82 b. BUN 16 mg/dL (Normal 10-20) c. PT 12.2 seconds (Normal 11-14) d. Fasting blood glucose 103 mg/dL 180. A nurse is admitting a client who has schizophrenia. The client states, “I’m hearing voices.” Which of the foll
...
82 b. BUN 16 mg/dL (Normal 10-20) c. PT 12.2 seconds (Normal 11-14) d. Fasting blood glucose 103 mg/dL 180. A nurse is admitting a client who has schizophrenia. The client states, “I’m hearing voices.” Which of the following responses is the priority for the nurse to state? a. “How long have you been hearing the voices?” b. “What are the voices telling you?” c. “Have you taken your medication today?” d. “I realize the voices are real to you, but I don’t hear anything.”-Last Priority - Taken last Tuesday. 1. A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel (AP) telling the client, “If you don’t eat, I’ll put restraints on your wrists and feed you.” The nurse should intervene and explain to the AP that this statement constitutes which of the following torts? a. Malpractice b. Battery- physical c. Assault- verbal d. Negligence 2. A nurse is providing discharge instructions to the parent of a newborn. Which of the following statement by the parent indicates an understanding of the teaching? a. I will suction my baby’s mouth before I suction his nose. b. I will lubricate the tip of the syringe with water prior to suction his nose. c. I should insert the syringe into the center of his mouth. d. I should compress the bulb after inserting it into the mouth. 3. A nurse is providing discharge teaching about car seat safety to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? a. I will place my baby in a forward- facing car seat in my back seat (facing the rear) b. I can place my baby in the front seat with the airbag turned off. (dont put newborn in front) c. I will position my baby at a 45 degree angle in the car seat. d. I can turn my baby car seat around when she weighs 15 pounds. 4. A nurse is planning care for a client who is in labor and has gonorrhea. Which of the following actions should the nurse include in the plan for delivery? a. Instill erythromycin ointment into the newborn's eye b. Apply miconazole vaginal cream to the mother prior to delivery83 c. Give oral sulfadiazine to the mother prior to delivery d. Administer penicillin G procaine IM to the newborn 5. A nurse is planning care for a client who has small-bore NG feeding tube in the jejenum. Which of the following is an appropriate action for the nurse to take to confirm placement? a. Instill two drops of blue food coloring formula b. Review an abdominal x-ray report. c. Verify the glucose level aspirated content. d. Auscultate for bubbling sound while injecting air through the tube.??? - i chose this but ima dohle check , i thought about verifying the placement at the moment 6. A charge nurse delegates to an AP the task of ambulating a client. At the end of the shift, the nurse discovers the client has not been ambulated. Which of the following actions should the nurse take first? a. Supervise the AP performing the task b. Remind the AP of her assigned tasks. c. Evaluate why the client was not ambulated. Asses the situation first. Yes. assess first d. Ambulate the client on behalf of the AP. Rationale: Care for the client comes first, so ambulate the patient because AP did not. Then you can investigate why AP did not do the task. 7. A nurse is caring for a client who has prescription for lactated ringer’s IV 4080/mL24hr. The nurse should set the IV infusion pump to deliver how many mL/hr to administer half of the total volume in the first 8 hr? Half = 2040 which need to be administered in 8hrs. So 2040ml/8hr = 255ml/hr 8. A nurse is providing teaching to a client who DM about glycosylated hemoglobin blood test. Which of the following statement by the client indicated an understanding of this test? a. I will need to drink a glucose solution to get an accurate result b. I will need to fast prior to taking this test not necessary c. I will use the result of this test daily to modify my insulin dosage. d. I will use this test to monitor how well I control my blood glucose. 9. A nurse is caring for a client who has CVC and develops an air embolism. Which of the following actions should the nurse take? a. Place the client in a left lateral trendelenburg position. b. Prepare the client for chest tube insertion (I put this one. -Jackie) c. Instruct the client to perform valsalva maneuver d. Remove the client catheter. Rationale: Page 98 ATI Med Surg Book. 10. A nurse is assessing a client who had a colostomy 24 hr ago. Which of the following finding is priority? a. THe client reports a pain level of 6 b. The stoma appears dark purple in color c. The colostomy has had no output d. The client refuses to look at the colostomy84 Rationale: Says notify provider when you see dark purple color which may indicate blood supply is compromised. mal_skin_ 11. A nurse is caring for a client who has new prescription for enalapril. The client report tingling and swelling around the mouth 1hr after receiving the medication. Which of the following actions should the nurse take first? a. Notify the rapid response team b. Obtain IV access.???? - whats that drug that dialtes brochionles that are constricted in case of an anaphylatci RXN ? i thought about that thats why i chose this. c. Document findings d. Elevate the lower extremity. 12. A nurse is admitting a client who is to undergo paracentesis for removal of ascetic fluid. Which of the following actions should the nurse take? a. Ensure the client has a full bladder just prior to the procedure b. Weigh the client before and after the procedure c. Administer a low-volume hypertonic enema the night before the procedure d. Place the client in a side-lying position for the procedure Rationale: Paracentesis is a procedure done to drain ascites fluid in the abdominal wall using a trocar and a needle. Decrease in weight can be a data to assess if procedure has been effective to reduce weight and remove ascites fluid in the abdominal wall. 13. A nurse is admitting a client who tells the nurse he has brought a copy of his advance directives. Which of the following actions should the nurse take? a. Place a copy of the document in the client's medical record. b. Request a social worker to review the document with the client (social worker does not need to review this) c. Ask the client to keep the document in his bedside table. (store it in a safe place) D. Have the provider approve the document. (does not need to be approved by MD) 14. A nurse is providing preop teaching to a client who is scheduled for uterine surgery and asks about the reason for the indwelling urinary catheter. Which of the following responses should the nurse make? a. The catheter will be used to administer pain medication after surgery. (not used for pain medication) b. The catheter will decompress your bladder during surgery. c. The catheter will decrease the risk for UTI from surgery. (risk for UTI) d. The catheter will immobilization after surgery. 15. A nurse is discharging a client who has a colostomy. The client states that she would like to use her moisturizing soap to clean around the stoma. Which of the following responses by the nurse is appropriate? a. It is acceptable to use this soap if it makes you comfortable. b. Lubricants in moisturizing soaps can interfere with adhesion of the appliance c. You may want to try other soaps to determine what is the best to clean around the stoma d. Use of moisturizing soaps can contribute to skin infections. (I put this one -Jackie) Rationale: Page 240 of Funds ATI book Moisturizing soap can interfere with adherence of pouch.85 16. A nurse in a clinic is assessing a 6-month-old infant. Which of the following findings should the nurse report to the provider? a. RR 26/min- 30 - 60 is normal they can be is respiratory distress ABCS b. Pulse 140/min c. Abdominal breathing- they are normally abdominal breathers d. Closed anterior fontanel Rationale: page 7 peds 2016 Newborn to 1 year old: RR= 30-35/min 17. A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include? a. “This type of seizure can be mistaken for daydreaming” (can be brief that sometimes they are mistaken for daydreaming and may not be detected for months) b. “The child usually has an aura prior to onset” c. This type of seizure last 30-60 sec” (begin and end abruptly) d. “This type of seizure has a gradual onset” (generalized onset) 18. A nurse is providing teaching about crutch safety to a client. Which of the following client actions indicates an understanding of the teaching? a. The client leans on both crutches to support body weight. (no) b. The client places the crutches 30cm (12in) to the front and side of each foot while standing (6in) c. The client flexes her elbows 10 degree when supporting weight by using the handgrips. (30deg) d. The client keeps her axillae free of pressure. (yes use your hand for pressure) 19. A nurse is assessing a client who received a Mantoux skin test 72hr ago for TB screening. Which of the following findings indicates a positive test? a. An area of ecchymosis b. A blister like area c. An elevated hardened area. d. A cool, blanched area. Rationale: Page 136 of MEDSURG ATI BOOK. An induration (palpable, raised, hardened area) of 10 mm or greater in diameter indicates a positive skin test. 20. A nurse is caring for a client who has a chest tube drainage. Which of the following findings indicates the nurse the presence of an air leak? a. Gentle bubbling in the suction chamber b. Continuous bubbling in the water seal chamber c. Fluid rising with inspiration and falling with expiration in the water seal chamber D. Serosanguineous fluid in the drainage collection chamber. Rationale:ATI Med Surg book page 106. Monitor the water seal chamber for continuous bubbling (air leak finding). If observed, locate the source ofthe air leak, and intervene accordingly (tighten the connection, replace drainage system). 21. A nurse is admitting a client to a med-surg unit. When performing medication reconciliation for the client. Which of the following actions should the nurse take? a. Compare new prescription with the list of medications the clients reports. b. Encourage the client to make his own list after he returns to his home. c. Exclude nutritional supplements from the list of medication the clients reports.86 d. Include any adverse effects of the medication the client might develop. 22. A nurse is caring for a toddler who has cancer and is experiencing stomatitis from chemotherapy. Which of the following intervention should nurse implement? a. Apply viscous lidocaine. b. Provide soft, nanacidic food c. Give peroxide mouth washes. d. Administer antiemetics 23. A nurse is teaching the family of an infant who has decreased cardiac output to congenital heart disease. Which of the following instruction should the nurse include in the teaching? a. Observe for manifestations of hunger in order to feed the infant before crying occurs keep crying to a minimum, crying increases workload of heart b. Bathe the infant and change the bed linens daily to reduce the risk of infection. c. maintain the infant in supine position when sleeping. d. Perform infant care activities frequently and intermittently throughout the day. 24. A nurse is providing teaching to a parent of a child who has varicella. Which of the following statements should the nurse include in the teaching? a. “Your child can return to school after a negative titer result.” b. “Your child can return to school 24 hours after beginning antibiotics.” c. “Your child can return to school once the lesions have crusted over.” d. “Your child can return to school once the fever has subsided.” 25. A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first? a. A client who has a fracture and is in balanced suspension traction b. A client who uses a wheelchair and is confused c. A client who is bedridden and wears a hearing aid d. A client who is ambulatory and receiving oxygen → RESCUE 26. A nurse is caring for four clients. Which of the following client data should the nurse report to the provider? a. A client who is 4 hr postoperative and has a heart rate of 98/min b. A client who has a total of 110 mL of serosanguineous fluid from a Jackson-Pratt drain within the first 24 hr following surgery c. A client who has a prescription for chemotherapy and an absolute neutrophil count of 75/mm3 d. A client who has pleurisy and reports pain of a 6 on a scale of 0 to 10 when coughing 27. A community health nurse is working with a family that is struggling to adapt following the loss of a family member. Which of the following actions should the nurse take first? a. Encourage the family to assign specific tasks to individual family members. b. Determine the roles of individual family members. c. Assist the family to establish a daily routine d. Refer the family to a grief support group. Rationale: Assess first.87 28. A nurse is planning to delegate tasks to an AP. Which of the following tasks should the nurse assign to the AP? a. Record the client's BP reading by 1000- documenting VS is RNS job b. Obtain a client temp prior to surgery- this CT is unstable since they are going to surgery c. Reposition a client- i didn't choose this because certain disease require ct;s to be in certain postions. d. Measure a client's urine output 29. A community health nurse is planning a program to address substance use in the adolescent population. Which of the following interventions should the nurse include as a method of secondary prevention? a. Facilitate referrals to substance use treatment programs (tertiary) b. Create anti-substance use media messages c. Establish an early detection program for substance use d. Provide education about the danger of substance abuse. (Primary) Rationale: Secondary preventions: Includes screening such as early detection. 30. A nurse in an ER is planning care for a client who has abdominal trauma from a MVC. Which of the following provider prescription should the nurse implement first? a. Administer RBC b. Place a large bore IV catheter in an upper extremity- IV FLUID REPLACEMENT IS PRIORITY AFTER ABCS c. Insert an indwelling urinary catheter d. Obtain a specimen for ABG analysis 31. A nurse is assessing a client who has a stage IV pressure ulcer and is undergoing treatment prescribed by a wound care consultant. For which of the following findings should the nurse contact the consultant to revise the plan of care? a. Weight loss of 5% in 10 days B. Appearance of pink tissue under eschar c. Hgb 15 g/dL d. Albumin level 4.0 g/dL 32. A nurse is assessing a client who is receiving magnesium sulfate for preeclampsia which of the following is the nurse's priority? a. Urinary output 35 ml/hr- > 30 ml is normal b. 2 deep tendon reflexes 2 is normal 3 or 4 is ABNORMAL d’t hyperreflexia. c. 3 pedal edema d. Respiratory rate 10/min- normal rate 12 -20 ATI PHARM 33. A nurse is developing a plan of care for an older adult client who has hearing loss. Which of the following instructions the nurse include in the plan? A. Increase the pitch of voice when speaking to the client low pitch B. Avoid using hand motions when speaking to the client C. Rephrase statements that the client misunderstands D. Ask the client to confirm an understanding of the instructions by nodding. (I put this one -Jackie)88 34 A nurse is collaborating with social services in the discharge planning for a young adult client who is below the poverty income level and will require home IV therapy. Which of the following resources the nurse recommend (SATA) A. Medicare Part A → must be 65 older (A; hospital care, home care, hospice, and skilled) B. Medicaid C. Adult day care D. Food stamps E. Respite care → Maybe? No. LOL. sorry paul. (yeah, no) Young Adult- 20-39 Medicaid → low socioeconomic status and children. 35. A nurse is reviewing legal issues in health care with a group of newly licensed nurses. Which of the following recommendations should the nurse make? A. Overestimate clients acuity to prevent short staffing B. Obtain personal professional liability insurance coverage C. Ensure that each client has a living will on file prior to treatment. D. Place copies of incident reports in client's medical records. 36. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration? a. A history of gastroesophageal reflux disease b. Receiving a high osmolarity formula c. Sitting in a high-Fowler’s position during the feeding d. A residual of 65 mL 1hr postprandial Rationale ATI MS p309: Complications: Aspiration of gastric secretion Causes: Reflux of gastric fluids into the esophagus can be aspirated into the trachea. 37. A charge nurse is observing a conflict between two nurses who both insist that the charge nurse favors the other when making assignments. Which of the following conflict-resolution strategies should the charge nurse use? A. Encourage collaboration between the two nurses when making the assignments B. Arrange for the nurses to have as few shifts together as possible C. Tell the nurses that the assignments will be more equitable in the future D. Ask each nurse to take turns making the assignments ATI Leadership 15 Open communication among staff & b/w staff and clients can help defray the need for conflict resolution. 38. A nurse is caring for a client who has received a first dose of losartan. Which of the following adverse effects should the nurse report to the provider immediately? A. Angioedema airway; A/E B. Cough C. Hypotension D. Itching Pharm 252 for HTN, HF. (Cozaar) 39. A nurse is caring for a client who has crohn’s disease. Which of the following should the nurse recommend for the client? A. Navy beans89 B. Bacon C. Banana D. Hard-boiled egg 40. A nurse is evaluating a client’s understanding of food nutrition labels. Which of the following statements by the client indicate an understanding of the teaching? a. The ingredient with the greatest weight appears first B. Food manufacturers provide nutrition information voluntarily c. Item serving size is consistent from one manufacturer to the next d. The daily values relate to a 1,500 calorie diet 2,000 41. A nurse is caring for a preschool-age child who has injuries due to abuse by her father’s partner. Which of the following actions by the nurse is appropriate? A. Limit visits by the father’s partner to 30 min B. Restruct the child’s interaction with other children on the unit C. Allow the father unlimited visitation with the child i assume father still has the right to see his child. He didn’t abuse him (I put this one -Jackie) D. Interview the child about the abuse with the father present. 42. A nurse is reviewing a client’s medical record. Which of the following findings places the client at increased for the development of heart failure? (SATA) A. Alcohol use disorder B. Osteoarthritis C. Sleep apnea D. Diabetes mellitus E. BMI 23 43. A nurse is caring for a client who has a history of depression and is experiencing a situational crisis. Which of the following actions should the nurse take first? A. Teach the client relaxation techniques B. Confirm the client’s perception of the event C. Help the client identify personal strengths. D. Notify the client’s support person. 44. A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse should recognize which of the following findings as an indication that the medication has been effective? A. Increased blood pressure- Loop diuretics decrease BP via making you PEE ALOt B. Decreased inflammation- loops are not pain meds they are for BP C. Weight loss- excretes excess fluids d/t HF D. Decreased pain - Loops are for BP 45. A nurse in an emergency department is assessing an adolescent who has conduct disorder. Which of the following questions is the priority for the nurse to ask the client? A. “How do you get along with your peers at school?” B. “Do you have thoughts of harming yourself” - safety is number 1 when it comes to priority90 C. “How do you manage your behavior?” D. “Do you have a criminal record?” 46. A nurse is planning care for a client who has cancer and is about to receive low dose brachytherapy via a vaginal implant applicator. Which of the following interventions should the nurse include in the plan of care? A. Ambulation four times daily B. Removal of vaginal packing C. Insertion of an indwelling urinary catheter so you will not have to get up and use the restroom D. Maintenance of NPO status until therapy is complete 47. A nurse is providing care for a client following a thoracentesis. If the client develops a pneumothorax, which of the following assessment findings should the nurse expect? A. Stridor B. Pain on inhalation chest pain that worsens when you breathe or pleuritic pain (I put this one -Jackie) C. Friction rub D. Bradycardia 48. A charge nurse is delegating care for a group of clients. Which of the following tasks should the charge nurse assign to a licensed practical nurse? A. Complete a discharge teaching for a client who has a new diagnosis of diabetes mellitus B. Perform a sterile dressing change for a client who has an abdominal wound C. Perform an admission assessment for a client who is scheduled for surgery D. Complete the Glasgow Coma Scale for a client who has an evolving stroke 49. A nurse is caring for a client who has bipolar disorder. Which of the following client findings is an indication that the client is about to experience a manic phase? A. The client is restless and has changes in his sleep pattern B. The client laughs out loud and is overly cheerful C. The client has disorganized thoughts and is easily distracted D. The client shows poor judgment and demands attention (I put this one -Jackie) 50. A nurse is caring for a client who has a spinal cord injury. Which of the following support devices should the nurse plan to use to prevent plantar flexion contractures? A. Sheepskin heel pad B. Trochanter roll C. Abduction pillow D. Footboard prevents plantar flexion contractures due to immobility (I put this one -Jackie) 51. A nurse is caring for a client who speaks a different language than the nurse and is using an interpreter. Which of the following actions should the nurse take when working with an interpreter? A. Pause in the middle of sentences B. Use gestures when speaking with the client C. Direct statements to the interpreter D. Speak in a normal voice at a natural pace91 52. A charge nurse is providing teaching to a newly licensed nurse about acceptable client identifiers before administering medications. Which of the following statements by the newly licensed nurse requires intervention? A. “I will check the client’s hospital arm band before administering medication” B. “I will ask the client for his hospital assigned number prior to giving medication” C. “I should check the client’s room number prior to giving medication” D. “I should ask the client to state his name before administering medication” 53. A nurse is providing discharge teaching to a client who has hyperlipidemia and is to start treatment with atorvastatin. The nurse should instruct the client to avoid taking the medication with which of the following? A. Aged cheese B. Caffeinated beverages C. Green, leafy vegetables D. Grapefruit juice 54. A nurse is caring for a 3-month-old infant who has gastroenteritis and is receiving monitoring for dehydration. For which of the following findings should the nurse monitor? A. Weight loss B. Bradycardia C. Bulging fontanel D. Distended jugular vein 55. A nurse is teaching a parent of a school-age child who is to begin a daily dose of methylphenidate. Which of the following should the nurse include in the teaching? A. “Your child should avoid foods containing tyramine” B. “Your child should avoid excess sodium intake” C. “You should administer the medication at bedtime” D. “You should administer the medication after breakfast” administer med immediately during or after meals (I put this one -Jackie; it is a ADHD medication) 56. A charge nurse is teaching a newly licensed nurse about clients designating a health care proxy in situations that require a durable power of attorney for healthcare (DPAHC). Which of the following information should the charge nurse include? A. “The proxy can make financial decisions if the need arises” B. “The proxy should manage legal issues for the client” C. “The proxy should make healthcare decisions for the client regardless of the client’s ability to do so” D. “The proxy can make treatment decisions if the client is under anesthesia” 57. A nurse is admitting a client who has been taking prednisone 10 mg PO daily for 10 months. Which of the following assessment findings should the nurse identify as an adverse effect of this medication therapy? A. Absence of hair on legs below the knees B. Swelling and decreased range of motion of the joints ( I put this one -Jackie) C. Thin extremities with obesity of the abdomen D. Bradycardia and postural hypotension9293 58. A nurse is caring for a client who had gastric bypass surgery 1 week ago and has manifestations of early dumping syndrome. Which of the following findings should the nurse expect? (Select all that apply) A. Hypertension B. Diaphoresis C. Syncope D. Fever - idr putting this one E. Dizziness Early manifestations: Feeling of fullness, weakness, dizziness, palpitations, sweating, abdominal cramping, and diarrhea 59. A nurse is caring for a male client who has a spinal cord injury. Which of hte following techniques should the nurse use when providing perineal care? A. Wash the penis from the scrotum to the tip using a spiral motion B. Discard the washcloth after cleansing the urethral meatus C. Don sterile gloves to prevent infection D. Use water with no soap to prevent skin irritation 60. A nurse is assessing a toddler whose parent is concerned about the child’s hearing ability. Which of the following findings indicates the need for further hearing evaluation? A. Lack of response to facial expressions B. Uses gestures to communicate C. Exaggerated startle response to sounds94 D. Prefers group over solitary play 61. A surgeon is obtaining informed consent from a client. When a nurse witnesses the client sign the consent form, which of the following legal requirements is the nurse confirming? a. The nurse explained the risks and benefits of the surgery- PROVIDERS JOB b. The nurse explained the surgical procedure in detail- PROVIDERS JOB c. The client knows she may not longer refuse the procedure- Client has the right to refuse even if its seconds prior to the surgery. d. The client agreed to the procedure voluntarily. - meaning she wasn’t forced to sign . 62. A nurse providing teaching about nutritional needs to an adolescent client. Which of the following statements by the client indicates an understanding of the teaching? a. I should consume about 1,300 milligrams of calcium a day b. Protein should be my main source of caloric intake c. I should limit my daily fat intake to 40 percent d. I should consume about 8 milligrams of iron a day 63. A nurse manager on an interprofessional team is creating a disaster plan. The nurse should include in the plan that which of the following actions is the responsibility of the unit nurse during a disaster? a. Determine the need for additional providers b. Act as a spokesperson to provider info to the media c. Decided which client should be transported for a higher level of care (I put this one -Jackie) d. Recommend to the provider a list of clients for early discharge 64. A nurse is caring for a client who is 2 hr postpartum. The client states, “i'm having difficulty emptying my bladder.” which of the following actions should the nurse take? a. Pour warm water from a squeeze bottle over the client’s perineum b. Hold analgesic meds until the client voids c. Place a transcutaneous electrical nerve stimulation (TENS) unit over the client’s bladder area d. Immerse the client’s hands in cool water 65. A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching? Idk the answer a. Eat 1g/kg of protein per day (I put this one -Jackie) b. Drink at least 3L of fluid daily ???? i picked this one but ima double check c. Consume foods high in potassium d. Take magnesium hydroxide for indigestion 66. A nurse is reviewing a client’s cardiac rhythm strips and notes a constant P-R interval of 0.35sec. Which of the following dysrhythmia is the client displaying? a. Premature atrial complexes????????????? b. Complete heart block c. Atrial fibrillation d. First degree atrioventricular block (I put this one -Jackie) 67. A nurse is reviewing laboratory values for a client who has bipolar disorder and takes lithium carbonate. Which of the following values should the nurse report to the provider? a. Sodium 137 meq/L95 b. Lithium 1.0 meq/L?????????????? c. WBC count 5,600 mm d. Thyroxine (t4) 2.8 mcg.dL (I put this one -Jackie) : lithium can cause hypothyroidism and goiter, T4 normal range is 4.6-12 68. A nurse is planning teaching for a client who has a newly implanted implantable cardioverter/defibrillator. Which of the following information should the nurse include? a. Return in two weeks for a follow up MRI - MRI should be avoided b. Expect to have a rapid pulse rate for the first few weeks ?? c. Resume tub baths and swimming after 24hr d. Wear loose fitting clothing (I put this one -Jackie) 69. A nurse is caring for a 2yr old toddler. Which of the following food choices should the nurse recommend to promote independence in eating? a. Grapes- choking hazrd b. Banana slices c. Hot dogs- choking haards d. Popcorn- choking hzard 70. A nurse is caring for a client who has a 22 gauge IV inserted 2 days ago and a new prescription for 2 packed RBCs. Which of the following actions should the nurse take? a. Transfuse each unit of packed RBCs over 5 hrs b. Replace the current IV site dressing prior to RBC infusion c. Start a new IV distal to the current IV site d. Place a larger gauge IV in the opposite extremity- RBC administration needs to have at least an 18 -20 bore gauge needle to administer. 71. A nurse is providing information for a client who has a new prescription for simvastatin. For which of the following should the nurse instruct the client to monitor and report to the provider? a. Fever b. Muscle weakness- statin drugs = RHABDOMYLOSIS c. Weight loss d. edema 72. A nurse is positioning a client for a cesarean birth. To prevent a compromise in placental blood flow during the intraoperative period, which of the following actions should the nurse take? a. Place a wedge under one of the client’s hips b. Assist the client into the lithotomy position c. Position the client in reverse trendelenburg d. Insert a pillow under the client’s knees 73. A nurse is planning to delegate the fasting blood glucose testing for a client who has DM to an assistive personnel. Which of th following actions should the nurse take? a. Determine if the AP has the skills to perform the test b. Assign the AP to ask the client if she has taken her antidiabetic meds today c. Help the AP perform the blood glucose test d. Have the AP check the medical record for the prior blood glucose test results96 74. A nurse is teaching an adolescent who has a type 1 diabetes mellitus and his parents how to dispose of his insulin syringes and needles at home. Which of the following instructions is appropriate? a. Seal the needles in zipper lock plastic bags and place them in a metal trash can b. Place the needles in a plastic container and then pour alcohol into the container c. Recap the needles and wrap them and the syringes in paper towels d. Place the needles in an aluminum coffee can and store them on a high shelf 75. A nurse is a long term care facility is caring for an older adult who has a dementia. The client believes he needs to get ready for work and is becoming increasingly agitated. Which of the following actions should the nurse take? a. Assist the client in selecting clothing for the day b. Tell the client that his behavior is unacceptable c. Administer an anti anxiety medication d. Inform the client that he no longer has a job to go to 76. A nurse is assessing a young adult male client having an unusual rash on the palms and hand and bottom of his feet. The nurse should further assess for which of the following infections? 1. Syphilis 2. Herpes simplex virus 2 3. Gonorrhea 4. Hepatitis B 77. A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching ? 1. “Repeat the dose if your child vomits w/in 1 hr taking the medication” 2. “Have your child drink a small glass of water after swallowing the medication” I put this one -Jackie 3. “You can add the medication to a half cup of your child’s favorite juice” 4. “Limit your child’s potassium intake while she is taking this medication” 78. A nurse in a family health clinic is caring for a client who requests information regarding the correct use of condoms. Which of the following statements should the nurse make? 1. When using implanted contraceptive methods, condoms should also be used to protect against STDs 2. Use of petroleum based lubricant with a condom increases the condom’s effectiveness 3. Ensure that the condom fits snugly over the tip of the penis 4. Condoms are equally effective for birth control with or without the use of vaginal spermicides 79. A nurse is assessing a client who is receiving a unit of packed RBCs. Which of the following findings should indicate to the nurse that the client is experiencing a hemolytic transaction reaction? 1. Bradycardia 2. Urticaria (hives) - allergic rxn (I put this one -Jackie) 3. Low blood pressure 4. Jugular vein distention - fluid overload Rationale: Hemolytic reactions: chills, headache, backache, dsypnea , hypotension, fever (KAPLAN)97 80. A nurse is providing teaching to the parents of a newborn about newborn genetic screening. Which of the following statements should the nurse include in the teaching? 1. A nurse will draw blood from your baby’s inner elbow 2. This test should be performed after your baby is 24 hrs old 3. This test will be repeated when your baby is 2 months old 4. Your baby will be given 2 ounces of water to drink prior to the test 81. A nurse is evaluating the outcomes for a client who had an amnioinfusion for oligohydraminos. Which of the following findings indicates an adverse response to this treatment? 1. Fetal cord compression 2. Placental insufficiency (OB p 102) - this CAUSES oligohydramnios, but the question is asking “adverse response” to amnioinfusion.. 3. Meconium aspiration 4. Uterine contractions - monitor the client to prevent uterine overdistention and increased uterine tone = can initiate/accelerate/intensify UTERINE CONTRACTIONS and cause nonreassurring FHR changes; (I put this one -Jackie) 82. A nurse has received clearance to go back to work after an occupational injury to her back. To reduce the risk of future lifting injuries, which of the following principles should the nurse use when lifting objects? 1. Bend at the waist to pick up the object 2. Keep the object close to her body as she lifts it 3. Twist at the waist when moving the object to her side 4. Stand with her feet close together when lifting the object 83. A nurse is teaching a client about a variety of stress management techniques. Which of the following instructions by the nurse is appropriate? 1. Tighten your muscles before relaxing them when using muscle relaxation techniques 2. Breathe in through your mouth and out through your nose when using deep breathing exercises 3. Imagine a situation that has been stimulating for you when practicing guided imagery 4. Talk to someone who you admire as the first step in using mindfulness techniques to relax 84. A nurse is caring for a client who has a prescription for a peripheral IV catheter. After puncturing the skin with the vascular access device and noting a blood return in the flashback chamber, which of the following actions should the nurse perform next? 1. Release the tourniquet 2. Retract the stylet 3. Advance the catheter into the vein 4. Flush the catheter with saline 85. A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following actions should the nurse perform first? 1. Administer an antiemetic medication 2. Replace the NG tube 3. Provide functioning of the suction device 4. Evaluate function of the suction device 86. A nurse is administering medications to a group of clients. Which of the following occurrences requires the completion of an incident report?98 1. A client requests his statin to be administered at 2100 2. A client asks for pain medication 1 hr early 3. A client vomits within 20mints of taking morning medications 4. A client receives his antibiotic 2 hrs late 87. A nurse is caring for a client who has prescriptions for furosemide and gentamicin. For which of the following complications should the nurse monitor the client? P .143 pharm 1. Ototoxicity ??????????? i’m positive and sure it this one but ima double check 2. Liver toxicity (I put this one -Jackie) 3. Hyperkalemia 4. Hypoglycemia Always remember for those two meds - OTOTOXICITY is always the complication 88. A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding? 1. Increased intracranial pressure 2. Upper extremity hypotension 3. Weak femoral pulses ( peds. P 112) 4. Frequent nosebleeds 89. A charge nurse is orienting a newly licensed nurse to the telemetry unit. Which of the following should the charge nurse identify as the purpose of telemetry monitoring? 1. To measure cardiac perfusion 2. To measure cardiac output 3. To identify dysrhythmias 4. To identify valve insufficiency 90. A nurse is caring for a client who is at 20 weeks of gestation and reports urinary frequency. Which of the following actions is appropriate? 1. Advise the client to limit her evening fluid intake 2. Obtain a specimen for culture and sensitivity 3. Check the client for rupture membranes 4. Assure the client that this is an expected finding during this trimester (urinary frequency is common in pregnancy) - occurs during first and third trimester 106. A nurse is providing discharge teaching to a client who has undergone bowel surgery with placement of a colostomy. Which of the following information should the nurse include in the teaching? a. Eat a low-fiber diet if constipation occurs. b. Apply a skin sealant around the stoma before applying the pouch. (I put this one -Jackie) c. Make a pinhole in the pouch to allow for gasses to vent. d. Cut the opening of the wafer 2 cm (0.8in) wider than the stoma 108. A home health nurse is teaching the caregiver of a client who has AIDS about infection control in the home. Which of the following information the nurse include in the teaching? a. Dispose of recapped needles and syringes in biohazard bag. b. Wash clothing twice in cold water and laundry detergent. c. Designate a separate bathroom in the home for the clients use.99 d. Make a new solution of bleach and water each day for disinfection. 109. A nurse is planning care for a group of clients and is working with one licensed practical nurse (LPN) and one assistive personnel (AP). Which of the following actions should the nurse take first to manage her time effectively? a. Delegate tasks to the AP. b. Determine goals of the day (I put this one -Jackie) c. Schedule daily activities. d. Develop an hourly time frame for tasks. 110. A nurse is assessing a client who has antisocial personality disorder. Which of the following characteristics should the nurse expect? a. Exaggerated expression of emotion b. Sensitive to criticism c. Needs continues reassurance d. Lack of remorse (I put this one -Jackie) 111. A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine? a. Hgb 14 g/dL b. WBC count 2,900/mm (I put this one -Jackie) me too!! AGRANULOCYTOSIS c. Fasting blood glucose 100 mg/dL d. Heart rate 58/min 112. A nurse is performing a dietary assessment for a client. Which of the following questions should the nurse ask when assessing the client’s dietary acculturation? a. “Are there any foods that you are allergic to?” b. “How do you feel about your current body weight?” c. “What questions do you have about reading food labels?” d. “ Do you have special customs that you follow for meals?” (I put this one -Jackie) 113. A nurse is preparing to document care in a client’s electronic health record. Which of the following entries by the nurse demonstrates appropriate documentation? a. “Client drank orange juice at HS.” b. “Client has a heart rate of 102/min” (I put this one -Jackie) ME TOO I CHOSE THIS ONE c. “Client is demanding of nurse’s attention.” d. “Client appears nervous.” 114. A nurse manager is planning a staff in-service to address advocacy in client care. The nurse should promote which of the following practices during the in-service? (select all that apply) a. Addressing client needs when providing resources * b. Making decisions about health care on client’s behalf c. Promoting health care access* d. Encouraging clients to seek further information from the provider * e. Honoring family requests to withhold medical information *(I put this one -Jackie) 115. A nurse is providing teaching to a client about risk factors for breast cancer. Which of the following factors should the nurse include as placing the client at an increased risk for developing breast cancer?100 a. A BMI less than 25 b. Use of hormone replacement therapy (I put this one -Jackie) c. Early menopause d. Fibrocystic breast disease 116. A charge nurse is concerned about a recent increase in facility-acquired catheter infections. Which of the following actions should the nurse take first? a. Schedule nursing staff training for infection control procedures b. Identify possible precipitating factors related to the infections (I put this one -Jackie) c. Meet with providers to discuss measure to decrease the infections d. Revise the current policy for catheter care 117. A nurse is caring for a client who is receiving intravenous antibiotics every 6 hr. Which of the following responses by the client is the priority for the nurse to evaluate? a. “My throat feels tight.” (I put this one -Jackie)- THS ONE I CHOSE! THIS CAN BE ANAPYLACTIC RXN !!! b. “ I don’t understand why I am getting this antibiotic.” c. “My arms burn each time that medication is running.” d. “This medication bag is still full.” 118. A nurse is teaching a group of newly licensed nurses caring for a client who has a Clostridium difficile infection. Which of the following instructions should the nurse include in the teaching? a. Apply a mask when providing care. b. Wear a gown while providing personal hygiene. (I put this one -Jackie) c. Place the client in a room with negative airflow. d. Wipe the stethoscope with alcohol after leaving the client's room. 119. A nurse is caring for a client who is alert and oriented and is receiving continuous ECG monitoring. The cardiac rhythm strips shows a wavy baseline, no distinguishable P waves, and an increased heart rate. The nurse should identify the cardiac rhythm as which of the following? a. Ventricular asystole b. Second-degree heart block c. Sinus Tachycard d. Atrial fibrillation (I put this one -Jackie) me too!!!!! A fib has no p waves and HIGH HEART RATE 120. A nurse is assessing a client who has type 1 diabetes mellitus and a blood glucose level of 52 mg/dL. Which of the following findings should the nurse expect? a. Deep respirations- this is KUSSMAUALS b. Hot, dry skin- HYPO is COOL and CLAMMY c. Bradycardia - HYPO is TACHY d. Blurred vision (I put this one -Jackie) me too!!!!!!! The rest is HYPERGYLCEMIA 121. A nurse is preparing to perform a sterile wound irrigation and dressing change for a client. Which of the following actions by the nurse indicates a break in surgical aseptic technique? a. Placing the supplies on the sterile field and leaving a 1-inch perimeter b. Applying a sterile gown after applying a sterile mask c. Balancing the bottle on the sterile basin while pouring the liquid d. Putting on sterile gloves after preparing the sterile field101 122. A nurse is preparing to administer several medications through a client’s nasointestinal tube. The nurse should ask the pharmacist about the availability of a different form for which of the following medications? a. Oral anticoagulant b. Statin tablet c. Antibiotic suspension d. Enteric-coated aspirin 123. A nurse is caring for a client who has a new prescription for clozapine. Which of the following should the nurse recognize as an adverse effect of this medication? a. Diarrhea b. Hypoglycemia c. Urinary frequency d. agranulocytosis 124. A nurse is planning care for a client who follows Buddhist dietary practices. Which of the following food selections should the nurse recommend for the client’s meal tray? a. Vegetable beef soup b. Spinach and strawberry salad c. Ham and cheese sandwhich d. Baked fish 125. A nurse in a mental health facility receives change-of-shift report for four clients. Which of the following clients should the nurse plan to assess first? a. A newly admitted client who has a hx of 4.5 kg (10lb) weight loss in the past 2 months b. A client who will be receiving her first ECT treatment today c. A client placed in restraints due to aggressive behavior d. A client who received a PRN dose of haloperidol 2 hr ago for increased anxiety 126. A nurse is providing teaching about immunizations to a client who is pregnant. Which of the following statements should the nurse include in the teaching? a. You can receive the immunization for influenza at any time during your pregnancy b. The immunization for varicella should be given at least 1 month prior to delivery c. The hepatitis B immunization should not be obtained until after you finish breastfeeding d. You can receive the rubella immunization during the third trimester of pregnancy 127. A public health nurse is teaching a group of new parents about SIDS. Which of the following statements by the parents indicates an understanding of the teaching a. “I will make sure the mattress in my baby’s crib is firm”
[Show More]
Last updated: 3 years ago
Preview 1 out of 29 pages
