(Test Bank) NURSING 6001 - Question Bank Together With Answers

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Quiz 1 The nurse provides care for a client diagnosed with acute pancreatitis. The nurse intervenes if the client makes which statement? (Select all that apply.) 1. “I may need to take antibiotics.” 2. “After I get better, I need to eat a high-fat diet.” 3. “I’m glad I won’t get sick like this again.” 4. “I’m glad my blood sugar will not be affected.” 5. “I should stop drinking alcohol.” 6. “I cannot have anything to eat or drink.” The nurse in the day care center observes a toddler squatting and panting after chasing a ball. Which action does the nurse take first? 1. Remove the child from the playground and encourage rest. 2. Check for sweating, color, and tachycardia. 3. Ask the child about a sore throat or achy joints. 4. Restrict the child from playing ball. The nurse cares for clients in the outpatient clinic. In which order will the nurse return the messages? Correct Answer 1. The "soft spot" on the head of the 4-day-old feels slightly elevated when asleep. 2. The circumcision site of the 3-day-old is slightly swollen. 3. The umbilical cord of the 5-day-old is soft and draining exudate. 4. When bed is bumped, a 2-day-old rapidly extends the extremities. The parents of a child diagnosed with hemophilia ask the nurse to explain the cause of the disease. Which response by the nurse is best? 1. "The father transmits the gene to the son." 2. "Both the mother and the father carry a recessive trait." 3. "The mother transmits the gene to her son." 4. "There is a 50% chance that the mother will pass the trait to each of the daughters." The 6-month-old is brought to the clinic for a well-baby checkup. During the exam, the nurse expects to observe which assessment findings? Select all that apply. 1. A pincer grasp. 2. Sitting with support. 3. Tripling of the birth weight. 4. Presence of the posterior fontanelle 5. Playing peek-a-boo. 6. Rolling from back to abdomen. A client with an endotracheal tube requires suctioning. Which statement is an accurate description of how the nurse performs the procedure? 1. Inserts the suction catheter 4 in into the tube. Applies suction for 30 seconds, using a twirling motion as the catheter is withdrawn. 2. Hyperoxygenates the client. Inserts the suction catheter into the tube, and suctions while removing the catheter in a back and forth motion. 3. Explains the procedure to the client. Inserts the catheter gently while applying suction, and withdraws using a twisting motion. 4. Inserts the suction catheter until resistance is met, and then withdraws it slightly. Applies suction intermittently as the catheter is withdrawn. A client comes to the outpatient psychiatric clinic for treatment of a fear of heights. The nurse knows that phobias involve which behaviors? 1. Projection and displacement. 2. Sublimation and internalization. 3. Rationalization and intellectualization. 4. Reaction formation and symbolization. The nurse cares for the prenatal client at 8 weeks’ gestation with a positive VDRL. When the nurse prepares the teaching plan, it is most important for the nurse to include which information? 1. Advise the client not to take any over-the-counter medications. 2. Instruct the client about the importance of taking all of the medication. 3. Inform the client to refrain from sexual activity. 4. Maintain the confidentiality of sexual partners or contacts. The nurse performs range-of-motion (ROM) exercises for an elderly client recently immobilized. The nurse identifies which statement as correct about range-of-motion? 1. Passive ROM exercises increase muscle strength. 2. A full ROM must be completed for the elderly client. 3. Exercises should be completed to the point of discomfort. 4. ROM assists the elderly to carry out activities of daily living (ADLs). The nurse cares for an older client scheduled for a colon resection this morning. The nurse notes the client had polyethylene glycol-electrolyte solution and a soapsuds enema the previous evening. This morning the client passes a medium amount of soft brown stool. Which conclusion by the nurse is most accurate? 1. The bowel preparation is incomplete. 2. The client ate something after midnight. 3. This is an expected finding before this type of surgery. 4. The client passed the last stool left in the colon. The nurse cares for the newborn infant diagnosed with fetal alcohol syndrome. The nurse expects to see which characteristics? 1. An infant large for gestational age (LGA), craniofacial abnormalities, and hydrocephalus. 2. An infant with a small head circumference, low birth weight, and undeveloped cheekbones. 3. An infant with a large head circumference, low birth weight, and excessive rooting and sucking behaviors. 4. An infant with a normal head circumference, low birth weight, and respiratory distress syndrome.The nurse watches as a parent and infant interact. The infant throws a toy to the floor numerous times. The parent picks up the toy and gives it back to the infant. If the parent does not immediately return the toy, the infant cries loudly. Which statement by the nurse is best? 1. “Be sure to wipe the toy off each time before you give it back. These floors are filthy.” 2. “Your baby is either stubborn or wants attention, I cannot figure out which.” 3. “I remember when my own baby used to do that.” 4. “I bet your baby is about 11 months old. This is normal behavior.” The nurse admits an older adult client who reports fever and chills to the medical unit. Which assessment finding most concerns the nurse? 1. The client’s HR 120 beats/min and BP is 90/60 mm Hg. 2. The client's RR is 18 breaths/min and BP is 110/70 mm Hg. 3. The client's white blood cell count is 16000/µL (16.00×109/L). 4. The client's platelet count is 325 ×10 3/µL (325×109/L). The nurse provides care for a client in an outpatient clinic who reports vaginal itching. Which recommendation to the client by the nurse isappropriate? 1. “Supplement your diet with yogurt and dairy products.” 2. “Douche with an over-the-counter preparation.” 3. “Wash the area with soap and water several times a day.” 4. “Wear underwear that is lined with a cotton crotch.” The nurse supervises care of a client in Buck traction. Which observations does the nurse determine are appropriate? (Select all that apply.) 1. The nurse removes the foam boot three times per day to inspect the skin. 2. The staff turns the client to the unaffected side. 3. The staff provides back care for the client once per shift. 4. The nurse asks the client to dorsiflex the foot on the affected leg. 5. The staff offers magazines to the client when the client reports pain. 6. The staff elevates the foot of the client ’s bed.The nurse assesses an older adult client who experienced a stroke. Which findings indicate to the nurse that the client has cognitive impairment? (Select all that apply.) 1. Ataxia. 2. Poor judgment. 3. Upper arm flaccidity. 4. Memory deficits. 5. Flat affect. The nurse assesses a 2-hour old newborn. The nurse notes the newborn’s hands and feet are bluish in color. T o which reason does the nurse attribute this finding? 1. A lack of adjustment to environmental temperature. 2. Poor perfusion of blood to the periphery of the body. 3. A lowered oxygen tension. 4. A low hemoglobin level. A client is prescribed 8 units of regular insulin per hour. The insulin is prepared with 500 units in 250 mL of 0.9% normal saline. At which rate in mL/hr will the nurse set the infusion pump? (Do not round. Record your answer using a whole number.) Ans: 4 mL/hr A toddler is prescribed phenobarbital 120 mg by mouth. The vial contains 160 mg of the medication in 5 mL. Which amount of medication in milliliters will the nurse administer to the client? (Record your answer using one decimal place. Do not round.) Ans: 3.7 mL The health care provider prescribes estrogen daily for a middle-age adult client. Which client statement indicates to the nurse that further teaching is necessary? 1. "There may be a change in my libido." 2. "I may experience a change in my weight." 3. "I may have some difficulty wearing my contact lenses." 4. "It is unnecessary for me to perform breast self-exams." A nurse in a rural community assesses residents for risk factors for heart disease. The nurse determines that which resident is at greatest risk to develop heart disease? 1. A resident who participates in a competitive weight lifting program. 2. A resident diagnosed with type 1 diabetes that is poorly controlled. 3. A resident whose grandfather died of heart failure at age 72. 4. A resident who drinks a glass of beer every night. The nurse provides care to a group of clients. In which order will the nurse complete care for these clients? (Please arrange in order. All options must be used.) Correct Answer 1. Assess a client diagnosed with a decreased level of consciousness who had an ischemic stroke yesterday. 2. Assess a client reporting weakness and tingling in the lower extremity accessed for a cardiac catheterization. 3. Notify the health care provider of serum potassium of 5.2 mEq/dL (5.2 mmol/L) in a client diagnosed with acute kidney failure. 4. Administer morning medications to a client scheduled for hemodialysis within the hour. The nurse provides care for a client diagnosed with Parkinson disease. Which client statements indicate a need for additional follow-up by the nurse? (Select all that apply.) 1. "I will likely be cured by the carbidopa-levodopa." 2. "I've read that deep brain stimulation may help my shakiness." 3. "I don't have enough energy to do yard work." 4. "I often feel dizzy when I first stand up after sitting for a while." 5. "My family notices that I am moving more slowly." 6. "Sometimes food seems to get stuck in my throat." A client receiving parenteral nutrition is to receive an intravenous fat emulsion infusion. Which action will the nurse take when administering the fat emulsion? 1. Administer it through separate tubing. 2. Provide it as intravenous boluses. 3. Wrap the infusion container in aluminum foil. 4. Infuse it through a central line. The nurse performs discharge teaching for an older adult client diagnosed with peripheral artery disease. It is important for the nurse to include which instruction? 1. “Soak in a tub of warm water twice per day or perform foot soaks.” 2. “Maintain a warm environment by using blankets or loose, layered clothing.” 3. “Elevate your legs above the level of your heart four times per day.” 4. “Sit for a total of 6 hours per day with your feet resting on the floor.” The nurse assesses a 1-month old infant. Which finding will the nurse investigate further? 1. Anterior fontanel taut when the infant cries. 2. Head lag present when the infant is pulled from a lying to a sitting position. 3. T op of the infant’s right knee is 1 inch higher than the left knee. 4. Left arm and leg extend when the head is turned to the left. A client diagnosed with a head injury is being prepared for a lumbar puncture. Which action will the nurse take first? 1. Obtain informed consent. 2. Measure pre-procedure vital signs. 3. Explain the procedure to client. 4. Locate a lumbar puncture tray. A client weighing 53 lb is prescribed IV atropine 0.02 mg/kg now. The medication available is 0.8 mg/mL. Which amount in milliliters will the nurse provide to the client? (Round at the end of the equation. Record your answer using one decimal place.) Ans: 0.6 mL The nurse provides care to a client admitted with mild hyponatremia secondary to excessive water consumption. Which intervention does the nurse anticipate including in the client's plan of care? 1. Administering 0.45% sodium chloride IV. 2. Restricting fluid intake.3. Administering 3% sodium chloride IV. 4. Encouraging frequent ambulation. A client is to undergo an electroencephalogram (EEG) the following day as part of the workup for evaluation of seizure activity. Which statement is approrpiate for the nurse to include when preparing the client for the test? 1. “Avoid drinking coffee, tea, or caffeinated beverages before the test.” 2. “You will need to wash your hair after the test, so do not bother washing it beforehand.” 3. “Be careful not to eat or drink anything for at least 6 hours before the test.” 4. “There will be harmless pricking sensations during the test as the electricity enters your brain.” The nurse provides care for a client diagnosed with spinal cord injury at the level of T1. The nurse notes profuse sweating, and the client reports a pounding headache and nasal stuffiness. In which order does the nurse provide care for this client? (Please arrange in order. All options must be used.) 1. Place the client in a sitting position. 2. Check the indwelling catheter tubing for kinks or obstruction. 3. Monitor the blood pressure every 10 to 15 minutes. 4. Label the chart with a visible note about the risk for autonomic dysreflexia. 5. Instruct the client about how to prevent autonomic dysreflexia. The nurse provides care for a comatose client. The nurse is unable to elicit a reaction after applying the trapezius squeeze, supraorbital pressure, mandibular pressure, and sternal rub. Which action does the nurse take next? 1. Administer diuretics as prescribed. 2. Lower the head of the bed. 3. Press a pencil to a finger or toe of each limb. 4. Begin cardiopulmonary resuscitation. A client with type 2 diabetes mellitus is prescribed pioglitazone and metformin. Which client health history information causes the nurse to question the prescription of these medications? (Select all that apply.)1. History of essential hypertension. 2. Weight loss of 30 lb (13.6 kg) over the past 6 months. 3. Being 6 weeks pregnant. 4. History of heart failure. 5. History of lactic acidosis. A child with failure to thrive has a positive sweat test. Which change does the nurse anticipate in this client's plan of care? 1. Administer replacement enzymes. 2. Apply oxygen. 3. Provide a salt-restricted diet. 4. Initiate intravenous therapy. The outpatient clinic nurse cares for an elderly client diagnosed with type 1 diabetes. Because the client is unwilling to perform blood glucose monitoring, the client tests urine for glucose and acetone. The nurse knows that blood glucose monitoring is preferred over urine testing for glucose because of which reason? 1. The renal threshold for glucose is elevated in the elderly. 2. Blood glucose monitoring is easier and less costly for clients to perform. 3. Urine testing for glucose provides false-positive readings. 4. Determination of the color on a reagent strip varies from person to person. The health care provider orders hydromorphone hydrochloride 15 mg IM for a client. The nurse observes for which adverse effects? 1. Photosensitivity and constipation. 2. Hypotension and respiratory depression. 3. T ardive dyskinesia and diplopia. 4. Dry mouth and tinnitus. The outpatient clinic nurse cares for an elderly client diagnosed with type 1 diabetes. Because the client is unwilling to perform blood glucose monitoring, the client tests urine for glucose and acetone. The nurse knows that blood glucose monitoring is preferred over urine testing for glucose because of which reason? 1. The renal threshold for glucose is elevated in the elderly. 2. Blood glucose monitoring is easier and less costly for clients to perform. 3. Urine testing for glucose provides false-positive readings. 4. Determination of the color on a reagent strip varies from person to person. At 32 weeks gestation, the client has an order for an ultrasound. The nurse determines that the client understands the procedure if the client makes which statement? 1. The results will inform us of the baby's size. 2. This test will evaluate the baby's lungs. 3. The test will show us if there is any problem in the baby's genes. 4. Early problems with the baby's blood can be identified with this test. The nurse cares for the child diagnosed with pediculosis capitis (head lice) who is being treated with permethrin 1% cream rinse. The nurse includes which information when instructing the child’s parents? 1. Apply the cream rinse every other day for 1 week. 2. Wash the child’s clothing and personal belongings in soap and cool water. 3. Repeat the application of the cream rinse in 7 days if nits are still present. 4. Comb the child's hair weekly with a nit comb. The nurse supervises an LPN/LVN administering an enema to a client. The nurse determines the LPN/LVN’s actions are appropriate if which action is observed? 1. The LPN/LVN places the solution 20 inches above the anus. 2. The LPN/LVN adjusts the temperature of the solution. 3. The LPN/LVN inserts the tube 6 inches. 4. The LPN/LVN positions the client left Sims' position. Individual StudyThe nurse teaches a group of nursing students about elder abuse. Which older adult client does the nurse list as most likely to be a victim of abuse? 1. A male diagnosed with moderate hypertension. 2. A male with newly diagnosed cataracts. 3. A female with advanced Parkinson disease. 4. A female diagnosed with early stage Lyme disease. A parent asks the nurse when an infant can begin to eat solid foods. The nurse assesses the infant’s readiness to begin eating solid foods. Which assessment finding indicates to the nurse that the parent should wait to introduce solid foods? 1. Intact suck-swallow reflex. 2. Drooling present. 3. Intact tongue extrusion reflex. 4. Easily distracted from breastfeeding. The nurse performs discharge teaching for a client after a right side mastectomy. It is important for the nurse to include which instruction? 1. Place a heating pad under the right shoulder nightly. 2. Keep the right arm in a sling for 4 weeks. 3. Attend the Reach to Recovery support group every day. 4. Use the left arm to measure the blood pressure. The nurse provides care to a client receiving total parenteral nutrition (TPN). Which intervention will the nurse include in the care plan for this client? 1. Change the solution bag every 24 hours. 2. Maintain the client on complete bed rest. 3. Stop the infusion every 4 hours to give medications.4. Flush the line with water prior to starting nutritional support. The nurse overhears two unlicensed assistive personnel (UAP) discuss a client’s protected health information (PHI) in a public elevator. Which action does the nurse take next? 1. Assess the elevator for visitors and nonstaff passengers. 2. Contact the supervisor on the floor where the UAPs work. 3. Instruct the UAPs to stop the conversation immediately. 4. Notify the hospital risk manager and ethics committee. The nurse discusses immunizations with a client in the third trimester of pregnancy. Which information is appropriate for the nurse to include? (Select all that apply.) 1. “Since you are not immune to rubella, you will get immunized after your baby is born. ” 2. “If needed, you can get the tetanus vaccine while you are pregnant. ” 3. “The pertussis vaccine should not be taken while you are pregnant. ” 4. “While pregnant, you should receive the influenza vaccine during flu season. ” 5. “If you are not immune to varicella, you should get the vaccination now. ” Which technique does the nurse implement when performing a physical examination of an infant during a well-child visit? 1. Avoid auscultating breath sounds while the infant sleeps. 2. Undress the infant, including the diaper, for the entire assessment. 3. Have the parent hold the infant during the examination. 4. Assess the infant’s ears first. The nurse prepares to obtain a wound culture from a client in long-term care. In which order will the nurse perform the steps necessary to culture the wound? (Please arrange in order. All options must be used.) 1. Assess pain level at wound site. 2. Perform hand hygiene and apply sterile gloves. 3. Clean exudate from wound and wound edges. 4. Insert tip of sterile swab into wound and rotate gently. 5. Ensure swab tip is in culture medium in collection container.The nurse observes a preschooler interact with the parent. Which observation by the nurse is most concerning? 1. The parent explains that injections will burn like a bee sting. 2. The parent tells the preschooler they will be left at the clinic if the child cries. 3. The parent offers to let the child sit in the parent’s lap while the nurse administers an injection. 4. The parent tells the child that it is okay to cry. The nurse instructs a client about the care of a new colostomy. Which information does the nurse include? (Select all that apply.) 1. Change the ostomy appliance following a meal. 2. Use a moisturizing soap to clean skin around stoma. 3. Place tissue on stoma when changing the appliance. 4. Cut the skin barrier 1/8 inch larger than the stoma. 5. Empty the pouch of stool before removing the appliance. 6. Check stoma for color, size, and shape. Individual Study 1 The spouse of a client recovering from an amputation contacts the home care nurse because the client experiences severe pain in the missing limb. Which response is the best for the nurse to make to the spouse? 1. “Is the client lying on the abdomen as prescribed? ” 2. “Please try to calm down. There is nothing to be upset about. ” 3. “Is the residual limb bleeding or does it have an unusual odor? ” 4. “That kind of pain is common after an amputation. Does the client have pain medication available? ” The nurse provides care to oncology clients. Which clients require further intervention from the nurse? (Select all that apply.) 1. The client receiving chemotherapy treatment for breast cancer who reports “always feeling tired.” 2. The client receiving a chemotherapeutic alkylating agent intravenously via an implanted port with redness on the chest. 3. The client with bladder cancer reporting that “nothing tastes good” and who drinks four cans of nutritional supplement daily.4. The client receiving radiation for lymphoma who reports there are handfuls of hair on the pillow every morning. 5. The client diagnosed with bone cancer who is receiving chemotherapy and is afebrile but has a productive cough. 6. The client who reports frequent bouts of diarrhea but states the nausea is manageable with occasional sips of fluid. The nurse provides care for a client diagnosed with left-sided weakness and impaired speech. Which intervention is appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? (Select all that apply.) 1. Maintain the head of the bed less than 30 degrees. 2. Monitor blood pressure regularly. 3. Obtain medical history for risk factors. 4. Assist the client with frequent oral care. 5. Determine readiness for smoking cessation. The nurse provides care for a client before surgery. Thirty minutes after administering the preoperative medication, the nurse observes the unlicensed assistive personnel (UAP) ambulate the client to the bathroom. Which action should the nurse take first? 1. Have the UAP assist the client back to bed. 2. Ask the UAP if the client had difficulty walking. 3. Determine why the UAP ambulated the client. 4. Ensure that the UAP receives the appropriate training. The nurse prepares to collect a 24-hour urine specimen for creatinine clearance. Which action does the nurse take? 1. Ask the laboratory if there is a preservative in the collection container. 2. Discard the last voided specimen prior to ending the collection. 3. Obtain a prescription from the health care provider for a urinary catheter. 4. Determine the client’s weight prior to beginning the urine collection. The nurse manager prepares to implement self-scheduling for the unit. In which order does the nurse manager proceed with this task? (Please arrange in order. All options must be used.) 1. Assess unit staffing needs. 2. Discuss unit staffing needs with supervisor.3. Hold a unit meeting to educate staff about self-scheduling. 4. Post a blank schedule on the unit for staff to choose their shifts. 5. Review the schedule and revise as needed. A client with a possible fracture of the right femur comes to the emergency department. The nurse supervises the transfer of the client from the car to a stretcher. Which is the bestaction by the nurse? 1. Instruct the client to stand on the left leg and to ease onto the stretcher. 2. Determine if the client fell from a high place. 3. Support the right leg above and below the right femur. 4. Ask the client if there is movement in the right hip or right knee. The nurse provides care for a client diagnosed with heart failure and treated with furosemide. Which client statement indicates to the nurse that the client is experiencing an adverse medication effect from furosemide? (Select all that apply.) 1. “My legs don’t want to hold me up.” 2. “I can’t seem to catch my breath.” 3. “I can’t get enough to drink today.” 4. “I feel like I might pass out.” 5. “My feet feel like two balloons.” The nurse provides an albuterol nebulizer treatment to a client recovering from respiratory failure. Which finding does the nurse expect to observe after treatment? (Select all that apply.) 1. Increased productive cough. 2. Increased wheezes in upper lobes. 3. Decreased crackles in lower lobes. 4. Reports of decreased anxiety. 5. Bilateral hand tremors. The unlicensed assistive personnel (UAP) calls the nurse and states, “The client in room 218 is reporting shortness of breath.” Which response by the nurse is appropriate? 1. “Call the respiratory therapist and request an arterial blood gas be performed.” 2. “Ask the client when the shortness of breath started.”3. “Ensure the nasal cannula is in the client’s nares.” 4. “Listen to the client’s lung sounds and notify me if you hear wheezing or crackles.” A client is prescribed irbesartan 300 mg by mouth twice a day. The medication is available in 150 mg tablets. Which number of tablets will the nurse provide for each dose? (Record your answer rounding to the nearest whole number.) Ans: 2 tabs The nurse provides care for a client who had a transurethral resection of the prostate (TURP). The client has a three-way urinary catheter connected by gravity with continuous bladder irrigation (CBI) of normal saline. Which observations require the nurse to intervene? (Select all that apply.) 1. T emperature of 101.4°F (38.3°C). 2. Urinary output of 100 mL in 4 hours. 3. Fluid leakage around the catheter tubing. 4. Blood pressure of 112/76 mm Hg. 5. 230 mL of sanguinous fluid in the catheter bag. 6. Client reports pressure in the pelvis. The nurse provides care for a client who just passed a renal calculus. The nurse sends the specimen to the laboratory. Which specimen analysis will assist the nurse to plan care? 1. Type of infection. 2. Size and number of calculi. 3. Antibodies. 4. Composition of the calculus. A client in the psychiatric unit continually states to the nurse, "My stomach is missing." Which response by the nurse is appropriate? 1. “Well then, you should not have any trouble losing weight.” 2. “Where did your stomach go?” 3. “It sounds like you feel very empty and alone.” 4. “I am here to help you, okay?”The nurse assesses the client who has a distended bladder. Because the client is unable to void, the health care provider prescribes catheterization. Which action does the nurse perform immediately after the catheter is inserted? 1. Clamps device after 500 mL of urine has drained. 2. Keeps the client in a prone position. 3. Asks the client to take deep breaths. 4. Asks if client has had the problem before. Study The nurse provides care for an older adult client after a left total hip replacement. Which finding will the nurse be most concerned about? 1. The client is positioned with a pillow between the legs. 2. The client moves slowly when getting out of bed. 3. The client ’s heels are on the bed with toes pointed upward. 4. The client uses an incentive spirometer every 2 hours. The school nurse performs scoliosis health screening with a group of middle school students. For which student will the nurse be the most concerned? 1. Child reports a painful right knee. 2. Child’s feet turn inward. 3. Child shifts weight from the right foot to the left foot. 4. Child’s left shoulder is higher than the right shoulder. The nurse receives report on a client admitted to the unit with a new diagnosis of abdominal aortic aneurysm (AAA). When teaching the client measures to reduce the risk of complications associated with AAA, which instruction does the nurse include? 1. Elevate the lower extremities above the level of the heart. 2. Encourage the increase of fluid intake and dietary fiber. 3. Utilize proper lifting techniques. 4. Avoid wearing a seatbelt while driving. A nurse in the pediatric clinic discusses the potential of lead exposure with the parents of preschoolers. It is important for the nurse to follow up on which statement made by a parent? 1. “I use water from the cold water tap for cooking.” 2. “My child likes to finger paint.” 3. “My spouse renovates old houses.” 4. “My child is very good about eating regular meals.” The nurse admits an older adult client diagnosed in the early stage of Alzheimer disease. Which factor causes the nurse to place the client on fall precautions? 1. Increased muscle tone and rigidity. 2. Restlessness and pacing. 3. Extension of the head and neck. 4. Shuffling gait. The nurse teaches a client who is newly diagnosed with type 1 diabetes mellitus. Which information does the nurse include in the client’s discharge teaching? (Select all that apply.) 1. Insulin administration. 2. Symptoms and treatment of hypoglycemia. 3. Reduction of physical activity. 4. The use of a portable blood glucose monitor. 5. Elimination of carbohydrates from diet. During a pregnant client’s nonstress test (NST), the nurse observes several late fetal heart rate decelerations. Which nursing action is most appropriate? 1. Reposition the client on the right side. 2. Notify the health care provider for further evaluation.3. Document these results in the client’s record. 4. Stop the oxytocin immediately. The health care provider prescribes vancomycin 40 mg/kg daily for a pediatric client weighing 90 pounds (40.9090909 kg). The medication is administered orally in four equally divided doses. The vancomycin is available as a 250 mg/5 mL concentration. How much medication does the nurse administer per dose? (Do not round. Record your answer using one decimal place.) Ans: 8.1 mL The nurse assesses a client in the emergency department. Which symptoms cause the nurse to suspect that the client is experiencing a panic attack? 1. Decreased perceptual field, diaphoresis, fear of going crazy, and palpitations. 2. Decreased blood pressure, chest pain, choking feeling. 3. Increased blood pressure, bradycardia, shortness of breath. 4. Increased respiratory rate, increased perceptual field, increased concentration ability. The client takes beclomethasone by metered dose inhaler (MDI). Which statement made by the client indicates that teaching is successful? 1. "I know it is time to have the prescription refilled when the canister floats in water." 2. "I will rinse my mouth and throat with water after each dose." 3. "I will be sure not to shake the canister before I use it." 4. "If the dose does not help, I will take extra and let the health care provider know the results." The nurse prepares to complete a health history with a client seeking treatment at the medical clinic for diabetes mellitus. Which question will best provide information about the client’s reason for seeking medical care? 1. “Has your diabetes been under control?” 2. “T ell me why you came to the clinic today.” 3. “How has your health been lately?”4. “Describe to me how you are feeling”. The nurse supervises a novice nurse providing care to a client with new symptoms of a cerebrovascular accident (CVA). Which actions by the novice nurse cause the seasoned nurse to intervene? (Select all that apply.) 1. Administers to the client aspirin 325 mg by mouth. 2. Prepares the client for a CT scan. 3. Assigns the client a 0 score on the National Institute of Health stroke scale screen. 4. Measures the client’s blood pressure. 5. Compiles a list of the client’s home medications. 6. Reassures the client that all symptoms will resolve. The nurse provides care for a client diagnosed with a detached retina. Which post-operative medication prescription does the nurse question? (Select all that apply.) 1. Droperidol. 2. Polyethylene glycol 3350. 3. Morphine sulfate. 4. Benzonatate. 5. Hydromorphone. 6. Clonidine. The nurse assumes care for a client from the post-anesthesia care unit (PACU). In which order does the nurse provide care for this client? (Please arrange in order. All options must be used.) 1. Perform a focused assessment of the client, including vital signs. 2. Observe incision or dressing and drainage tubes. 3. Review health care provider's postoperative prescriptions. 4. Develop a plan of care based on findings and the individual's risk factors. 5. Develop and implement individualized client education. Individual Study 2 The nurse provides care for the client diagnosed with heart failure and who takes digoxin 0.25 mg and furosemide 20 mg daily. Which assessment findings indicate the need for the nurse to intervene based on the current diagnosis and treatment regimen? (Select all that apply.) 1. Fatigue. 2. Intestinal colic. 3. Muscle cramps. 4. Cardiac dysrhythmia. 5. Anorexia.6. Alopecia. The spouse of a client diagnosed with a phobia is concerned by the client's sudden fear of elevators. The spouse asks the nurse what to do when the client becomes frightened. Which action does the nurse encourage the spouse to take first? 1. Ride the elevator with the client. 2. Encourage the client to get into the elevator. 3. Allow the client to avoid the elevator. 4. Encourage the client to discuss the fear. The nurse provides cares for a client reporting pain at the intravenous (IV) access site. Upon assessment, the nurse notes tenderness and redness at the site and redness proximally along the vein. It is most important for the nurse to take which action? 1. Slow the infusion rate and monitor the client’s response. 2. Stop the infusion and notify the health care provider. 3. Remove the IV and apply a pressure dressing. 4. Remove the IV and apply warm soaks. The nurse administers carbamazepine to a client for trigeminal neuralgia. Which therapeutic effect does the nurse expect after administering this medication? 1. Relieve accompanying depression. 2. Reduce the possibility of tonic-clonic seizures. 3. Relieve agonizing pain. 4. Provide sedation. 1er Test (ella) The nurse provides care for clients in the diabetic clinic. Which client does the nurse assess first? The nurse provides care for a client diagnosed with a cerebral vascular 1. The client with sunken eyeballs and a fruity breath odor. 2. The client reporting pain in both calves when exercising. 3. The client drinking copious water with constant hunger. 4. The client with difficulty sleeping and frequent crying.accident (CVA) who is being treated with heparin. The nurse is concerned by which observations? (Select all that apply.) 1. Petechiae on chest. 2. Partial thromboplastin time (PTT) 250 sec (control 38 sec). 3. Hematuria. 4. Platelet count of 150,000/mm 3 (150,000 ×10 9/L). 5. Reddish striae on thighs. 6. Hematocrit (Hct) 32% (0.32 proportion of 1.0). The school nurse assists with planning activities for a class of 10-year-old students. Which activity is appropriate for the nurse to encourage? 1. Using finger paints to create a painting. 2. Playacting a nurse-and-client scenario. 3. Solving math problems. 4. Writing a memoir. The nurse visits the home of a client diagnosed with gout. Which client comment causes the nurse concern during the assessment process? 1. “I am losing three pounds per week.” 2. “I drink eight glasses of liquid per day.” 3. “I am eating more whole grains and fresh fruits.” 4. “I do not drink alcoholic beverages anymore.” The client is prescribed carvedilol 12.5 mg orally twice daily. The pharmacy sends carvedilol 6.25 mg tablets to the unit. How many tablets does the nurse administer for each dose? (Do not round. Record your answer using a whole number.) Ans: 2 tabs The community health nurse provides care for a client who is taking multiple medications for constipation. Which medication causes the nurse the least concern? 1. Psyllium hydrophilic mucilloid. 2. Docusate sodium.3. Magnesium hydroxide. 4. Bisacodyl. The nurse observes an unlicensed assistive personnel (UAP) preparing to lift an object. Which principle of body mechanics does the nurse recommend to the UAP? 1. “Bend at the waist when you lift objects.” 2. “Carry objects close to your body or above your head.” 3. “Bend your knees when you lift objects.” 4. “Lean forward when you lift objects.” The nurse provides care for a client diagnosed with a closed head injury. The client begins to vomit. Which additional finding, if occurring with the noted emesis, does the nurse report to the health care provider (HCP)? 1. Increased lethargy. 2. Heart rate of 80 beats/min. 3. Sodium of 145 mEq/L (145 mmol/L). 4. Facial symmetry. The nurse manager on the unit is fiscally responsible for meeting goals related to personnel and supply expenses. T o meet budget expectations, it is important for the nurse manager to take which action? 1. Share budget expectations with the personnel on the unit. 2. Designate a staff nurse to assist with budget planning. 3. Post the budget on the bulletin board. 4. Ensure that provider needs are met. A client on the psychiatric unit begins to pace and continuously wring hands, and the nurse notes the client’s voice is becoming louder and angrier. Which action does the nurse take? 1. Utilize an organized team to place the client in seclusion.2. Allow time in the client’s private assigned room for reflection. 3. Redirect the client to a quiet activity such as journaling. 4. Assist the client to express feelings of anger and frustration. The nurse provides care for a client with a complete heart block (CHB). The nurse questions which prescription from the health care provider? 1. Administer lidocaine 50 mg IV push for premature ventricular contractions in excess of six per minute. 2. Prepare and administer epinephrine 2 to 10 mcg/min, titrating based on response. 3. Anticipate scheduling the client for a temporary pacemaker if the pulse continues to decrease. 4. Mix and administer 10 mL of 1:5000 solution of isoproterenol in 500 mL D 5W for sustained bradycardia below 30 beats/min. The nurse notes that the fetal position of a client at 38 week's gestation is left occiput anterior (LOA). Which location will the nurse find the point of maximum intensity of the fetal heart tones? When assessing a client admitted to rule out a myocardial infarction, the nurse determines a history of alcoholism. Which question is a priority for the nurse to ask the client? 1. “What over-the-counter medications do you take? ” 2. “How much alcohol do you consume each day? ” 3. “When did you have your last drink? ” 4. “Have you ever had symptoms of withdrawal? ”The nurse provides care for a 3-month-old infant diagnosed with developmental dysplasia of the left hip. The health care provider prescribes a Pavlik harness. The nurse instructs the parent about how to care for the infant in the harness. Which statement by the parent indicates to the nurse that additional teaching is necessary? (Select all that apply.) 1. “I need to place a shirt under the chest straps.” 2. “I should check for reddened areas under the straps.” 3. “I should place my baby’s diaper over the straps.” 4. “I will adjust the harness every couple of weeks.” 5. “I will avoid swaddling my baby’s legs.” 6. “I will place knee socks on my baby.” The nurse provides care to a client diagnosed with sinus arrhythmia. The nurse uses which site to assess the client's pulse? 1. Apical. 2. Radial. 3. Femoral. 4. Carotid. The community health nurse reviews recent laboratory tests for the caseload. Which client should the nurse see first based on the laboratory results? 1. Client with granular casts found in the urinalysis. 2. Client with urine specific gravity of 1.025. 3. Client with blood urea nitrogen of 16 mg/dL (5.7 mmol/L). 4. Client with serum creatinine of 1.0 mg/dL (88.4 µmol/L). The nurse observes children playing at a community picnic. Which situation is the most important for the nurse to intervene? 1. School-aged child picking at a scab located on the knee. 2. Preschooler running with a lollipop in the mouth. 3. T oddler lying on the ground kicking and screaming with the parents close by. 4. Infant lying on the back, head to the right side with the left arm and leg bent.