Predictor Flashcards
Which of these instructions should a nurse include in the teaching plan for a client who had removal of a cataract in the left eye?
“Take the prescribed stool softener to avoid increasing intraocular pressure.”
A client vomits during a continuous nasogastric tube feeding. A nurse should stop the feeding and take which of these actions?
Check the residual volume.
Which of these actions best demonstrates cultural sensitivity by a nurse?
The nurse asks clients about their beliefs and practices toward pregnancy.
Which of these manifestations would a nurse expect to observe in a 3-month-old infant who is diagnosed with dehydration?
Tachycardia
When assessing a client’s risk of developing nosocomial infection, a nurse plans to determine potential entry portals, which include:
The urinary meatus.
A client who is on the inpatient psychiatric unit has a history of violence. Which of these actions should a nurse take if the client is agitated?
Encourage the client to verbalize feelings.
Which of these measures should a nurse include when planning care for a school-aged child during a sickle cell crisis episode?
Providing pain relief
Which of these instructions should a nurse include in the plan of care for a 32-week gestation client who had an amniocentesis today?
“Call the clinic if you experience any abdominal cramps.”
An adolescent has a nursing diagnosis of fatigue related to inadequate intake of iron-rich foods. Selection of which of these lunches by the client indicates a correct understanding of foods high in iron content?
Beefburger with cheese.
A client has been admitted with acute pancreatitis. Which of these laboratory test results supports this diagnosis?
Elevated serum amylase level.
Which of these manifestations, if assessed in a client who is two-hours postoperative after abdominal surgery, should a nurse report immediately?
Vomiting and a pulse rate of 106/minute.
Which of these observations of a student nurse’s behavior while interacting with a client who is crying indicates a correct understanding of therapeutic communication?
The student sits quietly next to the client.
Which of these actions should a nurse take initially if a client who is diagnosed with diabetes mellitus develops tremors and ataxia?
Measure the client’s blood sugar level.
An elderly client is at increased risk of developing drug toxicity to prescribed medications due to declining hepatic and renal functioning. Which of these strategies should a nurse plan to decrease this risk?
Increasing the time interval between medication doses.
A client has persistent paranoid delusions that the food on the unit is poisoned. Which of these measures should a nurse include in the client’s care plan?
Allowing the client to eat food from sealed containers.
Thrombophlebitis is a complication that may result due to surgery. Which of these actions should a nurse take in the operating room to prevent this complication from occurring?
Apply sequential compression devices.
When discussing weight gain during pregnancy, a nurse should recommend that the total weight gain for a pregnant client who is at the ideal body weight for her height is:
25 to 35 pounds.
Which of these manifestations, if reported by a client who is 10-weeks-pregnant, supports the diagnosis of ruptured tubal pregnancy?
Sharp unilateral abdominal pain.
Which of these assignments, if made by a nurse to a nursing assistant, indicates that the nurse needs additional instructions regarding the principles of delegation?
“Please bathe the client in room
10, administer a back rub, and then evaluate if the back rub eased the client’s discomfort.”
client has the following order for regular insulin (Humulin R) on a sliding scale:
Blood sugar 150-180 mg: Give 2 units regular insulin. Blood sugar 181-200 mg: Give 4 units regular insulin. Blood sugar 201-220 mg: Give 6 units of regular insulin. Blood sugar above 220 mg: Call MD At 11 A.M., a nurse obtains a finger stick glucose
of 198 mg. The only syringe is a three milliliter one. Regular insulin is available as 100 units per milliliter. How many milliliters should the nurse administer?
0.04
Which of these nursing diagnoses is the priority for a client who is one hour postoperative after extensive abdominal surgery?
Risk for ineffective airway clearance.
A nurse should recognize that which of these occupations increases a person’s risk of developing hepatitis B?
Hemodialysis nurse.
Which of these assessments is the priority for a client who sustained second-degree burns of the face and neck?
Respiratory status.
A nurse should place a child who is two hours post-tonsillectomy and adenoidectomy in which of these positions?
side-lying
Which of these instructions should a nurse include in the discharge teaching for a client who has diabetes mellitus?
“Apply lotion to your feet each day.”
A nurse inadvertently administers an incorrect medication to a client. Which of these actions should the nurse take first?
Assess the client.
An elderly client who is receiving a blood transfusion develops a rapid bounding pulse and an elevated blood pressure. Which of these actions should a nurse take?
Stop the transfusion.
When caring for a client who has hepatitis B, a nurse should wear:
gloves when removing the intra- venous cannula.
Which of these outcome criteria is appropriate for a client who has a nursing diagnosis of ineffective airway clearance?
Clear lung sounds on auscultation.
A doctor prescribes liquid oral iron medication for a 4-year-old child. Which of these questions should a nurse ask the child’s mother to determine if the medication is being administered correctly?
“Are you using a straw to adminis- ter the medicine?”
A doctor prescribes liquid oral iron medication for a 4-year-old child. Which of these questions should a nurse ask the child’s mother to determine if the medication is being administered correctly?
“Are you using a straw to adminis- ter the medicine?”
Which of these assessment findings, if present in a 4-month-old infant who has severe diarrhea, should a nurse recognize as suggestive that the infant is dehydrated?
Decreased urine output.
When a newborn is 48 hours old, a nurse notes that the child is jaundiced. The nurse should recognize which of these conditions as a probable cause of the newborn’s jaundice?
Liver immaturity.
Which of these items should a nurse removed from the food tray of a client who is on a sodium-restricted diet?
Ketchup.
Which of these statements, if made by a client who had a total hip replacement, would indicate a correct understanding of the postoperative instructions?
“I will use a raised toilet seat in the bathroom.”
Which of these measures should a nurse include when planning care for an 88-year-old client who is admitted to the hospital with pneumonia?
Allowing the client to perform self-care as tolerated.
A client, who is newly diagnosed with cancer says to a nurse, “I suppose I need to complete all unfinished business as soon as possible.” Which of these responses is appropriate?
“It sounds like you are concerned with your diagnosis.”
Which of these interventions should plan for a child who is receiving chelation therapy for lead poisoning?
Keeping an accurate record of intake and output.
A nurse obtains these vital signs on an adult client. Which finding should the nurse follow up first?
Respiration, 30/minute, and deep.
When determining the duration of a uterine contraction, a nurse should measure the contraction from the:
beginning of one contraction to the end of that contraction.
A nurse should recognize which of these signs is a probable sign of pregnancy?
Positive pregnancy test.
All of these clients are on bed rest. Which one is the most at risk to develop skin breakdown?
An 84-year-old client who has been NPO for four days.
A client diagnosed with type 1 diabetes mellitus has a glycosylated hemoglobin A1c of 4.2%. A nurse should interpret this to mean that the client has:
been in relatively good diabetic control.
A nurse is caring for a client with burns and in reverse isolation. Which measures should the nurse include?
Wearing a gown, mask, and gloves when providing care to the client.
A physician has ordered 100 mg of Amoxicillin po for a child. The available liquid amoxicillin is 250 mg/5 mL. How many milliliters should a nurse administer?
2.0
A nurse charts on all assigned clients at 2:00 P.M. The nurse then remembers something that happened at 9:00 A.M. to a client who was not charted. Which of these actions should the nurse take?
Enter the scenario after the original 2:00 P.M. charting and mark it as a “late entry”.
While giving a bath to a client, a nurse notices that the client’s back appears reddened. Which of these interpretations and additional assessments should the nurse make?
The client is showing signs of pressure; press on the skin and observe for a return of color.
A newborn is placed under fluorescent light as part of the treatment for physiologic jaundice. During the duration of the newborn’s treatment, a nurse should:
cover the newborn’s closed eyes with patches.
Which of these symptoms should a nurse expect to assess in a client who develops hypoglycemia?
Diaphoresis.
A client is eight hours postoperative after transurethral resection of the prostate (TURP). Which of these observations, if noted by a nurse, indicates a complication?
BP 92/60 mm Hg, pulse rate 118/minute.
A nurse should assess a child who has diabetes mellitus (type 1) for symptoms of hyperglycemia, which include:
flushed skin and thirst.
Which of these laboratory test results should a nurse monitor for a client who is receiving intravenous heparin therapy at a rate of 1,500 units per hour for the treatment of an acute pulmonary embolism?
Partial thromboplastin time.
Which of these techniques should a nurse use to assess for correct placement of a nasogastric tube prior to administering a feeding?
Aspirate 10 mL contents and mea- sure the pH.
A client has shortness of breath when lying down and usually assumes an upright or sitting position in order to breathe more comfortably. A nurse should document this observation as:
orthopnea.
Which of these instructions should a nurse give to a client when collecting a sputum specimen?
“Take a deep breath, then cough and spit into this container.”
A client who is receiving radiation therapy has a nursing diagnosis of imbalanced nutrition: less than body requirements related to diminished taste perception and nausea. Which of these additional nursing diagnoses should a nurse consider for the client?
Risk for deficient fluid volume.
Which of these menus, if chosen by a parent of a child who has celiac disease, would indicate to a nurse that the parent understands the teaching about a gluten-free diet?
Broiled steak, baked potato, and spinach.
Which of these statements, if made by a nurse, is non-therapeutic because it disregards a client’s feelings and concerns?
“Everything will be okay.”
A client tells a nurse, “I am so scared about the interview tomorrow. I just know I will say the wrong thing and not get the job.” Which of these responses, if made by the nurse, will create a communication barrier?
“You need to relax, and everything will be fine.”
A young healthy adult, who has been exercising in hot weather, has fatigue, loss of appetite, and lightheadedness. Which of these assessments should a nurse make?
Measure the client’s body tem- perature.
