1. The nurse is teaching a client about self-examination. The client asks the nurse where
masses are most often found. Which response(s) by the nurse are most appropriate?
Select all that apply.
A. In the axilla
B. B
...
1. The nurse is teaching a client about self-examination. The client asks the nurse where
masses are most often found. Which response(s) by the nurse are most appropriate?
Select all that apply.
A. In the axilla
B. Beneath the nipple
C. Lower inner quadrant
D. Upper outer quadrant
E. Lower outer quadrant
2. The nurse is assessing a client with herpes zoster. Which characteristic(s) does not the
nurse expect to note when assessing the lesions of this infection? Select all that apply.
A. Clustered skin vesicles
B. A generalized body rash
C. Small blue-white spots with a red base
D. A fiery red edematous rash on the cheeks
E. Grouped vesicles on an erythematous base.
13. which action should the nurse take to monitor the effects of an acute stressor on a
hospitalized patient (Select all that apply)?
A. Assess for bradycardia
B. Ask about epigastric pain
C. Observe for increased appetite
D. Check for elevated blood glucose levels
E. Monitor for a decrease in respiratory rate
15. The health care provider plans to titrate a patient-controlled analgesia (PCA. Machine
to provide
pain relief for a patient with acute surgical pain who has never received opioids in the past.
Which of the following nursing actions regarding opioid administration are appropriate at
this time(select all that apply)?
A. Assessing for signs that the patient is becoming addicted to the opioid
B. Monitoring for therapeutic and adverse effects of opioid administration
C. Emphasizing that the risk of some opioid side effects increases over time
D. Educating the patient about how analgesics improve postoperative activity levels.
E. Teaching about the need to decrease opioid doses by the second postoperative day
18. On the examination the following question will ask to put in order: A patient who has an
infected
abdominal wound develops a temperature of 104 degree F. ( 40 C. All the following
interventions are included in the patient’s plan of care. In which order should the nurse
perform the following actions?
A. Sponge patient with water. 3
B. Administer intravenous antibiotics. 1
C. Perform wet to dry dressing change. 4
D. Administer acetaminophen (Tylenol) 2
29. The nurse that which of the following clients are at risk to develop pneumonia? Select
all that apply.
A. A 16 year old male who has experimented with cigarettes
B. A 25 year old female diagnosed with cystic fibrosis
C. A 36 year old male diagnosed with Addison’s disease
D. A 47 old male diagnosed with hypertension
E. A 68 year old with a fracture rib due to an auto accident
F. A 79 year old female in Buck’s traction due to a fractured hip
38. The nurse is developing a discharge-teaching plan for the client diagnosed with
congestive heartfailure. Which intervention should be included in the plan? Select all that
apply.
A. Notify health care provider of more than 1 pound a week
B. Teach client how to count the radial pulse when taking digoxin, a cardiac glycoside
C. Instruct client to remove the salt shaker from the dinner table
D. Encourage client to monitor urine output for change in color to become dark
E. Discuss the importance of taking the loop diuretic Furosemide at bedtime
39. The nurse Is caring diagnosed with myocardial infarction who is experiencing chest
pain. Which interventions should the nurse implement? Select all that apply.
A. Administer morphine via IV
B. Administer an aspirin orally
C. Apply oxygen via nasal cannula
D. Place the client in a supine position
E. Administer nitroglycerin subcutaneously
40. Which client teaching should the nurse implement for the client diagnosed with
coronary artery disease? Select all that apply.
A. Encourage a low-fat, low-cholesterol diet
B. Instruct client to walk 30 minutes a day
C. Decrease the salt intake to 2 grams a day
D. Refer to counselor for stress reduction techniques
E. Increase fiber in the diet
41.Which signs and symptoms should the nurse assess in any client who has a long term
valvular heart disease? Select all that apply.
A. Paroxysmal nocturnal dyspnea
B. Orthopnea
C. Cough
D. Pericardial friction rub
E. Pulsusparadous
42. The client is in ventricular fibrillation. Which interventions should the nurse
implement? Select all that apply.
A. Start cardiopulmonary resuscitation
B. Prepare to administer the antidysrhythmic adenosine IVP
C. Prepare to defibrillate the client
D. Bring the crash cart to the bedside
E. Prepare to administer the antidysrhythmicamiodarone IVP
43. The health care provider orders a medication in a dose that us considered toxic. The
nurse administers the medication to the client, who later suffers cardiac arrest and dies.
What consequence can the nurse expect from this situation? Select all that apply.
A. The health care provider can be charged with negligence, being the person who
ordered the
dose
B. As the employing agency, only the hospital can be charged with negligence
C. The nurse and physician may be terminated from employment to prevent a charge
of negligence
to the hospital;
D. Negligence will not be charged, as this event could happen to any reasonable
person
E. The nurse can be charged with negligence for administering the toxic dose
45. Which action would the nurse take to maintain medical asepsis when caring for a
client with diabetes mellitus on the medical nursing unit who requires irrigation of a
leg ulcer and insulin injections? Select all that apply.
A. Wash hands before and after client care.
B. Wear personal protective equipment during the dressing change
C. Recap a needle after administering insulin
D. Change the dressing for a diabetic ulcer using sterile gloves
E. Wipe the rubber stopper on the insulin vial before withdrawing dose
55. Chest trauma to at least one of the several pathologic states; what are they?
Select all that apply.
A. Hypovolemia
B. Cardiac failure
C. Pulmonary embolus
D. Hypoxemia
E. Aortic rupture
56.The occupational health nurse is assessing new employee at her company. What
would be important to assess in employee with a potential occupational respiratory
history? (Mark all that apply.)
A. Time frame of exposure
B. Effectiveness of respiratory protection used
C. General hygiene
D. Outside interests
E. Other areas lived
70. A nurse is talking with a delusional client when the fire alarm sounds and a staff
member closes the door to the client’s room. The client becomes very agitated and
declares, “The aliens have arrived!” which actions are appropriate for the nurse to
take? Select all that apply.
A. Leaving the room but telling the client she’ll return soon
B. Telling the client that there’s no danger and that everything’s fine
C. Telling the client that the alarm is just a drill and that he shouldn’t be afraid.
D. Staying with the client until she receives further instructions
E. Continuing to speak to the client in a reassuring tone
79. A nurse observes a nursing assistant bending over a bed as she helps an obese
client sit up. The nurse discusses her observations with the nursing assistant to
reinforce the need for proper body mechanics. Which response indicates that the
nursing assistant understands these principles? Select all that apply.
A. “I need to keep my back straight and lift with my tight muscles.”
B. “I need to keep my elbows bent and use my thigh muscles to bear the weight.”
C. “I should bend at the knees , keep my back straight, then pull the client up.”
D. “I should stand at the client’s side, grasp the draw sheet, and pull the client up
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