A nurse is caring for a client who has given informed consent for ECT. Just before the procedure, the client
tells the nurse she is considering not going forward with the treatment. Which of the following statements
by
...
A nurse is caring for a client who has given informed consent for ECT. Just before the procedure, the client
tells the nurse she is considering not going forward with the treatment. Which of the following statements
by the nurse is appropriate?
a. “You don’t have to go through with the treatment.”
b. “Most people who have this procedure feel better following the treatment.”
c. “It’s okay to be nervous before this treatment.”
d. “Your doctor wouldn’t have ordered this treatment unless it was necessary.”
2. While performing a routine assessment, a nurse notices fraying on the electrical cord of a client’s CPM
device. Which of the following actions should the nurse take first?
a. Report the defect to the equipment maintenance staff.
b. Ensure the device inspection sticker is current
c. Remove the device from the room
d. Initiate a requisition for a replacement CPM device
3. A nurse is caring for a client who is postoperative and has a new prescription for hydromorphone. Which of
the following actions should the nurse take?
a. Document administration of the medication upon removal from the medication dispensing system
b. Withhold the medication if the client does not appear to be in pain.
c. Count the current number of unit doses available in the medication dispensing system
d. Withhold the medication if the client has a fever
4. A nurse performing a change-of-shift assessment. Which of the following clients has the priority finding?
a. Type 2 DM and a blood glucose of 250 mg/dL
b. Pneumonia with a productive cough and a fever of 38.8° C (101.8° F)
c. 2 hr. post cast placement and has 2+ pitting edema and pallor
d. First-degree heart block and a heart rate of 62/min
5. A nurse in an outpatient mental health facility is providing teaching to a group of adolescents. Which of the
following statements by a client indicates an understanding of the teaching?
a. “I will limit my alcohol use to one drink daily while taking disulfiram.”
b. “I will avoid foods containing tyramine while taking fluoexetine.”
c. “I will take the sustained-release methylphenidate every morning.”
d. “I will take my lithium on an empty stomach.” (pharm pg. 64: taking lithium with food will help
decrease GI distress)
6. A nurse in the emergency department is assessing client who has major depressive disorder. Which of the
following actions should the nurse take first? [View Exhibit]
a. Administer Zofran to the client for nausea
b. Implement seizure precautions for the client
c. Encourage the client to verbalize feelings
d. Obtain the client’s weight
7. A nurse is completing an admission assessment for a client who ahs narcissistic personality disorder. Which
of the following should the nurse expect?
a. Suspicious of others
b. Exhibits separation anxiety
c. Ritualistic behavior
d. Preoccupied with aging
8. Drug Calc: Client weighs 99 lb. Prescribed diet of 1.5 g protein/kg/day. How many grams of protein per
day should the nurse include in the client’s dietary plan?
9. A nurse is planning care for a group of clients and is working with one LPN and one AP. Which of the
following actions should the nurse take first to manage her time effectively?
a. Develop an hourly time frame for tasks
b. Schedule daily activities
c. Determine goals of the day
d. Delegate tasks to the AP
10. A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate
via continuous IV infusion. Which of the following actions should the nurse include in the plan?
a. Restrict the client’s total fluid intake to 250 mL/hr.
b. Measure the client’s urine output every hour
c. Give the client protamine if signs of magnesium sulfate toxicity occur (antidote: calcium
gluconate)
d. Monitor the FHR via Doppler every 30 min
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