel- oped nephrotic syndrome. Which of the following dietary recommendations should the nurse include?
a. Increase phosphorus intake
b. Decrease protein intake
c. Increase potassium intake
d. Decrease carbohydrate intake
b. Decrease protein intake
A nurse is preparing to administer 1 unit of packed RBCs to an adult client. Which of the
following actions should the nurse plan to take?
a. Administer through a 22-gauge IV catheter
b. Prime the IV tubing with 0.45% sodium chloride
c. Complete the transfusion within 2 hour
d. Slow the transfusion rate if the client reports itching
c. Complete the transfusion within 2 hour
A nurse is admitting a client to the emergency depart- ment after a gunshot wound to the abdomen. Which of the following actions should the nurse take to help prevent the
onset of acute kidney failure?
a. Initiate beta blocker therapy
b. Insert a urinary catheter
c. Prepare the client for an intravenous pyelogram
d. Administer IV fluids to the client
d. Administer IV fluids to the client
A nurse is planning care for an older adult client who has Meniere’s disease. Which of
the following interventions should the nurse include in the plan?
a. Perform range-of-motion exercises to the client’s neck every 4 hour
b. Limit the client’s fluid intake to 1,500 ml/day
c. Encourage the client to change positions slowly
d. Administer aspirin if the client reports a headache
c. Encourage the client to change positions slowly
A nurse is caring for an adolescent client who has an acute kidney injury. Which of the following laboratory findings should the nurse antic- ipate?
a. BUN 8 mg/dl
b. Hgb 20 g/dl
c. Potassium 6.8 mEq/l
d. Creatinine 0.4 mg/dl
c. Potassium 6.8 mEq/l
A nurse is assessing an older adult client at a health fair. Which of the following statements by the client is the nurse’s priority?
a. “I can’t seem to get reading materials far enough away to see the words”
b. “I’m having more difficulty telling the difference between blues and greens”
c. “I’ve noticed that there is a gray ring around the colored part of my eye”
d. “In the last day, I have had a severe headache and pain around my right eye”
d. “In the last day, I have had a severe headache and pain around my right eye”
What belongs with HHS VS DKA
KEY
-FRUITY ORDOR BREATH
-SEIZURE ACTIVITY
-NAUSEA
-REVERSIBLE PARALYSIS
HHS
-
HHS
-SEIZURE ACTIVITY
- REVERSIBLE PARALYSIS
DKA
-NAUSEA
-FRUITY ODOR BREATH
A nurse is caring for a client who has duodenal ulcer. Which of the following actions
should the nurse take? Exhibit
a. Restrict the client’s fluid intake to 1,000 ml/day
b. Infuse packed RBCs
c. Administer the client’s naproxen prescription
d. Offer a snack before bedtime
b. Infuse packed RBCs
A nurse is admitting a client to a medical unit follow- ing placement of a permanent pacemaker. Which of the following findings requires further assessment by the nurse?
A. sneezing
b. Hiccups
c. Presence of a sharp spike prior to the QRS complex on the ECG
d. Presence of intrinsic P waves following a QRS complex on the ECG
b. Hiccups
hiccups indicate the pace maker is pacing the diaphragm instead of the heart
A nurse is reviewing ABG results for a client who has COPD. Which of the following
findings should the nurse expect?
a. pH 7.38
b. PaO2 85 mm Hg
c. PaCO2 48 mm Hg
d. HCO3- 25 mEq/l
c. PaCO2 48 mm Hg
A nurse is instructing a client who has a new diagnosis of type 1 diabetes mellitus about
the sick-day rules. Which of the following statements by the client indicates an understanding of the teaching?
a. “I will monitor my blood glucose every 8 hours”
b. “I will consume 250 grams of carbs daily while I’m sick”
c. “I will not take my diabetes medications while I am sick”
d. “I will check urine for ketones if my blood glucose is greater than 240 mg/dl
d. “I will check urine for ketones if my blood glucose is greater than 240 mg/dl
A nurse is developing a plan of care for a client who is returning from the PACU following a left below-the-knee amputation. Which of the following interventions should
the nurse include in the plan?
a. Provide the client with a firm mattress
b. Wrap the client’s residual limb with elastic bandage in a distal to proximal direction
c. Place the client’s residual limb in a dependent po- sition when possible
d. Keep the client in a supine position for 48 hours
b. Wrap the client’s residual limb with elastic bandage in a distal to proximal direction
-PRONE POSISTIONING
Do lie on a firm bed or couch.
-Do not put a pillow under your residual limb.
-Do not put pillows between your thighs.
-Do not cross your legs *
-Do not let your residual limb hang over the edge of the bed or couch
A nurse is caring for a client following a bron- choscopy. Which of the following actions should the nurse take first?
a. Check the client’s gag reflex
b. Inform the client they might experience a low-grade fever
c. Instruct the client to report bleeding
d. Provide the client with sips of water
a. Check the client’s gag reflex
A nurse in the emergency department is caring for a client who has a gunshot wound to the abdomen. Which of the following actions should the nurse take first?
a. Check the color of the client’s skin
b. Remove all of the client’s clothing
c. Administer an opioid analgesic
d. Prepare the client for periorbital lavage
a. Check the color of the client’s skin
A nurse is planning care for a client who has a central venous access device for intermittent infusions. Which of the following actions should the nurse include in the plan of care?
a. Flush the catheter using a 10ml syringe
b. Change the dressing every 24 hour
c. Use clean technique when changing the dressing
d. Cleanse the site with povidone-iodine
a. Flush the catheter using a 10ml syringe
A nurse is caring for a client who sustained a spinal cord injury in a diving accident.
Which of the following actions should the nurse take?
a. Assess the client’s neurological status every 8 hour
b. Monitor urine output hourly
c. Provide the client with a low-fiber diet
d. Log roll the client every 4 hour
b. Monitor urine output hourly
A nurse is planning care for a client who has unre- paired intertrochanteric fracture and has Buck’s traction placed to the affected leg. Which of the following interventions should the nurse include?
a. Situate the client’s heel in the heel of the traction boot
b. Apply weights of the traction to total 9.1 kg (20lb)
c. Place the footplate against the foot of the bed
d. Remove the boot for skin inspection every 12 hours.
a. Situate the client’s heel in the heel of the traction boot
A nurse is assessing a client who has arteriovenous (AV) graft in the left forearm. Which of the following findings should indicate to the nurse a complication of vascular access?
a. 2+ left radical pulse
b. Absence of a bruit
c. Presence of a palpable thrill
d. Dilated appearance of the AV site
b. Absence of a bruit
A client who is deaf and communicates using sign language is being admitted by a
nurse who does not know sign language.Which of the following actions should the nurse take?
a. Familiarize themselves with commonly used sign language
b. Ask a family member to be present during the admission
c. Obtain a board that uses colored pictures as com- munication
d. Request an interpreter during the initial assessment
d. Request an interpreter during the initial assessment
A nurse is providing discharge teaching to a client who will be self-administering insulin
at home. Which of the following information should the nurse include regarding needle
disposal?
a. “secure the cap tightly over the needle before you discard it”
b. “remove the needle from the syringe before you place it in the trash”
c. “you can discard needles in an empty bleach bottle with a lid”
d. “place your storage container in a recycle bin when it is full”
c. “you can discard needles in an empty bleach bottle with a lid”
A nurse is caring for a client admitted with a skull fracture. Which of the following
assessment findings should be of greatest concern to the nurse?
a. Bilateral pupil diameter changes from 4 to 2 mm
b. WBC count changes from 9,000 to 16,000/mm3
c. Pulse pressure changes from 30 to 20 mm Hg
d. Glasgow Coma Scale score changes from 14 to 9
d. Glasgow Coma Scale score changes from 14 to 9
A nurse is preparing to administer furosemide to a client who has acute heart failure. Which of the following laboratory results should the nurse identify as contraindications
for receiving the medications?
a. BUN 18 mg/dl
b. Creatinine 0.8 mg/dl
c. Potassium 3.2 mEq/l
d. Sodium 136 meEq/l
c. Potassium 3.2 mEq/l
A nurse is caring for a client who has hypotension, cool clammy skin, tachycardia, and tachypnea. In which of the following positions should the nurse place the client?
a. Reverse Trendelenburg
b. Feet elevated
c. High fowlers’
d. Side lying
b. Feet elevated
A nurse is providing instructions to a client who has primary syphilis. Which of the following instructions should the nurse include in the discharge plan?
a. “you will need cryotherapy for 1 to 2 weeks”
b. “you will need to take an antiviral medication for 6 months”
c. “you will need 3 follow-up blood tests within 24 month period”
d. “you will need to be monitored for 15 minutes after receiving each medication dose”
c. “you will need 3 follow-up blood tests within 24 month period”
tx for syphillis is pennicillin g
After the initial antibiotic, the CDC recommends follow-up evaluation, including blood tests at 6, 12, and 24 months. Repeat treatment may be needed if the patient does not respond to the initial antibiotic.
FROM MEDSURG BOOK
Benzathine penicillin G given IM as a single doseat the time of the initial visit with the health care provider is the evidence-based treatment for primary, secondary, and early latent syphilis
Allergic reactions to benzathine penicillin G can occur. Monitor for allergic signs and symptoms (e.g., rash, edema, shortness of breath, chest tightness, anxiety). Keep all patients at the health care agency for at least 30 minutes after they have received the antibiotic so signs and symptoms of an allergic reaction can be detected and treated. The most severe reaction is anaphylaxis. Treatment should be available and implemented immediately if symptoms occur.
A nurse is caring for a client who is postoperative following a partial thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider?
a. Client report of pain at the incision site
b. High-pitched sound on inspiration
c. Hypoactive bowel sounds
d. Loose tracheal secretions
b. High-pitched sound on inspiration
A nurse is caring for a client who has Parkinson’s disease and is prescribed a level 1
dysphagia diet. Which of the following items should the nurse remove from the client’s
tray?
a. Vanilla milkshake
b. Peanut butter
c. Chocolate pudding
d. Applesauce
b. Peanut butter
A nurse is caring for a client who is receiving contin- uous bladder irrigation following a
transurethral resection of the prostate (TURP). The client reports sharp lower abdominal
pain. Which of the following actions should the nurse first take?
a. Increase the client’s fluid intake
b. Reposition the client in bed
c. Check the client’s urine output
d. Administer PRN pain medication
c. Check the client’s urine output
A nurse is planning care for a client who has osteoarthritis of the knees. Which of the
following interventions should the nurse include in the plan?
a. Avoid using a topical salicylate cream
b. Administer acetaminophen for pain management
c. Place a large pillow under the client’s knees when resting
d. Apply an ice pack directly to client’s knees
b. Administer acetaminophen for pain management
A nurse is providing discharge teaching to a client who has tuberculosis. Which of the
following information should the nurse include in the teaching?
a. “You should wear an N95 respirator mask when you are at home”
b. “you will need to return in 2 weeks to provide a sputum specimen”
c. “You can drink alcohol after the first 6 weeks of treatment”
d. “Your provider will discontinue your medications after 3 months of therapy
b. “you will need to return in 2 weeks to provide a sputum specimen”
A nurse is caring for a client who has a history of chemotherapy-induced nausea and
vomiting. Which of the following medications should the nurse administer prior to
chemotherapy?
a. Ondansetron
b. Sertraline
c. Methylprednisolone
d. Diphenhydramine
a. Ondansetron
A nurse is performing an ear irrigation for a client. Which of the following actions should
the nurse take?
a. Use a cool fluid for irrigation
b. Insert the tip of the syringe 2.5cm (1in) into the ear canal
c. Tilt the client’s head 45 degrees
d. Point the tip of the syringe toward the top of the ear canal alternating between wound cares sites
d. Point the tip of the syringe toward the top of the ear canal alternating between wound cares sites
A nurse is providing teaching for a client who has tuberculosis and a new prescription
for pyrazinamide.The nurse should instruct the client to notify the provider if which of
the following adverse effects occurs?
a. Hair loss
b. Polyuria
c. Weight gain
d. Jaundice
d. Jaundice
A nurse is caring for a client who is receiving mechanical ventilation. Which of following
interventions should the nurse implement?
a. Empty water from the ventilator tubing daily
b. Suction the client’s airway every 4 hour
c. Maintain the client in supine position
d. Perform oral care every 2 hour
d. Perform oral care every 2 hour
A nurse is reviewing medications taken at home with a client who has angina. Which of
the following statements by the client indicates an understanding of the teaching?
a. “I should withhold my metoprolol if my heart rate is above 100 bpm”
b. “I should take my daily aspirin on an empty stom- ach”
c. “I should lie down before taking dose of isosorbide dinitrate”
d. “I should place a nitroglycerin tablet under my tongue every 10 minutes for up to four
doses”
c. “I should lie down before taking dose of isosorbide dinitrate”
A nurse is caring for a client who is caregiver for a relative who has chronic disease.
Which of the following statements indicates the client is adapting to the role change?
a. “I had to reschedule my doctor’s appointment last
b. I will expect my stools to be loose
c. “I’ve lost 15 pounds in the past 2 months”
d. “I need to get my blood pressure medicine refilled
d. “I need to get my blood pressure medicine refilled
A nurse is caring for a client who is 6 hr postoperative following a thyroidectomy. The
client reports tingling and numbness in the hands. The nurse should identify this as a
sign of which of the following electrolyte imbalances?
a. Hypocalcemia
b. Hypokalemia
c. Hypermagnesemia
d. Hypernatremia
a. Hypocalcemia
A nurse is caring for a client who is receiving total parental nutrition through a central
line. The current bag is nearly empty, and a new bag is unavailable from the pharmacy.
Which of the following actions should the nurse take?
a. Switch the infusion to a 10% dextrose solution
b. Discontinue the infusion and flush the line
c. Decrease the rate of infusion to last until the new bag is available
d. Start an infusion of 0.45% sodium chloride solution
Which of the following actions should the nurse take?
a. Switch the infusion to a 10% dextrose solution
A nurse is providing discharge teaching to a client who has an ileostomy. Which of the
following client statements indicates an understand- ing of the teaching?
a. “I will expect my stools to be loose”
b. “I will eat a high fiber diet’
c. “I will take a laxative when I’m constipated” d. “I will empty my bag when it is full”
a. “I will expect my stools to be loose”
A nurse is caring for a client who has an arteriove- nous graft. Which of the following
findings indicates adequate circulation of the graft?
a. Dilated appearance of the graft
b. Absence of a bruit
c. Normotensive blood pressure
d. Palpable thrill
d. Palpable thrill
A nurse is assessing a client who has heart failure and is receiving a loop diuretic.
Which of the following findings indicates hy- pokalemia?
a. Oliguria
b. Hypertension
c. Muscle weakness
d. Positive chvostek’s sign
c. Muscle weakness
A nurse in the emergency department is caring for a client who is in hypovolemic shock.
Which of the following actions should the nurse take first?
a. Obtain a blood specimen for type and crossmatch
b. Insert a large-bore IV catheter
c. Administer IV therapy
d. Monitor urine output
b. Insert a large-bore IV catheter
A nurse is providing discharge teaching to a client who is recovering from a sickle cell
crisis. Which of the following instructions should the nurse include?
a. Avoid extremely hot or cold temperatures
b. Limit fluids to 1.5 L per day
c. Limit alcohol intake to one drink per day
d. Avoid getting a flu vaccination
a. Avoid extremely hot or cold temperatures
A nurse is planning care for a client who has pul- monary embolism. Which of the
following interventions should the nurse include?
a. Initiate a continuous IV heparin infusion
b. Instruct the client to massage the lower extremities
c. Position the client on the left side
d. Measure vital signs every 4 hour
a. Initiate a continuous IV heparin infusion
A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of
the following findings should the nurse expect?
a. Hypothermia
b. Urine specific gravity 1.001 (<1.005)
c. Elevated blood pressure
d. BUN 15 mg/dl
b. Urine specific gravity 1.001 (<1.005)
A nurse is reviewing the laboratory reports of a client who has acute pancreatitis. Which
of the following findings should the nurse expect?
a. Elevated serum calcium
b. Elevated blood glucose
c. Decreased serum amylase
d. Decreased erythrocyte sedimentation rate
b. Elevated blood glucose
A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)?
a. Loss of peripheral vision
b. Deviation of the tongue from midline
c. Disequilibrium with movement
d. Inability to smell
c. Disequilibrium with movement
A nurse is preparing to perform ocular irrigation for a client following chemical splash to the eye. Which of the following actions should the nurse plan to take first?
a. Instill 0.9% sodium chloride solution into the affected eye
b. Administer proparacaine eyedrops into the affected eye
c. Collect information about the irritant that caused the injury
D. the medication is not expired
d) instill 0.9% sodium chloride solution into the affected eye
A nurse is providing discharge teaching to a client who has heart failure and instructs
him to limit sodium intake to 2 g per day.Which of the following statements by the client
indicates an understanding of the teaching?
a. “I can season my foods with garlic and onion salts”
b. “I can have mayonnaise on my sandwiches”
c. “I can have a frozen fruit juice bar for dessert”
d. “I can drink vegetable juice with a meal”
c. “I can have a frozen fruit juice bar for dessert”
A critical care nurse is assessing a client who has severe head injury. In response to
painful stimuli, the client does not open her eyes, displays decerebrate posturing, and
makes incomprehensible sounds. Which of the fol- lowing Glasgow Coma Scale scores
should the nurse assign the client?
a. 5
b. 2
c. 13
d. 10
a. 5
A nurse is preparing to administer a unit of packed RBCs to a client who is anemic.
Identify the sequence of steps the nurse should fol- low.
a. Obtain venous access using 19-gauge needle
b. Obtain the unit of packed RBCs from blood bank
c. Verify blood compatibility with another nurse
d. Initiate transfusion of the unit of packed RBCs
e. Remain with the client for the first 15 to 30 min of the infusion
a. Obtain venous access using 19-gauge needle
b. Obtain the unit of packed RBCs from blood bank
c. Verify blood compatibility with another nurse
d. Initiate transfusion of the unit of packed RBCs
e. Remain with the client for the first 15 to 30 min of the infusion
A nurse is caring for a client who is scheduled for a mastectomy. The client tells the
nurse, “I’m not sure I want to have a mastectomy.” Which of the following statements
should the nurse make?
a. “I can give you a list of other people who had the same procedure”
b. “You will be cancer-free if you have the procedure”
c. “I can give you additional information about the procedure”
d. “You should should get a second opinion regarding the procedure”
c. “I can give you additional information about the procedure”
A nurse in the emergency department is assessing a client. The patient presents with night sweats and low grade fever. Which of the following actions should the nurse take first?
a. Obtain a sputum sample for culture
b. Administer ondansetron
c. Initiate airborne precautions
d. Prepare the client for a chest x-ray
c. Initiate airborne precautions
A nurse is reviewing the medical record of a client to identify risk factors for colorectal cancer.The nurse should identify which of the following findings as increasing the
client’s risk?
a. History of Crohn’s disease
b. BMI of 24
c. Diet high in fiber
d. Age 46 years
a. History of Crohn’s disease
A home health nurse is making an initial visit to a client who has multiple sclerosis.
Which of the following actions is the priority for the nurse to take?
a. Discuss recommendations for eating and swallowing techniques
b. List strategies for family coping when dealing with possible role changes
c. Review the use of adaptive grooming devices to promote client independence
d. Give the client information about the local national multiple sclerosis society
a. Discuss recommendations for eating and swallowing techniques
A nurse is completing an assessment of an older adult client and notes reddened areas
over the bony prominences, but the client’s skin is intact. Which of the following
interventions should the nurse include in the plan of care?
a. Turn and reposition the client every 4 hr
b. Apply an occlusive dressing
c. Support bony prominences with pillows
d. Massage the reddened areas three times a day
c. Support bony prominences with pillows
A nurse is caring for a client who has a central venous access device and notes the tubing has become disconnected. The client develops dyspnea and tachycardia. Which of the following actions should the nurse take first?
a. Perform an ECG
b. Obtain ABG values
c. Turn the client to his left side
d. Clamp the catheter
d. Clamp the catheter
A nurse is taking an admission history from a client who reports Raynaud’s disease. Which of the following assessment findings should the nurse identify as a potential trigger for exacerbations
of Raynaud’s?
a. Eating a strict vegetarian diet
b. A history of herpes zoster
c. Taking amiodipine for hypertension
d. Using a nicotine transdermal patch
d. Using a nicotine transdermal patch
A nurse in a clinic receives a phone call from a client who recently started therapy with
an ACE inhibitor and reports a nagging dry cough. Which of the following responses by
the nurse is appropriate?
a. “your cough may require that you stop or change your medication”
b. “Increasing your daily fluid intake may eliminate your cough”
c. “sucking on lozenge may reduce the frequency of your cough”
d. You cough should go away in time”
a. “your cough may require that you stop or change your medication”
A nurse is caring for a client who has a contusion of the brainstem and reports thirst. The client’s urinary output was 4,000 ml over the past 24 hour. The nurse should
anticipate a prescription for which of the following IV medication?
a. Desmopressin
b. Epinephrine
c. Furosemide
d. Nitroprusside
a. Desmopressin
A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration?
a. Pitting, dependent edema
b. Distended jugular veins
c. Increased BP
d. Decreased BP
d. Decreased BP
A nurse is caring for a client who has a lower extremity fracture and a prescription for crutches. Which of the following client statements indicates that the client is adapting to their role change?
a. I will need to have my partner take over shopping for groceries and cooking the meals for us
b. These crutches will make it impossible to care for my child
c. I feel bad that I have to ask my partner to keep the house clean
d. Its going to be difficult to tell my parents I cant take them to their appointments
anymore
a. I will need to have my partner take over shopping for groceries and cooking the meals for us
A nurse is planning care for a client following a cardiac catheterization. Which of the
following actions should the nurse take?
a. Keep the client on bed rest for 24 hours
b. Limit the client’s fluid intake to 1 l per day
c. Maintain the client’s affected extremity in extension
d. Change the client’s dressing every 8 hour
c. Maintain the client’s affected extremity in extension
A nurse is providing discharge teaching to an older adult client following a left total hip arthroplasty. Which of the following instructions should the nurse include in the teaching?
a. Clean the incision daily with hydrogen peroxide
b. You can cross your legs the ankles when sitting down
c.You should use an incentive spirometer every 8 hours
d. Install a raised toilet seat in your bathroom
d. Install a raised toilet seat in your bathroom
A nurse is providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following client statements indicates an understanding of the teaching?
a. I can keep my medications for 1 year before replacing it
b. I should lie down when I take this medication
c. I should discontinue this medication if I develop a headache
d. I can take up to five tablets in 15 minutes before seeking medical attention
b. I should lie down when I take this medication
A nurse is preparing to administer lactated ringer’s via continuous IV infusion at 200 ml/hr. The IV tubing has a drop factor of 10 drops/ml. How many gtt/min should the nurse set the IV pump to administer? Round to near whole number.
A. 10
B. 22
C. 33
D. 4
C. 33
A nurse in an emergency department is preparing to perform an ocular irrigation for a
client. Which of the following actions should the nurse plan to take?
a. Assess the client’s visual acuity prior to irrigation
b. Have the client turn their head toward the unaffected eye
c. Hold the irrigator syringe 3.81 cm (1.5 in) above the eye
d. Perform the irrigation with sterile water for irrigation
d. Perform the irrigation with sterile water for irrigation
A nurse is reviewing the lab results of a lumbar puncture for a client who has manifestations of bacterial meningitis. Which of the following findings should the nurse expect?
A. Elevated glucose
B. Elevated protein
C. Presence of RBCs
D. Presence of D-dimer
B. Elevated protein
A nurse is assessing a client with a closed head injury who has received mannitol for manifestations of increased intracranial pressure (ICP). Which of the following findings indicates that the medication is having a therapeutic effect?
A.The client’s serum osmolarity is 310 mOsm/L.
B.The client’s pupils are dilated.
C.The client’s heart rate is 56/min.
D.The client is restless.
A.The client’s serum osmolarity is 310 mOsm/L.
A nurse is planning care for a client who has AIDS and has developed stomatitis. Which of the following interventions should the nurse include in the plan of care?
A.Rinse the mouth with chlorhexidine solution every 2 hr
B.Limit fluid intake with meals
C.Provide oral hygiene with a firm-bristled toothbrush after each meal
D.Avoid salty food
D.Avoid salty food
A nurse is caring for a client with Clostridium difficile who has contact-isolation
precautions in place. Which of the following actions should the nurse perform?
A.Instruct visitors to maintain a distance of at least 1 m (3 ft) from the client.
B.Wash hands with antimicrobial soap after leaving the client’s room.
C.Use dedicated equipment for the client.
D.Keep the doors to the client’s room closed at all times
C.Use dedicated equipment for the client.
For which patient would the nurse wash her hands with soap and water instead of using and alcohol-based hand rub?
A. Administering pills to a patient with HIV
B. Cleaning stool off of a patient with Clostridium difficile
C.Taking the temperature of a patient with asthma
D. Opening a cup of milk for a patient with vertigo
B. Cleaning stool off of a patient with Clostridium difficile
Incentive Spirometry instructions, which teaching is correct?
A. Blow into spirometer to elevate the balls in the device
B. cough deeply after each use
C. clean the mouthpiece with an alcohol swab after each use
D. use the spirometer every 8 hr.
B. cough deeply after each use
A nurse is planning care for a client who has dementia. Which of the following
interventions should the nurse plan to include?
a. Assist the client with toileting at least once every 4 hours.
b. Request a prescription for a nightly sedative.
c. Place the client’s bed at the lowest height.
d. Turn off all lights in the client’s room at night.
c. Place the client’s bed at the lowest height.
When the low-pressure alarm sounds. which of the following situations should the nurse recognize as a possible
cause of the alarm?
A.) Excess secretions
B.) Kinks in the tubing
C.) Artificial airway cuff (leak)
D.) Biting on the endotracheal tube
C.) Artificial airway cuff (leak)
The use of incentive spirometer. Which teaching is correct?
a. Position the mouthpiece 2.5cm (1 in) from the mouth (put in your mouth)
b. Place hands on the upper abdomen during inhalation (no hold spirometer)
c. Hold breaths about 3-5 secs before exhaling (repeat)
d. Exhale slowly through purse lips
d. Exhale slowly through purse lips
What drainage device uses gravity?
A. Penrose
B. Jackson pratt
C. Hemovac
D. Wet to dry
A. Penrose
A nurse in the post-anesthesia care unit is assessing a client following an
appendectomy and finds a 2-cm (3/4in) area of blood on the postoperative dressing. Which of the following actions should the nurse take?
a. Apply pressure
b. Loosen the dressing
c. Circle the drainage
d. Apply a new dressing
c. Circle the drainage
A nurse is teaching a female client who has a new diagnosis of Systemic Lupus Exacerbation(SLE) . The nurse should determine that the client needs more teaching when she identifies which of the following as a factor that can exacerbate SLE?
A.Pregnancy,
B.sunlight
C. Infection
D.Exercise
D.Exercise
A nurse is caring for a female patient who has toxic shock syndrome. Which of the of findings should the nurse expect?
A.Generalized rash
B. Pulmonary edema
C. Pneumonia
D. Deep vein thrombosis
A.Generalized rash
high fever.
chills.
malaise (uneasiness and despair)
headache.
fatigue.
a red, flat rash that covers most of the areas of the body.
low blood pressure.
vomiting.
A nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan of
care?
a. Place pillows under the client’s knees
b. Apply compression stockings to the lower extremities
c. Avoid use of anticoagulants
d. Discourage leg exercises while in bed
b. Apply compression stockings to the lower extremities
A nurse is preparing a patient for an ECG. The patient is anxious and says that he is afraid the equipment will give him an electric shock. Which of the following is an appropriate response by the nurse?
A. The machine only senses and records electrical currents coming from your heart.
B. The machine will need to be inserted surgically
C. This is a life long equipment used to pace your heart
D. This device will shock you if you heart rate falls below 60 beats per minute
A. The machine only senses and records electrical currents coming from your heart.
A nurse is caring for a client who experienced extensive burns to the arms and torso. Which of the following actions should the nurse take regarding the client’s oral nutritional intake?
a. Adhere to scheduled meal times three times daily
b. Encourage the client to eat as many calories as possible
c. Limit the client’s fluid intake to 1,500 ml/day
d. Avoid the use of supplemental feedings throughout the day
b. Encourage the client to eat as many calories as possible
A nurse is caring for a client who has a full-thickness burn injury covering 15% of theirbody. Which of the following actions should the nurse take?
a. Weigh the client once per week
b. Provide the client with a protein intake of 1g/kg/day
c. Maintain a daily count of the client’s calorie intake
d. Place the client on a low-carb diet
c. Maintain a daily count of the client’s calorie intake
A nurse is caring for a client who has a history of chemotherapy-induced nausea and
vomiting. Which of the following medications should the nurse administer prior to chemotherapy?
a. Ondansetron
b. Sertraline
c. Methylprednisolone
d. Diphenhydramine
a. Ondansetron
A nurse is planning care for a client who has left-sided hemiplegia following a stroke.
Which of the following actions should the nurse include in the plan of care?
a. Position the bedside table on the client’s left side
b. Place the plate guard on the client’s meal tray
c. Provide the client with a short handled reacher
d. Remind the client to use a cane on left side while ambulating
b. Place the plate guard on the client’s meal tray
A nurse is planning care for a client who has full-thickness burns on the lower extremities.
Which of the following interventions should the nurse include?
A.Provide a diet of fresh fruits and vegetables for the client.
B.Limit visitation time for the client’s children to 40 min per day.
C. Clean the equipment in the client’s room once per week.
D.Apply new gloves when alternating between wound care sites.
D.Apply new gloves when alternating between wound care sites.
-sterile gloves
which one of these clinical assessment findings should the nurse document and report for a client who has a
diagnosis of right sided heart failure indicating a complication with cardiac perfusion?
a. peripheral edema, ascites, JVD (splenomegaly and hepatomegaly)
b. weight gain, crackles, JVD
c. periorbital edema, moist cough, ascites
d. frothy, pink sputum, RR - 30, anxious
a. peripheral edema, ascites, JVD (splenomegaly and hepatomegaly)
A nurse is planning care for a client who has developed nephrotic syndrome. Which of
the following dietary recommendations should the nurse include?
a. Increase phosphorus intake
b. Increase potassium intake
c. Decrease carbohydrate intake
d. Decrease protein intake
d. Decrease protein intake
A nurse is caring for a client who has a contusion of the brainstem and reports
thirst. The client’s urinary output was 4,000 mL over the past 24 hr. The nurse
should anticipate a prescription for which of the following IV medications?
A. Desmopressin
B. Acetaminophen
C. Levothyroxinie
D. Albuterol
A. Desmopressin
A nurse is caring for a client immediately following a cardiac catheterization with a femoral artery approach. Which of the following actions should the nurse take?
A.Check pedal pulses every 15 min.
B. Insert indwelling catheter
C. Inititave intravenous line
D. place patient in Trensdelenburg
A.Check pedal pulses every 15 min.
A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of 7/min. The arterial blood
gas (ABG) values include: pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Oxygen saturation 80% Bicarbonate 28 mEq/L
Which of the following interpretations of the ABG values should the nurse make ?
A. Respiratory acidosis
B. Metabolic Acidosis
C. Normal
D. Respiratory Alkalosis
A. Respiratory acidosis
A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The client reports sharp lower abdominal
pain. Which of the following actions should the nurse first take?
a. Increase the client’s fluid intake
b. Reposition the client in bed
c. Check the client’s urine output
d. Administer PRN pain medication
c. Check the client’s urine output
A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction. Which of the following actions should the nurse take?
A. Ensure the client’s weights are hanging freely from the bed.
B. Change prescribed weights
C. make sure the weights are touching the ground
D. Do no assess drainage around pins
A. Ensure the client’s weights are hanging freely from the bed.
A nurse is caring for a client is who is 4 hr postoperative following a
transurethral resection of the prostate (TURP). Which of the following is
the priority finding for the
nurse report to the provider?
A. Thick, red-colored urine
B. sangeounous urine
C. clear urine
D. yellow cloudy urine
A. Thick, red-colored urine
A nurse is teaching a client who has Graves’ disease about recognizing the manifestations of the thyroid storm. Which of the following findings should the nurse include in the teaching?
a. Increased temperature
b. Decreased HR
c. Hypotension
d. Lethargy:
a. Increased temperature
A nurse is caring for a client who is post-op following a complete thyroidectomy.
Which of the following findings is the priority for the nurse to report to the provider?
A. Serosanguinous drainage.
B Client report of incisional pain.
C. Client report of nausea.
D.Muscle twitching
D.Muscle twitching
A nurse is preparing to discharge a client who has a halo device and is reviewing new
prescription from the provider. The nurse should clarify which of the following
prescriptions with the provider?
A.Take tub baths instead of showers.
B.May place a small pillow under the head when sleeping.
C.Increase intake of fiber-rich foods.
D.May operate a motor vehicle when no longer taking analgesics.
D.May operate a motor vehicle when no longer taking analgesics.
A nurse is assessing a client following extubation from a ventilator. For which of
the following findings should the nurse intervene immediately?
A.Sa02 92%
B. Stridor
C.Rhonchi
D.Sore throat
B. Stridor
A nurse is monitoring a client who is receiving two units of packed RBC’s. Which of the
the following manifestation indicates a hemolytic transfusion reaction?
a) back pain
b) Hypertension
c) Chills
d) bradycardia
c) Chills
-hypotention
-tachycardia
-lower back pain
A nurse is caring for a client who is post-operative following an endoscopy with
moderate (conscious) Sedation. Which of the following assessment findings is the
nurse’s priority?
a) Level of pain
b) Gag reflex
c) Warmth of extremities
d) Temperature
b) Gag reflex
A nurse is administering furosemide 80 mg PO twice-daily to a client who has
pulmonary edema. Which of the following assessment findings indicates to the nurse
that the medication is effective?
a) Respiratory rate of 24 / min
b) adventitious breath sounds
c) weight loss of 1.8 kg (4 lb) in the past 24 hours
d) elevation in blood pressure
c) weight loss of 1.8 kg (4 lb) in the past 24 hours
A nurse is caring for a client who has diabetes mellitus and has been following a
treatment plan for 3 months which of the following results should the nurse monitor
to determine long-term glycemic control?
a) Glycosylated hemoglobin level
b) fasting blood glucose level
c) oral glucose tolerance test results
d) post-prandial blood glucose level
a) Glycosylated hemoglobin level
A nurse is providing preoperative teaching for a client who is having left-sided cardiac catheterization. Which of the following information should the nurse include
in the teaching?
a) You should plan to remain in bed for 18 hours after the procedure
b) you will have blood pressure measurement every 5 minutes for the first two hours after the procedure
c) You will receive a general anesthetic during the procedure
d) you should expect a warm sensation after the injection of the contrast dye during
the procedure
d) you should expect a warm sensation after the injection of the contrast dye during
the procedure
A nurse is caring for a client who has a chest tube. The client asks why the fluid in the water -seal chamber rises and falls. Which of the following statements should the nurse make?
a) “ this means your lung is fully expanded “
b) “ this indicates a possible leak”
c) “ suction pressure that is too high causes this”
d) “ Your breathing pattern causes this”
d) “ Your breathing pattern causes this”
A nurse on an oncology unit is caring for a client who is receiving internal radiation
therapy. Which of the following actions should the nurse take?
a) Place the dosimeter film badge on a client’s door
b) wear a lead apron when providing client care
c) leave the door to the clients room open
d) allow visitors to hold the clients hand
b) wear a lead apron when providing client care
A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of
the following precautions should the nurse implement?
A. Ensure the client has a patient IV.
B. Place patient in side lying
C Remove furniture away for the patient
D.Obtain supplemental oxygen
A. Ensure the client has a patient IV.
A nurse is providing instructions about foot care for a client who has peripheral arterial disease. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching.
a. “I use my heating pad on a low setting to keep my feet warm.”
b. “I rest in my recliner with my feet elevated for about an hour every afternoon.”
c. “I soak my feet in hot water before trimming my toenails.”
d. “I apply a lubricating lotion to the cracked areas on the soles of my
feet every morning.
b. “I rest in my recliner with my feet elevated for about an hour every
afternoon.”
A nurse is assessing a client who has a pressure ulcer. Which of the
following findings should the nurse expect as an indication the wound is healing?
A.Dark red granulation tissue
B.Light yellow exudate
C.Dry brown eschar
D.Wound tissue firm to palpation
A.Dark red granulation tissue
A nurse is assessing a client who has myasthenia gravis. Which of the following client statements should indicate to the nurse that the client needs a referral for occupational therapy?
A.”I’ve been having problems with bladder control.”
B. “I have a hard time with brushing my hair.”
C. “I would rather be in a wheelchair than use a walker to get around.”
D. “I have difficulty swallowing food.”
B. “I have a hard time with brushing my hair.”
A nurse is teaching a client about using a metered-dose rescue inhaler.
Which of the following statements should the nurse include in the
teaching?
A.”Use peroxide to clean the mouthpiece of your inhaler.”
B”Exhale fully before bringing the inhaler to your lips.”
C.”Depress the canister after you inhale.
d. “Do not shake your inhaler before use
B”Exhale fully before bringing the inhaler to your lips.”
A nurse is caring for a client following a cardiac catheterization who has
hives and urticarial following the admin of IV contrast dye. Which of the
following meds should the nurse plan to administer?
A.Spironolactone
B.Diphenhydramine
C.Desmopressin
D.Metoclopramide
B.Diphenhydramine
A nurse is preparing to administer daily medications to a client who is
undergoing a procedure at 1000 that requires IV contrast dye. Which of the
following routine medications to give at 0800 should the nurse withhold?
a. Valproic acid
b. Metformin
c. Fluticasone
d. Metoprolol
b. Metformin
A nurse is reviewing the medical record of a client who is scheduled for a CT scan with contrast media. Which of the following medication should the nurse instruct the
client to withhold for 48 hours following the procedure?
a) Carvedilol
b) Furosemide
c) Metformin
d) Clopidrogel
c) Metformin
A nurse is providing discharge teaching for a client who has asthma and a new
prescription for a metered dose inhaler. Which of the following client statements
indicates an understanding of the teaching?
a) I should clean the cap of the inhaler once per week
b) I should shake the inhaler before I use it
c) I Should wait 15 seconds between puffs
d) I should inhale the medication quickly
b) I should shake the inhaler before I use it
A nurse is completing discharge teaching with a client who has a new diagnosis of
AIDS. Which of the following statements by the client indicates an understanding of
the teaching?
a) I will need to take my clothes to the dry cleaners to sterilize them
b) I will wipe up areas soiled with body fluids with alcohol and immediately
disposed of the trash (should be cleaned with bleach not alcohol)
c) I will be sure to wear gloves and wash my hands when I change my cat’s litter
box
d) I will increase the amount of fresh fruits and vegetables I consume
c) I will be sure to wear gloves and wash my hands when I change my cat’s litter box
A nurse is teaching about food choices to a client who has chronic kidney disease and
must limit potassium intake. Which of the following choices should the nurse
recommend as containing the least potassium?
a) Half cup non-fat yogurt
b) two tablespoons of peanut butter
c) 1 Cup white rice
d) one medium baked potato with skin
c) 1 Cup white rice
A nurse is providing teaching to a client who is postoperative following a total hip
arthroplasty. Which of the following statements should the nurse make?
a) “ use raised toilet seat to maintain your hips above the knees”
b) “ twist at the waist when standing from a seated position”
c) “move your stronger leg first when using a walker”
d) “ apply a heating pad to the operative hip to decrease pain”
a) “ use raised toilet seat to maintain your hips above the knees”
Which of the following oils is the best oil for a patient with athersclerosis?
A. Cocunut oil
B. Shea butter
C. Ghee
D. Olive oil
D. Olive oil
A community health nurse is reviewing home care instructions with an older adult
client who has a new diagnosis of heart failure. Which of the following is the priority
topic for the nurse to review with the client?
a) Daily sodium restriction
b) Daily exercise routine
c) Changes in weight
d) Fluid intake record
c) Changes in weight
A nurse is providing discharge teaching for a client who has a new tracheostomy. Which of the following statements by the client indicates an understanding of the teaching?
a. I’ll cut a slit in a clean gauze pad to use as a stoma dressing
b. I’ll remove the soiled tracheostomy ties prior to cleaning my stoma
c. I’ll insert the obturator after cleaning my stoma
d. I’ll cleanse the cannula with half-strength hydrogen peroxide
d. I’ll cleanse the cannula with half-strength hydrogen peroxide
A nurse is asking a preoperative client about food allergies. Which of the following food allergies indicates a potential reaction to propofol?
a. Strawberries
b. Shellfish
c. Avocados
d. Eggs
d. Eggs
A nurse is caring for a client who has hypotension, cool and clammy skin, tachycardia, and tachypnea. In which of the following positions should the nurse place the client?
a. Reverse Trendelenburg
b. Feet elevated
c. High-Fowler’s
d. Side-Lying
b. Feet elevated
A nurse is caring for a client who has anemia. Which of the following assessments
findings should the nurse anticipate with the client’s condition?
a. Flushed skin color
b. Heat intolerance
c. Bradycardia
d. Headache
d. Headache
A nurse is providing teaching to a client who is receiving opioids for pain management. Which of the following information should the nurse include in the teaching?
a. Itching indicates you are having an allergic reaction to the medication
b. Restrict fluid intake if you experience constipation
c. Avoid taking antiemetics with the medication
d.Monitor urinary output for retention
d.Monitor urinary output for retention
A nurse is caring for a client who has a sealed radiation
implant(BRACHYTHERAPY). Which of the following
actions should the nurse take?
a) Remove soiled linens from the room after each change
b) Give the dosimeter badge to the oncoming nurse at the end of the shift
c) Apply a second pair of gloves before touching the client’s implant if it dislodges
d) Limit family member visits to 30 min per day
d) Limit family member visits to 30 min per day
NGN QUESTION
NGN QUESTION #2
NGNG QUESTION #4
NGN QUESTION #5
NGN QUESTION #6
NGN QUESTION #7
NGN QUESTION #8
NGN QUESTION #9
NGN QUESTION #10
NGN QUESTON #11
NGN QUESTION #12
NGN QUESTION #13
NGN QUESTION #14
NGNG QUESTION #15
A nurse is assessing a client who has a gravity drain in place following an open cholecystectomy. Which of the following images should the nurse identify as a gravity drain?
A. Jackson Pratt
B Penrose drain
C. Gastromy feeding tube
D. Mushroom tip catheter style
E. Sump style tube with sheath
B Penrose drain
