19. The nurse is assigned to a client who has heart failure . During the morning rounds
the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse
auscultates, crackles bilaterally.
Which nur
...
19. The nurse is assigned to a client who has heart failure . During the morning rounds
the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse
auscultates, crackles bilaterally.
Which nursing intervention should be performed first?
A) Take the client's vital signs
B) Place the client in a sitting position with legs dangling
C) Contact the health care provider
D) Administer the PRN anti anxiety agent
The correct answer is B: Place the client in a sitting position with legs dangling
20. The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the
parents to
A) Dress the child warmly to avoid chilling
B) Keep the child away from other children for the duration of the rash
C) Clean the affected areas with tepid water and detergent
D) Wrap the child's hand in mittens or socks to prevent scratching
The correct answer is D: Wrap the child''s hand in mittens or socks to prevent scratching
21. A recovering alcoholic asked the nurse, "Will it be ok for me to just drink at special
family gatherings?" Which initial response by the nurse would be best?
A) "A recovering person has to be very careful not to lose control, therefore, confine your
drinking just at family gatherings."
B) "At your next AA meeting discuss the possibility of limited drinking with your
sponsor."
C) "A recovering person needs to get in touch with their feelings. Do you want a drink?"
D) "A recovering person cannot return to drinking without starting the addiction process
over."
The correct answer is D: "The recovering person cannot return to drinking without
starting the addiction process over."
22. In taking the history of a pregnant woman, which of the following would the nurse
recognize as the primary contraindication for breast feeding?
A) Age 40 years
B) Lactose intoleranceC) Family history of breast cancer
D) Uses cocaine on weekends
The correct answer is D: Uses cocaine on weekends
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