1) A nurse is caring for a client who has hepatic encephalopathy that is being treated with
lactulose. The client is experiencing excessive stools. Which of the following findings is
an adverse effect of this medicatio
...
1) A nurse is caring for a client who has hepatic encephalopathy that is being treated with
lactulose. The client is experiencing excessive stools. Which of the following findings is
an adverse effect of this medication?
a. Hypokalemia
b. Hypercalcemia
c. Gastrointestinal bleeding
d. Confusion
2) A nurse is caring for a client who has emphysema and is receiving mechanical
ventilation. The client appears anxious and restless, and the high-pressure alarm is
sounding. Which of the following actions should the nurse take first?
a. Obtain ABGs
b. Administer propofol to the client
c. Instruct the client to allow the machine to breathe for them.
d. Disconnect the machine and manually ventilate the client
3) A nurse is teaching a client who has family history of colorectal cancer. To help mitigate
this risk, which of the following dietary alterations should the nurse recommend?
a. Add full-fat yogurt to the diet
b. Add cabbage to the diet
c. Replace butter with coconut oil
d. Replace shellfish with red meat
4) A home health nurse is assigned to a client who was recently discharged from a
rehabilitation center after experiencing a right-hemispheric stroke. Which of the
following neurological deficits should the nurse expect to find when assessing the client?
(Select all that apply)
a. Expressive aphasia
b. Visual spatial deficits
c. Left hemianopsia
d. Right hemiplegia
e. One-sided neglect
5) A nurse is caring for a client who has viral pneumonia. The client’s pulse oximeter
readings have fluctuated between 79% and 88% for the last 30 min. Which of the
following oxygen delivery systems should the nurse initiate to provide the highest
concentration of oxygen?
a. Nonrebreather mask
b. Venturi mask
c. Simple face mask
d. Partial rebreather mask
6) A nurse is caring for a client who has bilateral pneumonia and an SaO2 of 85%. The client
has dyspnea with a productive cough and it using accessory muscles to breathe. Which
of the following actions should the nurse take first?
a. Obtain a prescription for ABGS
b. Administer IV antibiotics to the client
c. Instruct the client to use the incentive spirometer
d. Place the client in high-Fowler’s position
7) A nurse is planning care for a client who has extensive burn injuries and is
immunocompromised. Which of the following precautions should the nurse include in
the plan of care to prevent a Pseudomonas aeruginosa infection?
a. Encourage the client eat raw fruits and vegetables.
b. Avoid placing plants or flowers in the client’s room
c. Limit visitors to members of the client’s immediate family
d. Wear an N95 respirator mask when providing care to the client.
8) An older adult client is brought to an emergency department by a family member. Which
of the following assessment findings should cause the nurse to suspect that the client
has hypertonic dehydration?
a. Serum sodium level 145 mEq/L
b. Forearm skin tents when pinched
c. Respiratory rate decreased
d. Urine specific gravity 1.045
9) A nurse is an emergency department is reviewing the provider’s prescriptions for a client
who sustained a rattlesnake bite to the lower leg. Which of the following prescriptions
should the nurse expect?
a. Apply ice to the client’s puncture wounds.
b. Initiate corticosteroid therapy for the client
c. Keep the client’s leg above heart level
d. Administer an opioid analgesic to the client
10) A nurse is assessing a client who has had a suspected stroke. The nurse should place the
priority on which of the following findings?
a. Dysphagia
b. Aphasia
c. Ataxia
d. Hemianopsia
11) A nurse is teaching a young adult client how to perform testicular self-examination.
Which of the following instructions should the nurse include?
a. Compare both testicles by examining them simultaneously
b. Roll each testicle between the thumb and fingers
c. Perform testicular self-examination before a warm bath or shower
d. Perform self-examination of the testicles every 2 weeks
12) A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new
prescription for metformin. Which of the following statements by the client indicates an
understanding of the teaching?
a. “I will monitor my blood sugar carefully because the medication increases the
secretion of insulin.”
b. “I should take this medication with a meal.”
c. “I can expect to gain weight while taking this medication.”
d. “While taking this medication, I will experience flushing of my skin.”
13) A Nurse is teaching a client who has venous insufficiency about self-care. Which of the
following statements should the nurse identify as an indication that the client
understanding the teaching?
a. “I should avoid walking as much as possible.”
b. “I should sit down and read for several hours a day.”
c. “I will wear clean graduated compression stockings every day.”
d. “I will keep my legs level with my body when I sleep at night.:”
14) A nurse is assessing a client who has acute cholecystitis. Which of the following findings
is the nurse’s priority?
a. Anorexia
b. Abdominal pain radiating to the right shoulder
c. Tachycardia
d. Rebound abdominal tenderness
15) A nurse is reviewing the health record of a client who is scheduled for allergy skin
testing. The nurse should postpone the testing and report to the provider which of the
following findings?
a. Disease processes
b. Laboratory findings
i. Blood glucose (fasting) 102 mg/dL
ii. BUN 15 mg/dL
iii. Creatinine 1 mg/dL
iv. Prostate Specific Antigen (PSA) 1.5 mg/mL
c. Current medications
i. Ibuprofen PRN for headaches
ii. Olmesartan 20p mg PO daily
iii. Prednisone 5 mg PO daily
d. Family history
i. Gouty arthritis for 3 years
ii. Hypertension diagnosed 5 years ago
iii. 1 pack per day cigarette use for 15 years
iv. Family history of prostate cancer
16) A nurse is caring for a group of clients. The nurse should plan to make a referral to
physical therapy for which of the following clients?
a. A client who is receiving preoperative teaching for a right knee arthroplasty
b. A client who states they will have difficulty obtaining a walker for home use.
c. A client who reports an increase in pain following a left hip arthroplasty
d. A client who is having emotional difficulty accepting that they have a prosthetic
leg
17) A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following
laboratory findings should the nurse expect?
a. Negative urine ketones
b. BUN 32 mg/dL
c. pH 7.43
d. HCO3 -23 mEq/L
18) A nurse is planning teaching for a client who has bladder cancer and is to undergo a
cutaneous diversion procedure to establish a ureterostomy. Which of the following
statements should the nurse include in the teaching?
a. “You will still have the urge to void.”
b. “You can apply an aspirin tablet to the pouch to reduce odor.”
c. “You should cut the opening of the skin barrier one-eighth inch wider than the
stoma.”
d. “You should use a moisturizing soap when washing the skin around the stoma.”
19) A nurse is providing teaching for a female client who has recurrent urinary tract
infections. Which of the following information should the nurse include in the teaching?
a. Take tub baths daily
b. Drink at least 1 L of fluid daily
c. Wear underwear made of nylon
d. Void before and after intercourse
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