A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following should the actions the nurse take?
Request a rene
...
A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following should the actions the nurse take?
Request a renewal of the prescription every 8 hr. Check the client’s peripheral pulse rate every 30 min Obtain a prescription for restraint within 4 hr. Document the client’s condition every 15 minutes
postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care?
a.
Offer small amounts of clear liquids 6 hr following surgery (assess for
gag reflex first)
Give cromolyn nebulizer solution every 6 hr (for asthma)
A nursing planning care for a school-age child who is 4 hr
b.
c.
d. Administer analgesics on a scheduled basis for the first 24 hr 2. A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?
a. b. c.
A client who has sinus arrhythmia and is receiving cardiac monitoring A client who has diabetes mellitus and a hemoglobin A1C of 6.8%
A client who has epidural analgesia and weakness in the lower
extremities
Apply a warm compress to the operative site every 4 hr
d. A client who has a hip fracture and a new onset of tachypnea
3. A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse tak e?
a. Shave hairy areas of skin prior to application (apply to hairless, clean & dry areas to promote absorption; avoid oily or broken skin)
b. Wear gloves to apply the patch to the client’s skin
c. Apply the patch within 1 hr of removing it from the protective pouch (apply immediately)
d. Remove the previous patch and place it in a tissue (fold patch in half with sticky sides pressed together)
4. A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?
a.
b. c. d.
5.
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
6. A nurse is reviewing the laboratory results for a client who has Cushing’s disease. The nurse should expect the client to have an increase in which of the following laboratory values?
increased
A client who was just given a glass of orange juice for a low blood glucose level
A client who is schedule for a procedure in 1 hr (can wait)
A client who has 100 mL fluid remaining in his IV bag (can wait)
A client who received a pain medication 30 min ago for postoperative pain
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
a.
Serum glucose level-
b.
c.
d.
. 8. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displaces toxicity. Which of the following actions should the nurse take?
a. b. c. d.
Position the client supine
Prepare an IV bolus of dextrose 5% in water
Administer methylergonovine IM
Administer calcium gluconate IV
Serum calcium level-decreased
Lymphocyte count- decreased immune system.
Serum potassium level- decreased
Calcium gluconate is given for magnesium sulfate toxicity. Always have an injectable form of calcium gluconate available when administering magnesium sulfate by IV.
9. A charge nurse is teaching new staff members about factors that increase a client’s risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence?
a. b.
c.
Experiencing delusions Male gender
Previous violent behavior
d.
Risk factors also include: past history of aggression, poor impulse control, and violence. Comorbidity that leads to acts of violence (psychotic delusions, command hallucinations, violent angry reactions with cognitive disorders).
Individual Assessment for Violence
10. A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?
a. Place the cap from the solution sterile side up on clean surface b. Open the outermost flap of the sterile kit toward the body→ flap AWAY from the body's first
A history of being in prison
c. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field → 2.5 cm (1-inch) border around any sterile drape or wrap that is considered contaminated.
d. Set up the sterile field 5 cm (2 in) below waist level→ it says BELOW waist level; should be ABOVE waist level
11. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include?
a.
Eat a light snack before bedtime
b.
c.
d.
12. A home health nurse is preparing for an initial visit with an older adult client who lives alone. Which of the following actions should the nurse take first?
a. b. c.
Educate the client about current medical diagnosis Refer the client to a meal delivery program
Identify environmental hazards in the home
Stay in bed at least 1 hr if unable to fall asleep Take a 1 hr nap during the day
Perform exercises prior to bedtime
d. Arrange for client transportation to follow-up
appointments Rationale Priority: Assess first.
13. A nurse is assessing the remote memory of an older adult client who has mild dementia. Which of the following questions should the nurse ask the client?
a.
b.
“Can you tell me who visited you today?”
“What high school did you graduate from
c.
d.
14. A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching
“Can you list your current medications?” “What did you have for breakfast yesterday?”
a.
b.
c.
HYPOGLYCEMIC
15. A nurse is caring for a client who is receiving phenytoin for management of grand mal seizures and has a new prescription for isoniazid and rifampin. Which of the following should the nurse conclude if the client develops ataxia and incoordination?
HbA1c level greater than 8%- 6.5 - 8 is the target reference. > Blood glucose level greater than 200 mg/dL at bedtime
Blood glucose level less than 60 mg/dL before breakfast- < 70 =
d.
HbA1c level less than 7%
a. b.
c. d.
16. A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse?
The client is experiencing an adverse reaction to rifampin The client’s seizure disorder is no longer under control
The client is showing evidence of phenytoin toxicity
The client is having adverse effects due to combination antimicrobial therapy
a. b. c.
Increase in frequency of swallowing→ may indicate bleeding Moderate sanguineous drainage on the drip pad
Bruising to the face→ side effect
d. Absent gag reflex→ possibly due to anesthesia given. (1 hour postoperative) Rationale “Requires immediate action” choose the worst possibility that could lead to. ABC
17. A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki disease. Which of the following interventions should the nurse include in the plan of care?
a. Give scheduled doses of acetaminophen
every 6 hr
cardiac status
c. Administer antibiotics via intermittent IV bolus for 24 hr
d. Provide stimulation with children of the same age in the playroom
18. A nurse is planning an educational program for high school students about cigarette smoking. Which of the following potential consequences of smoking is most likely to discourage adolescents from using tobacco?
a. Use of tobacco might lead to alcohol and drug abuse
b. Smoking in adolescence increases the risk of developing lung
cancer later in life
of athletic ability
d. Smoking in adolescence increases the risk of lifelong addiction
19. A nurse is assessing a client who is prescribed spironolactone.
Which of the following laboratory values should the nurse monitor for
this client?
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