. A nurse is planning to obtain a 12-lead ECG for a client who has a history of cardiac dysrhythmias. Which of the following
actions should the nurse plan to take?
- tell the client to expect a mild stinging sensation
...
. A nurse is planning to obtain a 12-lead ECG for a client who has a history of cardiac dysrhythmias. Which of the following
actions should the nurse plan to take?
- tell the client to expect a mild stinging sensation during the test
- attach a blood pressure cuff to the clients upper arm
- assist the client to the orthopneic position
- instruct the client to remain as still as possible during the recording
2. A home health nurse is conducting a home inspection for a client who is at risk for falls. Which of the following instructions
should the nurse provide for the client?
- place area rugs on slick floor surfaces
- move the clients bed to the main floor of the house
- keep lighting in the home dim
-place the bedside table 2 feet away from the bed
3. A nurse is reinforcing teaching about common discomforts during the first trimester with a client who is at 10 weeks of
gestation. Which of the following examples should the nurse include?
- burning during urination
- leukorrhea
- swelling of the face
- diarrhea
4. A nurse is monitoring a client who is postoperative. Which of the following actions should the nurse take when collecting data
about the client's respirations?
- count the client's respirations for 15 seconds
- observe the movements of the client's chest wall
- place the client in a supine position
- inform the client when beginning to observe his respirations
5. A nurse is caring for a client who suddenly develops chest pain and dyspnea. Which of the following actions should the nurse
take first?
- place the client on bedrest
- elevate the head of the client's bed
- prepare the client for a ventilation perfusion scan
- obtain the clients ABG levels
6. A community health nurse is assisting in the development of a brochure about hypertension. Which of the following actions
should the nurse take?
- explain medical terminology using basic, one-syllable words
- present information from complex to simple
- write the information at an 8th-grade reading level
- use a 12 point font size
7. A nurse is reinforcing teaching with the support person of a client who is in the first stage of labor. Which of the following
instructions should the nurse include regarding effleurage?
- apply steady pressure with this tennis ball to her sacral area
- help her to focus on an object in the room
- gently stroke her abdomen during contractions
- assist her to breathe in deeply at the beginning of each contraction
8. A nurse is planning to complete an incisional dressing change for a client who is postoperative following an open
cholecystectomy. In which of the following areas should the nurse expect to find the client's incision? (you will find hot spots
to select in the artwork below. Select only the hot spot that corresponds to your answer.)
- PICTURE OF BODY
-
9. A nurse is reinforcing teaching with a newly licensed nurse about transcribing medication prescriptions. Which of the following
prescriptions should the newly licensed nurse identify is an accurate transcription?
- Heparin 5000 U subcutaneous every 8 hr
- MgSO4 10 g PO daily
- Doxazosin .5 mg PO at bedtime
- Lorazepam 0.5 mg PO PRN at bedtime
10.A nurse is reviewing laboratory data from a client who has diabetes mellitus.Which of the following laboratory tests is the most
accurate indicator of long -term disease management?
-Glycosylated hemoglobin.
-Urine ketones.
-Glucose tolerance test.
-Fasting blood glucose
11. A nurse is reinforcing teaching with a client who has a new prescription for ciprofloxacin. Which of the following information
should the nurse include in the teaching?
- Restrict your daily fluid intake while taking this medication
-take an antacid if the medication causes gastrointestinal upset
- this medication can increase your risk for sunburn
- expect to experience diarrhea while taking this medication
12. A charge nurse is discussing confidentiality requirements with a newly licensed nurse when sharing a client's medical information.
Which of the following individuals should the charge nurse identify as appropriate with whom to share client information?
-a nurse from another unit after a client commits suicide
- a client's employer who is concerned about safety due to substance use
- a social worker who is assigned to an involuntarily committed school-age client
- a client’s partner after the client reports intimate partner abuse
13. A nurse is caring for a client who follows a kosher diet. Which of the following menu items should the nurse include on the tray?
- clam chowder
- shrimp salad
- roasted salmon
- pulled-pork sandwich
14. A nurse is caring for a client who has been admitted to the mental health unit. While reinforcing teaching about the clients
prescribed medications, the nurse communicates truthfully about the adverse effects of the medications. Which of the following
ethical concepts is the nurse exhibiting?
- autonomy
- beneficence
- veracity
- justice
15. A nurse on a mental health unit is reinforcing with a client who has anorexia nervosa. Which of the following statements by the
client indicates an understanding of the teaching?
- the treatment goal is to be within 60 percent of my ideal body weight
- the staff will weight me every night before I go to bed
- the staff will watch me closely for 1 hour after each meal
- I should gain half of a pound per week to meet my treatment goal
16. A nurse is reinforcing teaching about preventing dental caries with the parent of a 12-month-old toddler. Which of the following
instructions should the nurse provide?i
- clean the teeth with a small, soft-bristled toothbrush
- use a 5-inch strip of toothpaste on the toothbrush
- position the bristles of your child’s toothbrush against the teeth at a 90-degree angle
- floss between your child’s teeth before brushing
17. A nurse is caring for a client who has major depressive disorder and is taking an antidepressant. The nurse should identify which
of the following findings as the priority to report to the provider?
- the client neglects personal hygiene
- the client is withdrawn and uncommunicative
- the client has a sudden increase in energy
- the client reports a change in sleeping patterns
18. A nurse in an acute care setting is preparing to administer medications to a client. Which of the following information should the
nurse obtain to identify the client?
- clients telephone number
- name of the client’s provider
- clients full medical diagnosis
- room number of the client
19. A nurse overhears two assistive personnel discussing a client’s medical history in the hallway. Which of the following actions
should the nurse take first?
- speak to the staff members in private about the client confidentiality
- report the incident to the charge nurse
- participate in an in-service about client confidentiality
- tell the staff members to stop their discussion
20. A nurse is caring for a child........................................................................................................CONTINUED
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