1. A nurse is providing teaching about the gastrostomy tube feedings to the parents of a school age child. Which of the following instructions should the nurse take?
A. . Administer the feeding over 30 min.
B. Place th
...
1. A nurse is providing teaching about the gastrostomy tube feedings to the parents of a school age child. Which of the following instructions should the nurse take?
A. . Administer the feeding over 30 min.
B. Place the child in as supine position after the feeding.
C. Charge the feeding bag and tubing every 3 days.
D. Warm the formula in the microwave prior to administration.
2. A nurse is administering digoxin 0.125 mg Po to an adult client. For which of the following findings should the nurse report to the provider? A. Potassium level 4.2 mEq/L.
B. Apical pulse 58/min.
C. D igoxin level 1 ng/ml.
D. Constipation for 2 days.
3. A nurse is caring for a client who is comatose and has advance directives that indicate the client does not want life-sustaining measures. The client’s family want the client to have life-sustaining measures. Which of the following action should the nurse take?
A . Arrange for an ethics committee meeting to address the family’s concerns. B . Support the family’s decision and initiate life-sustaining measures.
C. . Complete an incident report.
D. . Encourage the family to contact an attorney.
4. A nurse is caring for a client who wears glasses. Which of the following actions should the nurse take? A. S tore the glasses in a labeled case.
B. Clean the glasses with hot water.
C. Clean the glasses with a paper towel.
D. Store the glasses on the bedside table.
5. A nurse is teaching a group of newly licensed nurses about measures to take when caring for a client who is on contact precautions. Which of the following should the nurse include in the teaching?
A. Remove the protective gown after the client’s room.
B. Place the client in a room with negative pressure.
C. W ear gloves when providing care to the client.
D. Wear a mask when changing the linens in the client’s room.
6.A nurse is planning on care for a client who is recovering from an acute myocardial infarction that occurred 3 days ago. Which of the following instructions should the nurse include? A. Perform an ECG every 12 hr.
B. Place the client in a supine position while resting.
C. Draw a troponin level every 4hr.
D. O btain a cardiac rehabilitation consultation.
7. The nurse is reviewing the medical record of a client who is requesting combination oral contraceptives.
Which of the following conditions in the client’s history is a contradiction to the use of oral contraceptives? A. Hyperthyroidism.
B . Thrombophlebitis. C . Diverticulosis.
Hypocalcemia.
8 A nurse is caring for a client who request the creation of a living will. Which of the following actions should the nurse take?
A. Schedule a meeting between the hospital ethics committee and the client.
B. E valuate the client’s understanding of life-sustaining measures.
C. Determine the client’s preferences about post mortem care.
D. Request a conference with the client’s family.
9.A nurse is caring for an adolescent who has sickle-cell anemia. Which of the following manifestations indicates acute chest syndrome and should be immediately reported to the provider? A. Substernal
r etractions.
B. Hematuria.
C. Temperature 37.9 C (100.2 F).
D. Sneezing.
10.A nurse is preforming a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the
.following action should the nurse take?
A. Instill 500 ml of solution through the NG tube.
B. I nsert a large-bore NG tube.
C. Use a cold irrigation solution.
D. Instruct the client to lie on his right side.
11. A nurse is providing care for a client who is in the advance stage of amyotrophic lateral sclerosis. (ALS). Which of the following referrals is the nurse’s priority?
A. Psychologist.
B. Social worker.
C. Occupational therapist.
D. S peech-language pathologist.
12.A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis. Which of the following findings should the nurse report to the provider? A. WBC count 8,000/mm3.
B. Platelets 150,000/mm3.
C. Aspartate aminotransferase 10 units/L.
D. E rythrocyte sedimentation rate 75 mm/hr
13. A nurse is caring for a client who has generalized petechiae and ecchymoses. The nurse should expect a prescription for which of the following laboratory tests? A. Platelet count.
B. Potassium level.
C. Creatine clearance.
D. Prealbumin.
14. A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first?
A. Place an ice pack over the cast.
B. P alpate the pulse distal to the cast.
C. Teach the client to keep the cast clean and dry.
D. Position the casted extremity on a pillow.
15. A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? (Select all that apply)
A. . Keep objects in the client’s room in the same place.
B. . Ensure there is high-wattage lighting in the client’s room. C . Approach the client from the side.
D . Allow extra time for the client to perform tasks. E . Touch the client gently to announce presence.
16. A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has questions about the disease. To research the nurse should identify that which of the following electronic database has the most
comprehensive collection of nursing (Unable to read) articles?
A. MEDLINE
B. C INAHL.
C. ProQuest.
D. Health Source.
17. A nurse in an emergency department is assessing newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following should actions should the nurse take first?
A. Obtain a baseline ECG.
B. Obtain a blood specimen for ABG analysis.
C. Insert an 18-gauge IV catheter.
D. A dminister 100% humidified oxygen.
18. A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan?
A. Place food on the left side of the client’s mouth when he is ready to eat.
B. Provide total care in performing the client’s ADLs.
C. Maintain the client on bed rest.
D. P lace the client’s left arm on a pillow while he is sitting.
19. A nurse is caring for a client who is in a seclusion room following violent behavior. The client continues to display aggressive behavior. Which of the following actions should the nurse take?
A. . Confront the client about this behavior.
B. Express sympathy for the client’s situation.
C. Speak assertively to the client.
D. Stand within 30 cm (1 ft) of the client when speaking with them.
20. A nurse is caring for a client who is receiving brachytherapy for treatment of prostate cancer. Which of the following actions should the nurse take?
A. Cleanse equipment before removal from the client’s room.
B. L imit the client’s visitors to 30 min per day.
C. Discard the client’s linens in a double bag.
Discard the radioactive source in a biohazard bag
21. A nurse is assessing a client who has left-sided heart failure. Which of the following should the nurse identify as a manifestation of pulmonary congestion?
A. Frothy, pink sputum.
B. Jugular vein distention.
C. Weight gain.
D ..Bradypnea
22. A nurse is caring for a client who is in labor and requires augmentation of labor. Which of the following conditions should the nurse recognize as a contraindication to the use of oxytocin.
A. Diabetes mellitus.
B. Shoulder presentation.
C. P ostterm with oligohydramnios. (I think Maternal Newborn Chapter 15 page 100)
D.Chorioamnionitis
23. A nurse is assessing a client who has left-sided heart failure. Which of the following should the nurse identify as a manifestation of pulmonary congestion?
A. Frothy, pink sputum.
D. Jugular vein distention.
E. Weight gain.
.Bradypnea
24. A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for paternal fluid therapy. The guardian asks. “What are the indications that my baby needs an IV?” Which of the following responses should the nurse make?
A . “Your baby needs an IV because she is not producing any tears” B . “Your baby needs an IV because her fontanels are budging”
C . “Your baby needs an IV because she is breathing slower than normal” D . “Your baby needs an IV because her heart rate is decreasing”
25. A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make?
A. “Taking furosemide can cause your potassium levels to be high”
B. “Eat foods that are high in sodium”
C. “ Rise slowly when getting out of bed”
D. “Taking furosemide can cause you to be overhydrated”
26. A nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder. Which of the following interventions should the nurse take? A. Allow the client enough time to perform rituals.
B. Give the client autonomy in scheduling activities.
C. Discourage the client from exploring irrational fears.
D. Provide negative reinforcement for ritualistic behaviors.
27. A nurse is caring for a client who has depression and reports taking ST. John’s wort along with citalopram. The nurse should monitor the client for which of the following conditions as a result of an interaction between these substances?
A . Serotonin syndrome B . Tardive dyskinesia
C. Pseudo parkinsonism.
D. Acute dystonia.
28. A nurse is assessing a client who is receiving packed RBCs. Which of the following findings indicate fluid overload?
A. Low back pain.
B. D yspnea.
C. Hypotension.
D. Thready pulse.
29. A nurse is calculating a client’s expected date of delivery. The client’s last menstrual period began on April
. Using Nagele’s rule, what date should the nurse determine to be the client’s expected delivery date? (Use mmdd format.)
0 119 date
30. A nurse is discussing group treatment and therapy with a client. The nurse should include which of the following as being a characteristic of a therapeutic group? A. The group is organized in an autocratic structure.
B . The group encourages members to focus on a particular issue. (Mental Health Chapter 8 Page 42) C . The group must be led by a licensed psychiatrist.
D . The group encourages clients to form dependent relationships.
31. A nurse manger is reviewing documentation with a newly licensed nurse. Which of the following notations by the newly licensed nurse indicates an understanding of the teaching.
U NSURE IF ON THE REPORT
A. “OOB with assistance for breakfast”
B. “Given 2 mg MSO4 IM for report of pain”
C. “Dressing changed qd”
D. “Administered 8 u regular insulin sq.”
32. A nurse is preparing to administer eye drops to a school-age child. Identify the actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
1. Apply pressure to the lacrimal punctum.
2. Ask the child to look upward.
3. Pull the lower eyelid downward.
4. Instill the drops of medication.
5. Place the child in a sitting position.
5 2 3 4 1
33. A nurse is caring for a client who speaks a language different from the nurse. Which of the following should the nurse take?
A. Request an interpreter of a different sex from the client.
B. Request a family member or friend to interpret information for the client.
C. Direct attention toward the interpreter when speaking to the client.
D. Review the facility policy about the use of an interpreter.
34. A nurse is caring for a client who is in labor and is receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion?
O N THE REPORT needs double checking A.
Urine output 20 ml/hr.
B . Montevideo units constantly 300 mm Hg. C . FHR pattern with absent variability.
D . Contractions every 5 min that last 30 seconds.
35.A public health nurse is managing several projects for the community. Which of the following interventions should the nurse identify as a primary prevention strategy?
A. . Teaching parenting skills to expectant mothers and their partners.
B. . Conducting mental health screenings at the local community center. C. Referring client who have obesity to community exercise programs.
D. Providing crisis intervention through a mobile counseling unit.
36. A nurse is preparing to administer an autologous blood product to a client. Which of the following actions should the nurse take to identify the client?
A. . Match the client’s blood type with the type and cross match specimens.
B. . Confirm the provider’s prescription matches the number on the blood component. C . Ask the client to state the blood type and the date of their last blood donation.
D . Ensure that the client’s identification band matches the number on the blood unit.
37. A nurse is performing physical therapy for a client who has Parkinson’s disease. Which of the following statements by the client indicates the need for a referral to physical therapy?
A. “I have been experiencing more tremors in my left arm than before”
B. “I noticed that I am having a harder time holding on to my toothbrush”
C. “ Lately, I feel like my feet are freezing up, as they are stuck to the ground”
D. “Sometimes, I feel I am making a chewing motion when I’m not eating”
38. A nurse is reviewing laboratory data for a client who has chronic kidney disease. Which of the following findings should the nurse expect? A. Increased creatine.
B. Increased hemoglobin.
C. Increased bicarbonate.
D. Increased calcium.
39. A nurse is administering a scheduled medication to a client. The client reports that the medication appears different than what they take at home. Which of the following responses should the nurse take?
A. “Did the doctor discuss with you that there was a change in this medication?”
B. “I recommend that you take this medication as prescribed”
C. “Do you know why this medication is being prescribed to you?”
D. “ I will call the pharmacist now to check on this medication”
40 A nurse is teaching at a community health fair about electrical fire prevention. Which of the following information should the nurse include in the teaching? A. Use three pronged grounded plugs.
B. Cover extension cords with a rug.
C. Check the tingling sensations around the cord to ensure the electricity is working.
D. Remove the plug from the socket by pulling the cord.
41. A charge nurse is recommending postpartum client discharge following a local disaster. Which of the following should the nurse recommend for discharge?
A. A 42-year-old client who has preeclampsia and a BP of 166/110 mm Hg.
B. A 15-year-old client who delivered via emergency cesarean birth 1 day ago.
C. A client who received 2 units of packed RBCs 6 hr. ago for a postpartum hemorrhage.
D. A client who delivered precipitously 36 hr. ago and has a second-degree perineal laceration.
42. A nurse in a provider’s office is reviewing the laboratory results of a group of clients. Which to report?
A. Herpes simplex.
B. Human papillomavirus
C. Candidiasis
D. C hlamydia
43. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian
A. A client who has a prescription for warfarin and states “I will need to limit how much spinach I eat”.
B. A client who has gout and states, “I can continue to eat anchovies on my pizza.”
C. A client who has a prescription for spironolactone and states “I will reduce my intake of foods that contain potassium”.
D. A client who has (Unable to read) and states “I’ll plan to take my calcium carbonate with a full glass of water”.
44. A nurse is preparing to measure a temperature of an infant. Which of the following action should the nurse take?
A . Place the tip of the thermometer under the center of the infant’s axilla. B . Pull the pinna of the infant’s ear forward before inserting the probe.
C . Insert the probe 3.8 cm (1.5in) into the infant’s rectum. D . Insert the thermometer in front of the infant’s tongue.
45. A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella rooster. Which of the following information should the nurse include?
A. . Children who have varicella are contagious until vesicles are crusted.
B. . Children who have varicella should receive the herpes zoster vaccination. C . Children who have varicella should be placed in droplet precaution.
D . Children who have varicella are contagious 4 days before the first vesicle eruption.
46.A nurse is reviewing the laboratory report of a client who has been having lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect?
A. Withhold the next dose.
B. Increase the dosage.
C. Discontinue the medication.
D. A dminister the medication.
47. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse administer?
A . Pregabalin Lorazepam Colchicine Codeine.
48. A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take?
A . Prime IV tubing with 0.9% sodium chloride.
Use a 24-gauge IV catheter Obtain filter less IV tubing.
Place blood in the warmer for 1 hr.
49. A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following should the toddler participate?
A. Looking at alphabet flashcards.
B. P laying with a large plastic truck.
C. Use scissors cut out paper shapes.
D. Watching a cartoon in the dayroom.
50. A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary recommendations should the nurse make?
A. Coffee with creamer.
B. Lettuce with sliced avocados.
C. B roiled skinless chicken breast with brown rice.
D. Warm toast with margarine.
51. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take?
A. Obtain the newborn’s body temperature using a tympanic thermometer.
B. (Unable to read) FACES pain scale.
C. A uscultate the newborn’s apical pulse for 60 seconds.
D. Measure the newborn’s head circumference over the eyebrows and below the occipital prominence. (NOT)
52. A nurse is caring for a client who is at 38 weeks gestation, is in active labor, and has ruptured membrane. Which of the following actions should the nurse take?
A. Insert an indwelling urinary catheter.
B. . Apply fetal heart rate monitor. C . Initiate fundal massage.
D . Initiate an oxytocin IV infusion.
53. A nurse is assessing a client who is 30 min postoperative following an arterial thrombectomy. Which of the following findings should the nurse to report?
A. . Chest pain
B. . Muscle spasms.
C. . Cool, moist skin.
D. . Incisional pain.
54. A nurse is completing an incident report after a client fall. Which of the following competencies of Quality
and Safety Education for Nurse is the use demonstrating? A
B. Patient (Unable to read)
C. Evidence based practice.
D. Informatics.
. Quality improvement.
55. A nurse is talking with another nurse on the unit and smells alcohol on her breath. Which of the following actions should the nurse take?
A. Confront the nurse about the suspected alcohol use.
B. Inform another nurse on the unit about the suspected alcohol use.
C. Ask the nurse to finish administering medications and then go home.
D. N otify the nursing manager about the suspected alcohol use.
56. A nurse is caring for a client who has diaper dermatitis. Which of the following actions should the nurse take?
A . Apply zinc oxide ointment to the irritated area. B . (Unable to read)
C . Wipe stool from the skin using store bought baby wipes.
Apply talcum powder to the irritated area.
66. A nurse is reviewing the facility’s safety protocols considering newborn abduction with the parent of a newborn. Which of the following statements indicates an understanding of the teaching?
A. “Staff will apply identification band after first bath” B.
C. “I can remove my baby’s identification band as long as she is in my room”
D. “I can leave my baby in my room while I walk in the hallway”
57. A nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the nurse make in the medical record?
A. “Morphine 3 mg SQ every 4 hr. PRN for pain.”
B. “ Morphine 3 mg Subcutaneous (Unable to read)
C. “Morphine 3.0 mg sub q every 4 hr. PRN for pain.”
D. “Morphine 3 mg SC q 4 hr. PRN for pain.”
58. A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first? A. Notify the provider.
B. Report the incident to the nurse manager.
C. M onitor vital signs.
D. Fill out an incident report.
59. A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make?
A. “Dehydration is treated with calcium supplements”
B. “ Dehydration can increase the risk of preterm labor”
C. “Dehydration associated gastroesophageal reflux”
D. “Dehydration is caused by a decreased hemoglobin and hematocrit”
60. A nurse is receiving a change-of-shift report for an adult female client who is postoperative. Which of the following client information should the nurse report?
A. (Unable to read)
B. (Unable to read)
C. A nswer might be lower platelets.
D. (Unable to read)
61. A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as clinical staff. Which of the following instructions should the nurse include?
A. Use the client’s children to provide interpretation.
B. ( Answer was the nurse was going to do the interpretation)
C. Offer client’s translation services for a nominal fee.
D. Evaluate the clients’ understanding at regular intervals.
62 C
63 A
64. C
65. D
6 6.C
D. .
6 7.A
.
6 8.B
6 9.A
7 0.C
7 1.D
7 2.C
7 3.D
7 4.C
7 5.A
7 6.C
7 7.C
7 8.B
79. C
80. D
81. A
82. B
83. A
84. A
85. A
86. C
87. A
88. C
89. D
90. C
91. A
92. A
93. A
94. A
95. C
96. C
97. D
98. D
99. D
100. D
101. A
102. B
103. B
104. D
105. A
106. A
107. D
108. B
109. C
110. B
111. D
112. C
113. B
114. C
115. A
116. D
117. B
118. D
119. D
120. A
121. C
122. A
123. A
124. C
125. D
126. D
127. Intradermal Injection areas A. Buttocks.
B. . Upper back.
C. . Hamstring area.
nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the following are expected findings? (Select all that apply.)
a. Impulse control difficulty b. Left hemiplegia
c. Loss of depth perception
d. Aphasia
e. Lack of situational awareness
128.A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention?
f. Teach the client to scan the right to see objects on the right side of her body. g. Place the bedside table on the right side of the bed.
h. Orient the client to the food on her plate using the clock method.
i. Place the wheelchair on the client’s left side.
129.A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? (Select all that apply.)
j. Have suction equipment available for use. k. Feed the client thickened liquids.
l. Place food on the unaffected side of the client’s mouth.
m. Assign an assistive personnel to feed the client slowly. n. Teach the client to swallow with her neck flexed.
130.A nurse is caring for a client who has global aphasia (both receptive and expressive.). Which of the following should the nurse include in the client’s plan of care? (Select all that apply.)
o. Speak to the client at a slower rate.
p. Assist the client to use flash cards with pictures.
q. Speak to the client in a loud voice.
r. Complete sentences that the client cannot finish. s. Give instructions one step at a time.
131.A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding?
t. Impulse control difficulty
u. Poor judgement
v. Inability to recognize familiar objects
w. Loss of depth perception
nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take?
a. Position the client in an upright position, leaning over the bedside table.
b. Explain the procedure.
c. Obtain ABG’s.
d. Administer benzocaine spray.
133.A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.47, PaCo2 32 mm Hg. HCO3 22 mm Hg. The nurse should recognize that the client is experiencing which of the following acid-base imbalances?
e. Respiratory acidosis f. Respiratory alkalosis
g. Metabolic acidosis
h. Metabolic alkalosis
nurse is assessing a client following bronchoscopy. Which of the following findings should the nurse report to the provider?
i. Blood-tinged sputum
j. Dry, nonproductive cough
k. Sore throat
l. Bronchospasms
135.A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in the client’s room? (Select all that apply.)
m. Oxygen equipment
n. Incentive spirometer
o. Pulse oximeter
p. Sterile dressing
q. Suture removal kit
136.A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risks for complications? (Select all that apply.)
r. Dyspnea
s. Localized bloody drainage on the dressing t. Fever
u. Hypotension
v. Report of pain at the puncture site
nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the client’s room? (Select all that apply.)
a. Oxygen
b. Sterile water
c. Enclosed hemostat clamps
d. Indwelling urinary catheter e. Occlusive dressing
138.A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first?
f. Obtain a chest x-ray
g. Apply sterile gauze to the insertion site.
h. Place tape around the insertion site.
i. Assess respiratory status.
139.A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? (Select all that apply.)
j. Continuous bubbling in the water seal chamber
k. Gentle constant bubbling in the suction control chamber
l. Rise and fall in the level of water in the water seal chamber with inspiration and expiration
m. Exposed sutures without dressing
n. Drainage system upright at chest level
140.A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse instruct the client to do?
o. Lie on it left side.
p. Use the incentive spirometer.
q. Cough at regular intervals.
r. Perform the Valsalva maneuver.
141.A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? (Select all that apply.)
s. Encourage the client to cough every 2 hours.
t. Check the continuous bubbling in the suction chamber.
u. Strip the drainage tubing every 4 hours.
v. Clamp the tube once a day. w. Obtain a chest x-ray.
nurse is orientation a newly licensed nurse who is caring for a client who is receiving mechanical ventilation and is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse indicates and understanding of PSV?
a. “It keeps the alveoli open and prevents atelectasis.”
b. “It allows preset pressure delivered during spontaneous ventilation.”
c. “It guarantees minimal minute ventilator.”
d. “It delivers a preset ventilatory rate and tidal volume to the client.”
143.A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? (Select all that apply.)
e. Confusion f. Pale skin
g. Bradycardia
h. Hypotension
i. Elevation blood pressure.
144.A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching?
j. Apply a vest restraint if self-extubation is attempted.
k. Monitor ventilator settings ever 8 hours.
l. Document tube placement in centimeters at the angle of jaw. m. Assess breath sounds every 1 to 2 hours.
145.A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client?
n. Nonrebreather mask o. Venturi mask
p. Nasal cannula
q. Simple face mask
146.A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following modes of ventilation that increase the effort of the client’s respiratory muscles should the nurse include in the plan of care? (Select all that apply.)
r. Assist-control
s. Synchronized intermittent mandatory ventilation t. Continuous positive airway pressure
u. Pressure support ventilation
v. Independent lung ventilation
nurse is monitoring a group of clients for increased risk for developing pneumonia. Which of the following clients should the nurse expect to be at risk? (Select all that apply.)
a. Client who has dysphagia b. Client who has AIDS
c. Client who was vaccinated for pneumococcus and influenza 6 months ago
d. Client who is postoperative and received local anesthesia.
e. Client who has a closed head injury and is receiving ventilation f. Client who has myasthenia gravis
148.A nurse in a clinic is caring for a client whose partner states the client woke up this morning, did not recognize him, and did not know where she was. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nurse’s priority?
g. Obtain baseline vital signs and oxygen saturation.
h. Obtain a sputum culture.
i. Obtain a complete history from the client.
j. Provide a pneumococcal vaccine.
149.A nurse is caring for a client who has pneumonia. Assessment findings include temperature 37.8 C (100 F), respirations 30/min, blood pressure 130/76, heart rate 100/min, and SaO2 91% on room air. Prioritize the following nursing interventions.
k. Administer antibiotics. (3)
l. Administer oxygen therapy. (1)
m. Perform a sputum culture. (2)
n. Administer an antipyretic medication to promote client comfort. (4)
150.A nurse in a clinic is assessing a client who has sinusitis. Which of the following techniques should the nurse use to identify manifestations of this disorder?
o. Percussion of posterior lobes of lungs
p. Auscultation of the trachea
q. Inspection of the conjunctiva r. Palpation of the orbital areas
151.A nurse is teaching a group of clients about influenza. Which of the following client statements indicates an understanding of the teaching?
s. “I should wash my hands after blowing my nose to prevent spreading the virus.”
t. “I need to avoid drinking fluids if I develop symptoms.”
u. “I need a flu shot every 2 years because of the different flu strains.”
v. “I should cover my mouth with my hand when I sneeze.”
nurse in the emergency department is caring for a client who is having an acute asthma attack. Which of the following assessments indicates that the respiratory status is declining? (Select all that apply.)
a. SaO2 95% b. Wheezing
c. Retraction of sternal muscles
d. Pink mucous membranes
e. Premature ventricular complexes (PVC’s)
153.A nurse is caring for a client 2 hours after admission. The client has an SaO2 of 91%, exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medication should the nurse expect to administer?
f. Antibiotic
g. Beta-blocker
h. Antiviral
i. Beta2 agonist
154.A nurse is providing discharge teaching to a client who has a new prescription for prednisone for asthma. Which of the following client statements indicates an understanding in teaching?
j. “I will decrease my fluid intake while taking this medication.”
k. “I will expected to have black, tarry stools.” l. “I will take my medication with meals.”
m. “I will monitor for weight loss while on this medication.”
155.A nurse is assessing a client who has a history of asthma. Which of the following factors should the nurse identify as a risk for asthma?
n. Gender
o. Environmental allergies
p. Alcohol use
q. Race
156.A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. Which of the following client statements indicates an understanding of the teaching?
r. “This medication can decrease my immune response.” s. “I take this medication to prevent asthma attacks.”
t. “I need to take this medication with food.”
u. “This medication has a slow onset to treat my symptoms.”
nurse is providing discharge teaching to a client who has COPD and a new prescription for albuterol. Which of the following statements by the client indicates and understanding of the teaching?
a. “This medication can increase my blood sugar levels.”
b. “This medication can decrease my immune response.”
c. “I can have an increase in my heart rate while taking this medication.”
d. “I can have mouth sores while taking this medication.”
nurse is preparing to administer a dose of a new prescription of prednisone to a client who has COPD. The nurse should monitor for which of the following adverse effects of this medication? (Select all that apply.)
a. Hypokalemia
b. Tachycardia
c. Fluid retention
d. Nausea
e. Black, tarry stools
nurse is discharging a client who has COPD. Upon discharge, the client is concerned that he will never be able to leave his house now that he is on continuous oxygen. Which of the following is an appropriate response by the nurse?
a. “There are portable oxygen delivery systems that you can take with you.”
b. “When you go out, you can remove the oxygen and then reapply it when you get home.”
c. “You probably will not be able to go out at much as you used to.”
d. “Home health services will come to see you so you will not need to get out.”
nurse is instructing a client on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching?
a. “I will place the adapter on my finger to read my blood oxygen saturation level.”
b. “I will lie on my back with my knees bent.”
c. “I will rest my hand over my abdomen to create resistance.” d. “I will take in a deep breath and hold it before exhaling.”
nurse is planning to instruct a client on how to perform pursed-lip breathing. Which of the following should the nurse include in the plan of care?
a. Take quick breaths upon inhalation.
b. Place you hand over your stomach.
c. Take a deep breath in through your nose.
d. Puff your cheeks upon exhalation.
home health nurse is teaching a client who has active tuberculosis. The provider has prescribed the following medication regimen: isoniazid 250 mg PO daily, rifampin 500 mg PO daily, pyrazinamide 750 mg PO daily, and ethambutol 1 mg PO daily. Which of the following client statements indicate the client understands the teaching? (Select all that apply.)
a. “I can substitute one medication for another if I run out because that all fight infection.” b. “I will wash my hands each time I cough.”
c. “I will wear a mask when I am in a public area.”
d. “I am glad I don’t have to have any more sputum specimens.”
e. “I don’t need to worry where I go once I start taking my medications.”
nurse is teaching a client who has tuberculosis. Which of the following statements should the nurse include in the teaching?
a. “You will need to continue to take the multi-medication regimen for 4 months.”
b. “You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication.”
c. “You will need to remain hospitalized for treatment.”
d. “You will need to wear a mask at all times.”
nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed on a multi-medication regimen. Which of the following instructions should the nurse give the client related to ethambutol?
a. “Your urine can turn a dark orange.”
b. “Watch for a change in the sclera of your eyes.” c. “Watch for any changes in vision.”
d. “Take vitamin B6 daily.”
nurse is preparing to administer a new prescription for isoniazid (INH) to a client who has tuberculosis. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication?
a. “You might notice yellowing of your skin.”
b. “You might experience pain in your joints.” c. “You might notice tingling of your hands.”
d. “You might experience loss of appetite.”
nurse is providing information about tuberculosis to a group of clients at a local community center. Which of the following manifestations should the nurse include in the teaching? (Select all that apply.)
a. Persistent cough
b. Weight gain c. Fatigue
d. Night sweats
e. Purulent sputum
nurse is caring for a group of clients. Which of the following clients are at risk for pulmonary embolism? (Select all that apply.)
a. A client who has a BMI of 30
b. A female client who is postmenopausal c. A client who has a fractured femur
d. A client who is a marathon runner
e. A client who has chronic atrial fibrillation
168.A nurse is assessing a client who has a pulmonary embolism. Which of the following information should the nurse expect to find? (Select all that apply.)
f. Bradypnea
g. Pleural friction rub
h. Hypertension i. Petechiae
j. Tachycardia
169.A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states she is anxious and is unable to get enough air. Vital signs are HR 117/min, respirations 38/min, temperature 38.4 C (101.2 F), and blood pressure 100/54 mm Hg. Which of the following nursing actions is the priority?
k. Notify the provider.
l. Administer heparin via IV infusion. m. Administer oxygen therapy.
n. Obtain a spiral CT scan.
170.A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate and immediate concern for the nurse?
o. “I am allergic to morphine.”
p. “I take antacids several times a day.”
q. “I had a blood clot in my leg several years ago.”
r. “It hurts to take a deep breath.”
nurse is caring for a client who is to receive thrombolytic therapy. Which of the following factors should the nurse recognize as a contraindication to the therapy?
a. Hip arthroplasty 2 weeks ago
b. Elevated sedimentation rate
c. Incident of exercise-induced asthma 1 week ago
d. Elevated platelet count
nurse is assessing a client following a gunshot wound to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax? (Select all that apply.)
a. Tachypnea
b. Deviation of the trachea
c. Bradycardia
d. Decreased use of accessory muscles e. Pleuritic pain
nurse is reviewing the prescriptions for a client who has a pneumothorax. Which of the following actions should the nurse perform first?
a. Assess the client’s pain.
b. Obtain a large-bore IV needle for decompression.
c. Administer lorazepam.
d. Prepare for chest tube insertion.
nurse is reviewing discharge instructions for a client who experienced a pneumothorax. Which for the following statement should the nurse use when teaching the client?
a. “Notify the provider if you experience weakness.”
b. “You should be able to return to work in 1 week.”
c. “You need to wear a mask when in crowded areas.”
d. “Notify your provider if you experience a productive cough.”
nurse in the emergency department is assessing a client who has a suspected flail chest. Which of the following findings should the nurse expect? (Select all that apply.)
a. Bradycardia b. Cyanosis
c. Hypotension d. Dyspnea
e. Paradoxic chest movement
nurse in the emergency department is assessing a client who was in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6 C (101.4 F), and SaO2 92% on room air. Which of the following actions should the nurse take first?
a. Obtain a chest ex-ray.
b. Prepare for chest tube insertion.
c. Administer oxygen via high-flow mask.
d. Initiate IV access.
177.A nurse is orientation a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome (ARDS). Which of the following statements by the newly licensed nurse indicates understanding of the teaching?
e. “This medication is given to treat infection.”
f. “This medication is given to facilitate ventilation.”
g. “This medication is given to decrease inflammation.”
h. “This medication is given to reduce anxiety.”
nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome? (Select all that apply.)
a. A client who experienced a near-drowning incident
b. A client following coronary artery bypass graft surgery
c. A client who has a hemoglobin of 15.1 mg/dL d. A client who has dysphagia
e. A client who experienced a drug overdose
nurse is planning care for a client who has severe respiratory distress system (SARS). Which of the following actions should be included in the plan of care for this client? (Select all that apply.)
a. Administer antibiotics.
b. Provide supplemental oxygen.
c. Administer antiviral medications.
d. Administer bronchodilators.
e. Maintain ventilatory support.
nurse is caring for a client who is receiving vecuronium for acute respiratory distress syndrome. Which of the following medications should the nurse anticipate administering with this medication? (Select all that apply.)
a. Fentanyl
b. Furosemide c. Midazolam
d. Famotidine
e. Dexamethasone
nurse is orienting a newly licensed nurse on the care of a client who is to have a line placed for hemodynamic monitoring. Which of the following statements by the newly licensed nurse indicates effectiveness of the teaching?
a. “Air should be instilled into the monitoring system prior to the procedure.”
b. “The client should be positioned on the left side during the procedure.”
c. “The transducer should be level with the second intercostal spaced after the line is placed.” d. “A chest x-ray is needed to verify placement after the procedure.”
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