1. A nurse is assessing a client who has received an antibiotic. The nurse should identify which of the following findings as an indication of a possible allergic reaction to the medication?
A. Bradycardia
B. Headache
...
1. A nurse is assessing a client who has received an antibiotic. The nurse should identify which of the following findings as an indication of a possible allergic reaction to the medication?
A. Bradycardia
B. Headache
C. Joint pain
D. Hypotension
2. A nurse on a mental health unit is caring for a client who has schizophrenia and is experiencing auditory hallucinations telling them to hurt others. The client is refusing to take anti-psychotic medication. Which of the following responses should the nurse make?
A. “You should plan to take this medication for a few weeks.”
B. “You will regret it if you do not take this medication.”
C. “This medication will help you respond to the voices.
D. “This medication will help you stop the voices you are hearing.”
3. A nurse is providing care for a patient who has depression and is to have electroconvulsive therapy. Which of the following conditions should the nurse identify as increasing the client’s risk for complications?
A. Hyperthyroidism
B. Renal calculi
C. Diabetes mellitus
D. Cardiac dysrhythmias
4. 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/mm
B. Platelets 150,000/mm
C. Aspartate aminotransferase 10 units/L D. Erythrocyte sedimentation 75 mm/hr
5. A nurse is suctioning the airway of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following findings should the nurse identify as an indication that suctioning has been effective?
A. Presence of a productive cough
B. Decreased peak inspiratory pressure
C. Thinning of mucous secretions
D. Flattening of the artificial airway cuff
6. 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. Stand within 30cm (1 ft) of the client when speaking with them.
B. Express sympathy for the client’s situation.
C. Confront the client about his behavior. D. Speak assertively to the client.
7. A nurse is caring for a client who is immediately postoperative following an adrenalectomy to treat Cushing’s disease. Which of the following actions is the nurse’s priority?
A. Reposition the client for comfort every 2 hours
B. Observe for any indications of infection
C. Document amount and color of the incisional drainage. D. Monitor the client’s fluid and electrolyte status.
8. A nurse is caring for a client who is scheduled for a surgical procedure and states, “I don’t want to have this surgery anymore.” Which of the following responses should the nurse make?
A. “We can manage your care following the procedure without complications.” B. “You have the right to refuse the procedure.”
C. “Your doctor thinks the surgery is necessary.”
D. “Let me review the procedure so you can understand what is going to happen.”
9. A nurse is evaluating a client who has borderline personality disorder. Which of the following behaviors indicates an improvement in the client’s condition?
A. Impulsive behaviors
B. Decreased clinging behavior
C. Liability of mood
D. Dependent behavior
10. A nurse is teaching a group of school-age children about healthy snack options. Which of the following snacks should the nurse include?
A. Air-popped popcorn
B. Milkshake made with whole milk.
C. Baked potato chips
D. Cheesecake
11. A nurse is providing teaching to a client who has a new prescription for enoxaparin. Which of the following medications for pain relief should the nurse include in the teaching that can be taken concurrently with enoxaparin?
A. Naproxen sodium
B. Ibuprofen
C. Acetaminophen
D. Aspirin
12. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse plan to administer?
A. Colchicine
B. Lorazepam C. Pregabalin
D. Codeine
13. A nurse is caring for a client who has congestive heart failure and is receiving furosemide and digoxin. Which of the following laboratory values indicates that the client is at risk for developing digoxin toxicity?
A. Glucose 150 mg/dL
B. Magnesium 1.3 mEq/L C. Potassium 3.1 mEq/L
D. Sodium 134 mEq/L
14. A nurse is caring for a client who had an embolic stroke and has a prescription for alteplase. Which of the following in the client’s history should the nurse identify as a contraindication for receiving alteplase?
A. Hip arthroplasty 1 week ago correct
B. Obstructive lungs disease
C. Retinal detachment
D. Acute kidney failure 6 months ago
15. A nurse is providing discharge teaching for a client who has a new implantable cardioverter defibrillator (ICD). Which of the following client statements demonstrates understanding of the teaching?
A. “I will soak in the tub rather than showering.”
B. “I can hold my cellphone on the same side of my body as the ICD.” C. “I will wear loose clothing over my ICD.”
D. “I will avoid using my microwave oven at home because of my ICD.”
16. A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25ml/hr. Which of the following interventions should the nurse anticipate?
A. Clamp the catheter tubing for 30 min
B. Initiate continuous bladder irrigation
C. Obtain a urine specimen for culture and sensitivity
D. Administer a fluid bolus
17. A nurse is caring for a client who has experienced a stillbirth. Which of the following actions should the nurse take during the initial grieving process?
A. Avoid talking to the client about the newborn
B. Discourage the client from allowing friends to see the newborn C. Offer to take pictures of the newborn for the client
D. Assure the client that she can have additional children
18. A nurse is caring for a client who has a major burn injury. Which of the following actions is the nurse’s priority to prevent wound infection?
A. Use sterile dressings for wound care
B. Apply topical antibiotics to the client’s wounds.
C. Place the client in protective isolation.
D. Maintain consistent hand washing by staff.
19. A nurse is speaking with the caregiver of a client who has Alzheimer’s disease. The caregiver states, “Providing constant care is very stressful and is affecting all areas of my life.” Which of the following actions should the nurse take?
A. Discuss methods of how to communicate with the client about problem solving behaviors.
B. Suggest that the caregiver seek a prescription for an antipsychotic medication for the client. C. Assist the caregiver to arrange a daycare program for the client.
D. Recommend allowing the client to have time alone in their room throughout the day.
20. A nurse is caring for a client who is 1 hr postpartum and unable to urinate. Which of the following actions should the nurse take?
A. Administer a benzodiazepine
B. Perform a fundal massage
C. Place an ice pack on the client’s perineum D. Place the client’s hand in warm water
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