1. A nurse is planning care for a preschool-age child who is in the acute phase of Kawasaki disease. Which of the following interventions should the nurse include in the plan of care?
a. Give acetaminophen to control th
...
1. A nurse is planning care for a preschool-age child who is in the acute phase of Kawasaki disease. Which of the following interventions should the nurse include in the plan of care?
a. Give acetaminophen to control the child’s fever
B. Monitor the client’s cardiac status (Peds p120)
c. Administer antibiotics via intermittent IV bolus for 24 hrs
d. Provide stimulation with children of the same age in the playroom
2. A nurse observes a client on the psychiatric unit muttering and standing near a window. The client states, “The voices are telling me to jump.” Which of the following is an appropriate response by the nurse?
a. “Do you recognize the voices as belonging to anyone you know?”
B. “I understand the voices are frightening you, but I do not hear any voices.”
c. “That can’t be true. The only voices in this room are yours and mine.”
d. “You shouldn’t be afraid when you think the voices are telling you to hurt yourself.” Rationale: try to reorient the client back to reality.
3. A nurse is caring for a client who is preparing his advance directives. Which of the following statements by the client indicates an understanding of advance directives? (Select all that apply.)
a. “I need an attorney to witness my signature on the advance directives.” *(nurse witnesses it)
b. “I have the right to refuse treatment.” (Leadership p38)
c. “My doctor will need to approve my advance directives.” (just needs to write a prescription)
d. “My health care proxy can make medical decisions for me.” (Leadership p38)
e. “I can’t change my advance directives once submitted.” (yes you can)
4. A client who is pregnant voices her concern that her 3-year-old son will feel left out once the newborn arrive. Which of the following statements by the nurse is appropriate?
a. “Offer your son a gift when the baby receives one.” (Provide a gift from the infant to give the sibling)
b. “Teach your son to change the baby’s diapers.” (Allow older siblings to help in providing care for the infant)
c. “Tell your son to kiss the baby.” (Maternity p126: Let the sibling be one of the first to see the infant) Don’t force interactions betch
d. “Move your son to a toddler bed when the baby arrives. (do this weeks prior to baby’s arrival)
5. A nurse is teaching a client who has nephrotic syndrome about dietary management. Which of the following instructions should the nurse include in the teaching?
a. Limit total daily sodium intake to 4 to 5 grams
B. Obtain most calories from complex carbohydrates
c. Consume a high-protein diet (Sufficient amount of protein, high potassium, low sodium)
d. Avoid intake of soy products.
Rationale: Excess of protein should be avoided because a very high protein diet may cause tubular damage to the kidneys as the kidneys will have to filter more of the proteins. But moderate protein intake (about 1 gm/kg body weight) is mandatory to compensate for the protein loss in the urine.
6. A nurse is interviewing an adolescent client who has a history of physical aggression due to anger management issues. Which of the following is an appropriate question by the nurse?
a. “Did you think about removing yourself from the situation when you became angry?”
b. “Why do you get angry when things don’t go your way?”
c. “How do you think others feel when you express anger?”
D. “What are you thinking about when you express anger?” (assessing the underlying issue of aggression)
7. A nurse is planning care for a client who has a sealed radiation implant and is to remain in the hospital for 1 week. Which of the following should the nurse include in the plan of care?
a. Wear a dosimeter film badge while in the client’s room. (Med Surg p583)
b. Ensure family members remain at least 3 feet from the client (should be at least 6ft)
c. Limit each of the client’s visitors to 1 hr per day. (should be 30 minutes)
d. Remove dirty linens from the room after double bagging. Keep in the room
8. A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take? talaga
a. Sit at or below the client’s eye level during feedings (Funds p215: Observe for aspiration and pocketing of food in the cheeks or other areas of the mouth)
b. Talk with the client during her feeding
c. Discourage the client from coughing during feedings (encourage pt to cough to prevent aspiration)
d. Instruct the client to lift her chin when swallowing (tuck chin)
9. A nurse is caring for a preschool child who is dehydrated. Which of the following assessment findings indicates moderate dehydration?
a. Bradypnea
B. Oliguria (Funds p343)
c. Diaphoresis
d. Excessive tears
10. A nurse is providing teaching to a parent of a child who has varicella. Which of the following statements should the nurse include in the teaching?
a. “Your child can return to school after a negative titer result.”
b. “Your child can return to school 24 hours after beginning antibiotics.”
c. “Your child can return to school once the lesions have crusted over.”
d. “Your child can return to school once the fever has subsided.”
11. A nurse is providing information for a client who has a new prescription for simvastatin. For which of the following should the nurse instruct the client to monitor and report to the provider?
a. Muscle weakness - rhabdomyolysis
b. Edema
c. Weight loss
d. Fever Rationale: Simvastatin
Although mild muscle pain is a relatively common side effect of statins, some people who take statin medications to lower their cholesterol may have severe muscle pain. This intense pain may be a symptom of rhabdomyolysis, a rare condition that causes muscle cells to break down. The most common signs and symptoms of rhabdomyolysis include:
● Severe muscle aching throughout the entire body
● Muscle weakness
● Dark or cola-colored urine
The higher the dose of statins, the higher the risk of rhabdomyolysis becomes. The risk also increases if certain drugs — including cyclosporine (Sandimmune) and gemfibrozil (Lopid) — are taken in combination with statins. However, the risk of developing rhabdomyolysis from statin therapy is very low, around 1.5 for each 100,000 people taking statins. Rhabdomyolysis or milder forms of muscle inflammation from statins can be diagnosed with a blood test measuring levels of the enzyme creatinine kinase. If you notice moderate or severe muscle aches after starting to take a statin, contact your doctor. If you have signs and symptoms of rhabdomyolysis, stop taking your statin medication immediately and seek medical treatment right away. If necessary, your doctor may take steps to help prevent kidney damage and other complications.
12. A nurse on a medical-surgical unit is receiving report on four clients. Which of the following clients should the nurse assess first?
a. A client who is receiving warfarin and has an INR of 3.3
b. A client who had an NG tube inserted 6 hrs ago and has abdominal distention
c. A client who is 4 hrs postoperative following a thyroidectomy and reports fullness in the back of the throat (edema can lead to resp distress)
d. A client who has acute kidney injury, a creatinine of 4 mg/dL, and a BUN of 52 mg/dL
13. A nurse is receiving report on four postpartum clients. Which of the following clients should the nurse plan to attend to first?
a. A client who reports changing her perineal pad every 2 hrs
b. A client who reports abdominal pain during breastfeeding
c. A client who has a urine output of 250 mL in 6 hrs
D. A client who has hyporeflexia while receiving magnesium sulfate
14. A nurse is providing nutritional teaching regarding appropriate food choices to a client who has a new diagnosis of uric acid calculi. Which of the following should the nurse include in the teaching?
a. Roast beef
b. Chicken breast
c. Low-fat yogurt (avoid purine foods: organ meats & shellfish & poultry)
d. Tuna fish
15. A nurse in the emergency department is caring for a client who has a full-thickness burn of the thorax and upper torso. After securing the client’s airway, which of the following is the nurse’s priority intervention?
a. Preventing infection
b. Offering emotional support
c. Providing pain management
D. Initiating IV fluid resuscitation repeat
16. A nurse is caring for a client who will undergo a procedure. The client states she does not want the provider to discuss the results with her partner. Which of the following is an appropriate response for the nurse to make?
a. “The provider will be tactful when talking to your partner.”
B. “You have the right to decide who receives information.”
c. “Is there a reason you don’t want your partner to know about your procedure?”
d. “Your partner can be a great source of support for you at this time.”
17. A nurse is providing teaching about dietary recommendations to the parents of a school-age child who has acute kidney injury. Which of the following recommendations should the nurse include in the teaching?
a. Provide low-calcium foods
b. Provide high-phosphorus foods
C. Provide low-potassium foods
d. Provide high-sodium foods
Rationale: P. 380 MS PHOSPHATE , POTASSIUM, SODIUM AND MAGNESIUM NEED TO BE RESTRICTED
18. A nurse is planning care for a school-age child who is 4 hr postoperative following perforated appendicitis.
Which of the following actions should the nurse include in the plan of care?
a. Apply a warm compress to the operative site every 4 hr
b. Offer small amounts of clear liquids 6 hrs following surgery
c. Give cromolyn nebulized solution every 8 hr
D. Administer analgesics on a scheduled basis for the first 24 hrs
19. A nurse is assessing a client who is 8 hr postpartum and has been unable to void. Which of the following actions should the nurse take first?
a. Pour warm water over the client’s perineum
b. Offer the client a sitz-bath
c. Insert a sterile catheter
d. Administer an analgesic
20. A nurse is providing nutritional teaching for an older adult client who has seizure disorder and a new prescription for phenytoin. Which of the following statements by the nurse is appropriate?
a. “Limit foods that contain folic acid while taking this medication.”
b. “You should expect a change in the color of your stool while taking this medication.”
c. “Increase your intake of vitamin D while taking this medication.” - phenytoin complication (bone pain and weakness)
d. “Plan to take this medication with antacids.”
21. A nurse is assessing a client who sustained fractures to both legs in a motor-vehicle crash. Which of the following findings indicates the client is experiencing a fat embolism?
a. Pete$h&ae )* the $he+t a*d a-d)me* / 01a$t&$e te+t 2345 6
b. Decreased pedal pulses
c. Pain unrelieved by opioid analgesics
d. Crepitus at the knee joint
22. A nurse is teaching a client who is at 41 weeks of gestation about a nonstress test. Which of the following information should the nurse include in the teaching?
a. “You will have a Doppler transducer applied to your abdomen during the test.”
b. “You should massage one of your nipples to stimulate contractions of your uterus.”
c. “You will need blood work before and after the test.”
d. “You should avoid eating or drinking for 4 hrs before the test.”
23. A home health nurse is assessing a client who has amyotrophic lateral sclerosis (ALS) and has had recent weight loss. Which of the following is the priority admission data for the nurse to obtain? TALAGA
a. Changes in appetite
b. Daily fluid intake
c. Swallowing ability - aspirations precautions
d. Prescribed medications
24. A nurse is providing discharge teaching for a client who has myelosuppression following chemotherapy treatment. Which of the following statements should the nurse include in the teaching?
a. “Eat a diet rich in fresh fruits and vegetables.”
B. “Wear disposable gloves under gardening gloves while working with house plants.”
c. “Children may visit as long as they’ve recently received a live influenza vaccination.”
d. “Check your temperature weekly.”
BONE MARROW SUPPRESSION- IMMUNOCOMPROMISED. AVOID
25. A nurse is caring for a client who has undergone a modified radical mastectomy. The client has a closed-suction drain. Which of the following actions should the nurse take?
a. Maintain the client in supine position for the first 24 hrs
b. Secure the drain to the bedding
c. Reset the vacuum by compressing the container
d. Position the affected extremity below the level of the client’s heart
26. A nurse is providing discharge instructions to a client who is 1-day postoperative vertical banded gastroplasty for morbid obesity. Which of the following statements demonstrates an understanding for the dietary teaching?
a. “It should take me 30 to 60 minutes to eat a meal”
b. “I will be limited to pureed foods for the next 6 months.” (weeks)
c. “I should eat three meals per day.”
d. “Vomiting is common and I will have to learn to live with it.”
SERVE TO RESTRICT AND DECREASE FOOD INTAKE HELPS TO PROMOTE WT. LOSS
27. A home health nurse is visiting a client whose partner states that she is overwhelmed by caring for him. When suggesting respite care, which of the following explanations should the nurse provide?
a. “Respite care offers financial resources to help care for your husband.”
b. “Respite care includes volunteers who will perform household tasks.”
c. “Respite care provides clinicians to work with you in caring for your husband.”
D. “Respite care allows for time away from caring for your husband.”
28. A nurse is collecting a specimen for urinalysis and culture from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take during collection?
a. Obtain the urinalysis specimen before the culture specimen.
b. Collect 2 mL or urine for each specimen.
c. Drain the specimen from the drainage bag.
D. Clamp the catheter distal to the injection port.
29. A nurse is caring for four clients. Which of the following clients should the nurse care for first?
a. A client who has hypothyroidism and is stuporous
b. A client who has a burn requiring a sterile dressing change
c. A client who received a chemotherapy treatment and reports nausea
d. A client who had an appendectomy 2 days ago and has diminished bowel sounds
Rationale: Myxedema Coma. Myxedema coma is a rare, life-threatening complication of untreated hypothyroidism. Symptoms include a severe drop in body temperature (hypothermia), delirium, reduced lung function, slow heart
rate, constipation, urine retention, seizures, stupor, fluid build-up, and finally coma. It is uncommon, but may develop in untreated patients subjected to severe stress, such as infection, surgery, or extreme cold.
30. A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu. The nurse should recognize which of the following findings as a potential contraindication to using lavender?
a. The client has a history of alcohol use disorder
b. The client has a history of asthma- Lavender is known to decrease inflammation - IT HELPS ON ASTHMA
c. The client takes Vitamin C daily
D. The client takes furosemide twice daily- Lavender reduced blood pressure, furosemide does the same
31. A nurse is providing discharge teaching to a client following a total hip arthroplasty. Which of the following statements by the client indicates an understanding of the teaching?
a. “I won’t cross my legs when I sit in a chair.”
b. “I don’t need to use a walker when walking around my house.”
c. “I will stay in bed for 3 days after returning home before starting leg exercises.”
d. “I will bend over at my hips to tie my shoes.” bend at your knees
32. A nurse is assessing a client who is experiencing a pulmonary embolism. Which of the following manifestations should the nurse expect?
a. Hypertension
B. Dyspnea
c. Bradycardia
d. Frothy sputum
33. A nurse is performing a neurological examination on a client as part of a complete physical assessment. The nurse determines that cranial nerve XI is intact when the client performs which of the following actions?
a. Shrugs his shoulders CN 11 = Accessory or spinal
b. Frowns symmetrically
c. Sticks his tongue out
d. Identifies a sour taste
34. A nurse is preparing to administer lactated Ringer’s 500 mL IV to infuse over 4 hrs. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole noumber. Use a leading zero if applicable. Do not use a trailing zero.)
31 gtt/min
4x60= 240mins
500/240 = 2.08 x 15 gtt = 31.25 or 31
35. A nurse is teaching an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching?
a. HbA1c level greater than 8%
B. HbA1c level less than 7%
c. Blood glucose level less than 60 mg/dL before breakfast
d. Blood glucose level greater than 200 mg/dL at bedtime
36. A nurse is caring for a client who develops a lower left leg deep-vein thrombosis following surgery. Which of the following actions should the nurse take?
a. Apply warm, moist compresses to the affected extremity
b. Check for the presence of a Homan’s sign
c. Form a 5 cm (2 in) cuff at the top of the antiembolism stocking
d. Massage the left lower extremity
37. A nurse working in an acute care mental health facility is assessing a client who has schizophrenia. Which of the following findings should the nurse expect?
a. Euphoric mood (bipolar)
b. All-or-nothing thinking
c. Hypochondriasis
D. Disorganized speech
38. A nurse is developing a nutritional care plan for a client who has COPD with severe dyspnea. To promote intake, which of the following instructions is appropriate to include in the plan of care? TALAGA
a. Administer a bronchodilator after meals
b. Ambulate the client before each meal
c. Offer the client three large meals each day
D. Limit fluid intake with meals
39. A nurse is caring for four clients who are scheduled for surgery the same day. Which of the following laboratory values indicates the need for intervention before surgery? TALAGA
a. WBC 9,800/mm3
b. Creatinine 0.9 mg/dL
c. Fasting blood glucose 108 mg/dL
D. Potassium level 5.2 mEq/L
40. A nurse in a long-term care facility is managing the care of an older adult client who has difficulty swallowing and occasional choking during meals. The nurse should initiate a referral to which of the following members of the interprofessional care team? TALAGA
a. Social worker
b. Respiratory therapist
c. Speech-language pathologist
d. Occupational therapist
41. A nurse in an oncology clinic receives a call from the partner of a client who has pancreatic cancer. The partner tells the nurse that she is able to manage the client’s physical care, but she doesn’t want to leave him home alone while she travels for work. Which of the following referrals should the nurse make?
a. Community outreach center = is a safe and productive place for youth to interact with peers and participate in activities to promote positive youth development.
b. Respite care
c. Skilled nursing facility
d. Restorative care
Rationale: Taking care of an older or ill family member can be enormously rewarding — but it can be physically and emotionally draining as well. That’s why it’s important for caregivers to seek occasional respite from their responsibilities. Whether it’s for a few hours a week to run errands or a few weeks a year to take a much-needed vacation, respite care offers you the chance reduce stress, restore energy and keep your life in balance.
42. A nurse is caring for a client who has deep-vein thrombosis of the left lower extremity. Which of the following actions should the nurse take? (Click on the “Exhibit” button below for additional client information. There are three tabs that contain separate categories of data.)
a. Massage the affected extremity every 4 hr (don’t massage = can dislodge emboli)
b. Administer acetaminophen
c. Withhold heparin IV infusion - not enough info, anticipate giving Heparin, but check labs and hx beforehand otherwise the patient might be harmed/killed
d. Position the client with the affected extremity lower than the heart (elevate affected leg)
43. A nurse preceptor is working with a newly licensed nurse to care for a client who has vancomycin-resistant
[Show More]
 JY21.png)
