Kaplan - QBANK
The nurse cares for a 17-year-old girl diagnosed with cancer receiving chemotherapy. Which of the following statements indicates to the nurse that the client has a realistic perception of her health st
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Kaplan - QBANK
The nurse cares for a 17-year-old girl diagnosed with cancer receiving chemotherapy. Which of the following statements indicates to the nurse that the client has a realistic perception of her health status?
The client is brought to the emergency department by friends who state, "He has been hanging
with the wrong crowd. We are worried he is using drugs." The nurse notes that the client stares blankly and has an unsteady gait, stiff muscles, and eyes that are moving rapidly side to side and up and down. The nurse plans care. Which is MOSTimportant for the nurse to anticipate?
The nurse assesses a client in the outpatient clinic. The client states she was diagnosed with
osteoarthritis 15 years ago and takes aspirin multiple times per day. Which of the following actions by the nurse is MOST appropriate?
The medical nurse enters the room of a confused patient diagnosed with angina pectoris in
order to remove the patient's nitroglycerin patch for the night. Upon opening the patient's gown, the nurse sees that the patch is not evident where charting indicated it was placed. What is the FIRST action the nurse should take?
The 35-year-old mother of five children ranging in age from 4 to 17 years tells the health service
nurse, "The father of my children passed away 3 weeks ago. We had been apart for several years, but the children have taken his death really badly." When asked how she herself has handled the death, she replies, "I am doing OK. I have been focused on helping the children. I can hardly believe it happened. He was only 34 years old. I don't know if and when it will really hit and upset me that he is gone." Which of the following responses by the nurse is MOST appropriate initially?
The nurse in the outpatient surgery prepares a 2-year-old child for a myringotomy for
placement of tympanostomy tubes. It is MOST important for the nurse to take which of the following actions?
A patient diagnosed with type 2 diabetes mellitus is treated for hypertension with propanolol
(Inderal). History reveals that the patient is diagnosed with glaucoma and is allergic to sulfa. The nurse is MOST concerned if an order was written for which of the following medications?
The nurse instructs a client on a postpartum about proper perineal care. The nurse determines
that further teaching is needed if the client states which of the following?
A woman comes to the outpatient clinic in the 16th week of her pregnancy. The client asks the
nurse why she is going to receive RhoGAM (Rho [D] globulin) during her pregnancy. Which of the following is the BEST response by the nurse?
A client in the psychiatric unit continually complains to the nurse that his stomach is missing.
Which of the following responses by the nurse is MOST appropriate?
The nurse performs teaching for a client receiving clonidine (Catapres-TTS) transdermal patch.
Which of the following statements, if made by the client to the nurse, indicates teaching is successful?
A 6-year-old girl is brought to the well-child clinic for a checkup by her mother. While the child is
playing in the clinic playroom, the nurse observes her behavior. Which of the following activities demonstrates to the nurse that the child has musculoskeletal development that is age- appropriate but not advanced for her age?
The nurse cares for clients in the emergency department. The nurse assesses a client following a
car wreck. Which of the following observations, if made by the nurse, warrants the nurse remaining with the client?
The school nurse is observing a high-school basketball game. Two cheerleaders are tumbling
and hit each other in mid-air. One of the cheerleaders begins to cry and says, "I think my arm is broken." Which of the following actions should the school nurse take FIRST?
The nurse instructs the mothers of toddlers about safety precautions for their children's eyes,
ears, and noses. Which of the following is the MOST important statement for the nurse to include?
Which of the following observations of a comatose 57-year-old woman requires an immediate
intervention by the nurse?
The nurse in the day care center observes a 2-year-old boy squatting and panting after chasing a
ball. Which of the following actions should the nurse take FIRST?
The clinic nurse instructs a young adult scheduled in 2 days for surgery. It is MOST important for
the nurse to report which of the following client statements to the physician?
The nurse cares for a newborn diagnosed with a myelomeningocele. The nurse identifies that
which of the following actions is MOST important?
The nurse discusses skateboard safety with a group of parents. It is MOST important for the
nurse to include which of the following statements?
The nurse cares for clients in the senior citizens facility. A client relates to the nurse that, "I had
pneumonia once, and I don't want to get it again." To develop an effective teaching plan for this
client, it is MOST important for the nurse to obtain an answer to which of the following questions?
A patient on the inpatient psychiatric unit is diagnosed with dissociative identity disorder. Which
of the following occurrences BEST indicates to the psychiatric nurse that the patient is improving?
The nurse instructs a client receiving acyclovir (Zovirax). The nurse determines that teaching is
effective if the client states which of the following?
1. "The medication will cure my disease."
2. "I should take this medication with food."
3. "I'm glad that I only have to take this once a day."
4. "I can apply lotion on the lesions if they begin to hurt."Strategy: "Teaching is effective" indicates correct information.
1) virus lays dormant in ganglia; medication is not a cure
2) CORRECT— may cause nausea and vomiting; antiviral used to treat herpes
3) given 5 times/day
4) OTC lotions and creams may delay healing and cause spread of lesions
A nurse on the psychiatric unit overhears one client yelling at another client, "You are always
borrowing my things. Stay out of my way!" Which of the following responses by the nurse is BEST?
1. "You both seem very upset with each other."
2. "You sound very angry with the other client."
3. "We will have to make a plan to prevent this from happening."
4. "You must leave this room immediately because you are out of control."Strategy: Determine the outcome of each answer. Is it appropriate?
1) nurse should address the aggressor; important to set limits by explaining expected behaviors
2) CORRECT— address the aggressor to try to diffuse the anger
3) contracting is appropriate, but first de-escalate the situation
4) will further escalate the situation
The nurse manager of the psychiatric unit plans the biweekly unit-wide multidisciplinary team
case conference focused on one particular patient. Which of the following patients is MOST important for the manager to select for discussion?
A home health nurse makes an initial visit to a client diagnosed as legally blind. Which of the
following recommendations should the nurse make FIRST?
1. Call a plumber to set the hot-water tank's thermostat at 100 degrees.
2. Use battery-operated appliances rather than electrical appliances.
3. Remove most of the furniture from the home
4. Purchase clothing that is easy for the client to don.Strategy: "FIRST" indicates priority.
1) CORRECT— reduces possibility of burns by hot water
2) can be taught to use electrical appliances safely
3) no reason to remove furniture; articles and furniture should be kept in the same positions so that client knows where they are
4) client can learn to dress self; does not necessarily require special clothing
The nurse is caring for a patient with a casted left leg. Which of the following exercises should
the nurse recommend?
The nurse cares for a client diagnosed with thrombocytopenia due to acute lymphocytic
leukemia. The nurse should assign this client
The home care nurse performs an initial visit to the home of a client diagnosed with a
myocardial infarction. The client's nose is bleeding, and he reports that he is unable to stop the bleeding. It is MOST important for the nurse to ask which of the following questions?
1)
The nurse on the pediatric unit cares for a 7-year-old girl under observation for cerebral
concussion after being struck by her 10-year-old brother's bicycle. The parents are at the bedside and begin to discuss the cause of the accident. Which of the following statements, if made by the parents, validates the nursing diagnosis of dysfunctional family process?
The nurse plans care for an adult woman admitted with toxic shock syndrome. The nurse is
MOST concerned if the client states which of the following?
A client is scheduled for surgery in 10 days for removal of a pilonidal cyst. The nurse notes the
client is diagnosed with adrenal insufficiency and has been taking prednisone 5 mg PO bid. The nurse expects the physician to take which of the following actions?
The nurse prepares for the admission of a patient diagnosed with diabetes and a latex allergy.
The only private room on the unit is occupied by a patient diagnosed with tuberculosis. The nurse should take which of the following actions when assigning the new patient to a room on the unit?
The nurse changes the dressing on a client with a large abdominal wound with two Penrose
drains in place. What is the priority information for the nurse to include when recording this procedure?
The nurse admits a client from the emergency room with left-sided paralysis. The client is alert
and oriented, but his speech is slurred. It is MOST important for the nurse to include which of the following instructions for the nursing assistant?
A famous rock star is admitted to a psychiatric unit with a diagnosis of major depression with
psychotic features. A nurse who works on the medical surgical unit asks the psychiatric nurse why the patient was admitted. Which of the following responses by the nurse is BEST?
The nurse in the emergency department cares for a client diagnosed with a possible cervical
spinal cord injury. It is MOST important for the nurse to assess for which of the following?
A community experiences a prolonged heat wave. The emergency department nurse expects to
see which of the following indications if a patient is admitted with a diagnosis of heat stroke?
The clinic nurse evaluates a client diagnosed with type 1 diabetes. Which of the following
observations indicates to the nurse that the client is not rotating insulin injection sites?
The physician orders cefuroxime (Ceftin) 250 milligrams orally every 12 hours. Cefuroxime
(Ceftin) is available in 125 milligrams/tablet. How many tablets should the nurse administer?2 tabs
The school nurse finds a teenager slumped on the floor of the bathroom with a razor blade in
his hand, bleeding from his wrist. Which of the following responses by the nurse is MOST appropriate?
The nurse instructs a teenager newly diagnosed with type 1 diabetes. Which of the following
statements, if made to the nurse by the client, indicates that teaching is effective?
A patient is admitted to the hospital for treatment of recurrent deep vein thrombosis (DVT) of
the right leg. The nurse is MOST concerned if which of the following is observed?
A mother of a 7-year-old girl and 2 1/2-year-old boy tells the clinic nurse that she works full-
time, loves to garden in her spare time, and has lots of house plants. She relates to the nurse that her 2 1/2-year-old is "into everything all the time and drives me to distraction!" Which of the following responses by the nurse is BEST?
The nurse expects the emotional responses of a client with a cerebral vascular accident (CVA) of
the left hemisphere to be MOST influenced by which of the following?
The nurse cares for clients in the Emergency Department (ED). The nurse is approached by
transport personnel asking the nurse to sign out a client for transport for magnetic resonance imaging (MRI). The client states "I was in a car accident and there is something wrong with my left eye." Which of the following responses by the nurse to the transport personnel is MOST appropriate?
A patient who is diagnosed with leukemia and has a platelet count of 1,000/mm3 is scheduled
to receive a platelet transfusion. The new graduate nurse reviews with the nurse manager the plans for the transfusion. It is MOST important for the manager to respond to which of the following statements made by the new graduate nurse?
The nurse is caring for a patient with a deep vein thrombosis (DVT). The nurse should notify the
physician if the patient complains of which of the following?
A 1-month-old infant is brought to the pediatrician's office. Which of the following findings, if observed by the nurse, warrants further investigation?
The nurse cares for clients in a physician's office. A client complains of a sore throat and fever.
Culture indicates the client has group A beta-hemolytic Streptococcus infection and urinalysis reveals a large amount of protein and a large number of red blood cells. The physician prescribes antibiotics. The client informs the nurse that he would like to schedule a follow-up appointment in 6 weeks after the client returns from an international conference. Which of the following actions should the nurse take NEXT?
The nurse reviews the principles of correct body mechanics with a nurse aide. Which of the
following suggestions by the nurse is MOST appropriate?
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