1) A nurse is reinforcing teaching to a client who was recently prescribed a 2,000 mg sodium restricted diet. Which of the following nutritional selections by the client indicates a need for further teaching? - ANSWER ¾
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1) A nurse is reinforcing teaching to a client who was recently prescribed a 2,000 mg sodium restricted diet. Which of the following nutritional selections by the client indicates a need for further teaching? - ANSWER ¾ cup of canned tomato juice
The nurse would recognize that the client didn't understand because tomato juice has a lot of sodium in it.
2)A nurse in a provider’s office is reinforcing teaching to the parents of a child who has allergies and is prescribed Benadryl 25mg every six hours as needed. Available is diphenhydramine 12.5/5mL. How many teaspoons of medicine does the nurse need to instruct the parents to administer per dose? - ANSWER 2 tsp
3) A nurse is caring for a client who has been prescribed a full liquid diet. Which of the following is appropriate to include in the client’s diet? - ANSWER Grape Juice, Ice Cream
4)A nurse is examining a client's lymphatic system. Identify the site nurse should palpate to assess the posterior cervical lymph nodes. - ANSWER Toward the back of the neck
5) A nurse is preparing to administer a tap water enema to a client. In which of the following positions should the nurse place the client? - ANSWER Sims
6) A nurse in a provider's office is caring for a client who has depression and is taking St. Johns Wort. The herbal supplement is thought to improve which of the following? - ANSWER Mood
St. John's Wort is widely used in the U.S. and other countries as an herbal supplement for treating mild to moderate depression and to relieve depression-related anxiety.
7) A nurse is caring for a client who is immobile and has developed a pressure ulcer. Which of the following characteristics is associated with a stage II pressure ulcer? - ANSWER partial thickness skin loss
Characteristics for a stage II ulcer include partial thickness skin loss. The nurse would know this because she is familiar with the stages of pressure ulcers.
8) A nurse on a pediatric unit is caring for an infant who is diagnosed with larynotrachebronchitis. While performing a respiratory examination the nurse hears which sound? - ANSWER STRIDOR
Stridor is a harsh high-pitched sound heard on inhalation or expiration. It is caused by turbulent air flow secondary to a narrowing or blockage in the upper airway and is a common clinical manifestation of acute laryngotracheobronchiti
9) A nurse is performing a respiratory examination on a client who has pneumonia. Which of the following sounds should the client be elected over areas if consolidation during percussion? - ANSWER Dullness
The nurse would know that a client with pneumonia likely would have a dullness sound in his lungs.
10) A nurse is preparing to measure the blood pressure of a client who has hypertension. Which of the following actions by the nurse when taking blood pressure can result in an inaccurately low reading? - ANSWER Using a cuff that is too wide.
Using a cuff that is too wide can result in a false low blood pressure reading.
11) A nurse on a rehabilitation unit is caring for a client who was admitted 3 days ago. Upon review of the client's medical record, which of the following actions should the nurse take? - ANSWER restrict fluid intake
Manifestations of fluid volume excess are indicated in the client's physical assessment findings of 2+ peripheral edema, elevated blood pressure, respiratory crackles bilaterally, and a BUN level that is below the expected reference range; therefore, it is appropriate for the nurse to restrict the client's fluid intake.
12) A nurse in caring for a client who is scheduled for a biopsy of a tumor located in the left lower lobe of the lung. The clients states, I will quit smoking if the results don't come back positive for cancer. - ANSWER Bargaining.
The statement made by the client is an example of bargaining. Clients or families might promise to improve or change habits as a part of the grieving process.
13) A nurse is reinforcing teaching to a client who is newly diagnosed with Lyme disease. The nurse should indicate that the diseases could by transmitted in which of the following ways? - ANSWER Vector
The nurse would know that the way Lyme disease is typically transmitted is through a tick, therefore it would fall in the vector category.
14) A nurse is preparing to administer an IM injection to an adult client who has a BMI of 30. Which of the following needle lengths is appropriate to administer the injection in the vetrogluteal muscle? - ANSWER 1 ½
A 1 1/2 inch needle is used for IM injections in adults. This length of needle is appropriate to use when administering an IM injection in the ventrogluteal muscle, which is a site commonly used for IM injections, in adults who have a BMI of 30.
15) A nurse is preparing to ausculate a clients heart. Which of the following positions is best for detecting a low pitched diastolic murmur? - ANSWER lying on side
This image represents the left lateral recumbent position, which is the best position for detecting a low-pitched diastolic murmur.
16) A nurse is preparing to transfer a client from a bed to a chair. The nurse should take which of the following actions to prevent a lift injury? - ANSWER Stand close to the client
To prevent a lift injury when transferring the client from the bed to a chair, the nurse should stand close to the client. Standing close to the client decreases reaching for the client and reduces stress on the nurse's back.
17) A nurse is caring for a client who is receiving vancomycin for a beta hemolytic streptococci infection. For which of the following adverse effects should the nurse monitor? - ANSWER hearing loss
THIS drug might cause hearing loss. Ototoxicity, an auditory nerve injury, is the most serious adverse effect of vancomycin and can result in hearing loss.
18) A nurse is assisting with the admission of a client who is scheduled for a surgical procedure. The nurse administers a prescribed a dose of lorazepam preoperatively. Which of the following statement by the client indicates the medication has been effective? - ANSWER I feel very relaxed now
Lorazepam is a benzodiazepine and is frequently given preoperatively to relieve anxiety and to promote relaxation. With this response the nurse would know that the drug has done its job effectively
19) A nurse is reinforcing a teaching to a client who has fractured ankle and is learning to walk up the stairs. Identify the sequence of the actions the client should be taught when using a modified 3-point crutch gait. - ANSWER Bear weight on unaffected leg,
transfer weight to crutches,
advance unaffected leg,
shift weight from crutches to unaffected leg,
and go up stairs.
20) A nurse is collecting data on a newly admitted client who is reporting abdominal discomfort. When examining the abdomen, which of the following techniques should the nurse perform first? - ANSWER Inspection
Inspection should be performed first while conducting an abdominal assessment on a client. Inspection allows the nurse to note the contour and symmetry of the ab
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