Predictor Flashcards
1
Q
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?
A
“Take the prescribed stool softener to avoid increasing intraocular pressure.”
2
Q
A client vomits during a continuous nasogastric tube feeding. A nurse should stop the feeding and take which of these actions?
A
Check the residual volume.
3
Q
Which of these actions best demonstrates cultural sensitivity by a nurse?
A
The nurse asks clients about their beliefs and practices toward pregnancy.
4
Q
Which of these manifestations would a nurse expect to observe in a 3-month-old infant who is diagnosed with dehydration?
A
Tachycardia
5
Q
When assessing a client’s risk of developing nosocomial infection, a nurse plans to determine potential entry portals, which include:
A
The urinary meatus.
6
Q
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?
A
Encourage the client to verbalize feelings.
7
Q
Which of these measures should a nurse include when planning care for a school-aged child during a sickle cell crisis episode?
A
Providing pain relief
8
Q
Which of these instructions should a nurse include in the plan of care for a 32-week gestation client who had an amniocentesis today?
A
“Call the clinic if you experience any abdominal cramps.”
9
Q
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?
A
Beefburger with cheese.
10
Q
A client has been admitted with acute pancreatitis. Which of these laboratory test results supports this diagnosis?
A
Elevated serum amylase level.
11
Q
Which of these manifestations, if assessed in a client who is two-hours postoperative after abdominal surgery, should a nurse report immediately?
A
Vomiting and a pulse rate of 106/minute.
12
Q
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?
A
The student sits quietly next to the client.
13
Q
Which of these actions should a nurse take initially if a client who is diagnosed with diabetes mellitus develops tremors and ataxia?
A
Measure the client’s blood sugar level.
14
Q
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?
A
Increasing the time interval between medication doses.
15
Q
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?
A
Allowing the client to eat food from sealed containers.
16
Q
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?
A
Apply sequential compression devices.
17
Q
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:
A
25 to 35 pounds.
18
Q
Which of these manifestations, if reported by a client who is 10-weeks-pregnant, supports the diagnosis of ruptured tubal pregnancy?
A
Sharp unilateral abdominal pain.
19
Q
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?
A
“Please bathe the client in room
10, administer a back rub, and then evaluate if the back rub eased the client’s discomfort.”
20
Q
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?
A
0.04
21
Q
Which of these nursing diagnoses is the priority for a client who is one hour postoperative after extensive abdominal surgery?
A
Risk for ineffective airway clearance.
22
Q
A nurse should recognize that which of these occupations increases a person’s risk of developing hepatitis B?
A
Hemodialysis nurse.
23
Q
Which of these assessments is the priority for a client who sustained second-degree burns of the face and neck?
A
Respiratory status.
24
Q
A nurse should place a child who is two hours post-tonsillectomy and adenoidectomy in which of these positions?
A
side-lying
25
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."
26
A nurse inadvertently administers an incorrect medication to a client. Which of these actions should the nurse take first?
Assess the client.
27
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.
28
When caring for a client who has hepatitis B, a nurse should wear:
gloves when removing the intra- venous cannula.
29
Which of these outcome criteria is appropriate for a client who has a nursing diagnosis of ineffective airway clearance?
Clear lung sounds on auscultation.
30
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?"
31
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?"
32
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.
33
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.
34
Which of these items should a nurse removed from the food tray of a client who is on a sodium-restricted diet?
Ketchup.
35
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."
36
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.
37
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."
38
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.
39
A nurse obtains these vital signs on an adult client. Which finding should the nurse follow up first?
Respiration, 30/minute, and deep.
40
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.
41
A nurse should recognize which of these signs is a probable sign of pregnancy?
Positive pregnancy test.
42
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.
43
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.
44
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.
45
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
46
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".
47
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.
48
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.
49
Which of these symptoms should a nurse expect to assess in a client who develops hypoglycemia?
Diaphoresis.
50
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.
51
A nurse should assess a child who has diabetes mellitus (type 1) for symptoms of hyperglycemia, which include:
flushed skin and thirst.
52
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.
53
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.
54
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.
55
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."
56
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.
57
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.
58
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."
59
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."
60
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.
61
Which of these nursing measures is the priority for a child who has hemophilia and who sustains a leg injury?
Administering the missing factor VIII to the child.
62
Which of these outcomes should a nurse focus on for a client who had a bronchoscopy two hours ago?
Preventing aspiration.
63
A client who had a coronary artery bypass graft four days ago suddenly develops sinus tachycardia and reports shortness of breath and dizziness. Which
of these interpretations and actions should a nurse take?
This may be an early sign of heart failure; notify the physician.
64
Which of these lunch selections, if made by a client who has congestive heart failure, should a nurse recognize as indicative of a need for additional instructions?
Egg salad sandwich with mayonnaise, pickles, and seltzer water.
65
Which of the statements if made by a client who is taking furosemide (Lasix), supports a nursing diagnosis of knowledge deficit?
"I will need to add more salt to my diet because this medication will increase its excretion."
66
Which of these statements, if made by a client who has chronic obstructive pulmonary disease, indicates improvement?
"I can now walk one more block than I could last month."
67
An 8-month-old infant is admitted to the hospital because of failure to thrive. Which of these actions should a nurse plan?
Consistently assign the care of the infant to the same staff.
68
Which of these actions should a nurse include to enhance the effectiveness of client teaching sessions?
Initially demonstrate and explain the procedure to the client.
69
Which of these laboratory test results is more important for a nurse to assess for a client who reports chest pain?
Troponin level.
70
A nurse should explain to a primigravida that urine tests will be done at each prenatal visit throughout the pregnancy to measure:
glucose and protein.
71
Which of these manifestations should a nurse expect to observe in a client who is diagnosed with paranoid schizophrenia?
Suspiciousness
72
Which of these measures should an emergency room nurse include when speaking with a family experiencing the loss of an infant from Sudden Infant Death Syndrome (SIDS)?
Encouraging the parents to take the opportunity to say goodbye.
73
Which of these assessments is the priority for a client who is admitted with recurrent depression?
Presence of a suicide plan.
74
Which of these changes in the assessment data of a child who has congestive heart failure should a nurse recognize as indicative of a therapeutic response to prescribed medication therapy?
Increased urine output.
75
Which of these assignments, if delegated to unlicensed assistive personnel (UAP) by a nurse, is appropriate?
The UAP is assigned to measure a client's intake and output.
76
A client who has a history of asthma develops
an acute asthma attack. Which of these questions should a nurse ask when assessing the etiology of this attack?
"Have you eaten any new foods recently?"
77
Which of these foods should a nurse suggest that a client who is diagnosed with irondeficiency anemia choose for dinner?
Cooked dry beans, green leafy vegetables, and dried fruits.
78
A nurse in a prenatal clinic performs Leopold's maneuvers on a client who is 8-months-pregnant primarily to:
determine the fetal presentation.
79
A child is brought to the clinical for serum lead screening because of ingestion of lead-based paint. Which of these manifestations, if present in the child, would indicate early signs of lead toxicity?
Behavior changes.
80
Which of these recommendations should a nurse make when teaching a client who is to start taking oral prednisone (Deltasone)?
"Take this medicine in the morning with food or milk.
81
Which of these actions should a nurse take prior
to initiate prescribed antibiotic therapy for a client who has a urinary tract infection?
Obtain a urine culture specimen.
82
When caring for a client who is receiving oxygen therapy via nasal cannula, a nurse should instruct the client:?
To breathe through the nose.
83
Each of these clients has impaired mobility related to knee surgery. Which client should a nurse assess first?
A 59-year-old who has a history of hypertension.
84
The mother of a 2-month-old tells a nurse that the baby is consuming six ounces of plain commercial formula seven times a day, plus one ounce of cereal in the morning and at bedtime. Based on this information, the nurse should conclude that the baby's diet is:
look this question up
85
A nurse plans to assess a client's recent memory. Which of these questions should the nurse include?
"What did you have for breakfast?"
86
A client who has a breast tumor says to a nurse,
"I am so anxious. Why did I have to get sick now?" Which of these responses, if made by the nurse, is therapeutic?
"Tell me more about your concerns."
87
Which of these actions, if taken by a nurse who is transferring a client from the bed to the chair, is correct?
The nurse supports the client in an upright standing position for a few moments.
88
A nurse should assist a pregnant client who is in the first trimester to achieve the developmental task of this stage of pregnancy, which is:
accepting the fact that she is pregnant.
89
When interacting with a client who is paranoid, a nurse should:
maintain a professional attitude towards the client.
90
Which of these tasks is appropriate for a nurse to delegate to a nursing assistant in an acute care unit?
Measure the blood pressure of a client who was admitted with an asthma attack yesterday.
91
Which of these techniques should a nurse plan to use with a client who is delusional?
Focus on reality-based topics.
92
Which of the following manifestations should a nurse recognize as suggestive of right-sided heart failure?
Jugular vein distention and pedal edema.
93
Which of these statements, if made by a nursing student prior to a sterile dressing change, is correct?
"I understand that sterile objects that are below my waist are considered contaminated."
94
A nurse reviews a client's prenatal record and notes that the client's last menstrual period (LMP) was on September 18th. Using the Naegele's rule, the nurse should calculate that the client's expected date of delivery (EDD) will be:
June 25th.
95
Which of these instructions should a nurse give to a client who has venous insufficiency regarding the use of elastic stockings (TEDs)?
"Put the TEDs on before you get up in the morning."
96
A nurse assesses a client who is scheduled for a total abdominal hysterectomy at 10:00 A.M. WHich of the factors should the nurse recognize as most likely to influence the outcome of the surgery?
The client takes one acetysalicylic acid (baby Aspirin) daily.
97
A client's urine output is 500 mL in 24 hours. Which of these actions should a nurse take?
Report the findings to the physician.
98
A nurse should question an order for a potassium chloride intravenous infusion for which of these clients?
A client who has anuria.
99
A 22-year-old college student has a heart rate that is 48/minute and regular during a routine physical examination. Which of these questions should a nurse consider when analyzing this heart rate?
Is this student an athlete?
100
Which of the following clients should a nurse recognize is most likely to develop diabetic ketoacidosis?
A 23-year-old who has type 1 diabetes mellitus, and is being treated for a tooth abscess.
101
Which of these postoperative complications in the first hour after surgery requires immediate intervention?
Dehiscence of a wound.
102
Which of these assessments should a nurse make of a client who had a knee replacement this morning?
Pain.
103
Which of these actions should a nurse take prior to assisting an elderly client to shave his face?
Determine what medications the client takes.
104
Which of these factors should a nurse consider when delegating tasks to unlicensed assistive personnel (UAP)?
The UAP's previous experiences on the unit.
105
Which of these nursing diagnoses is the priority for a young adult client who has first-degree burns on the legs and smoke inhalation from a fire in the home?
Impaired gas exchange.
106
A child who has cystic fibrosis is receiving pancrelipase (Pancrease MT) with meals and snacks. To determine if the desired effects of the pancreas are achieved, a nurse should consider which of these questions?
Are the child's stools of normal consistency?
107
When assessing a group of children, a nurse should recognize which child is at increased risk of developing acute glomerulonephritis?
A 4-year-old who had a streptococcal infection a week ago.
108
A client says to a nurse, "I am Alexander the Great. I am a world leader and must return to my kingdom. I am not taking any medications. I do not want anyone to come near me. I need to protect myself if they do." Which of these problems should the nurse focus on first?
Risk for violence.
109
When a client who has a diagnosis of depression is taking a monoamine oxidase (MAO) inhibitor, which of these dietary instructions should a nurse give to the client?
"Avoid foods that contain tyramine, such as aged cheeses."
110
Which of these strategies should a nurse plan for a client who is manic and has lost 30 pounds?
Nutritious finger foods.
111
A 15-year-old child who has type I diabetes mellitus receives an injection of regular insulin 5 units and isophane (NPH) insulin 15 units subcutaneously at 7:00 A.M. before eating breakfast. At 10:30 A.M., the child tells the school nurse, "I am sweating and feel weak." Which of these actions should the nurse take first?
Measure the blood sugar.
112
A client who has a head injury is drowsy and lethargic and has clear nasal discharge. Which of these actions should a nurse take?
Test the drainage for glucose.
113
Which of these actions, if taken by a nursing assistant, should a nurse recognize as increasing the client's risk of developing a nosocomial infection?
Placing the Foley catheter drainage bag on the bed while transferring the client.
114
A nurse is preparing a client for a vaginal examination. Which of these statements should the nurse make?
"Go into the bathroom and empty your bladder."
115
A licensed practical nurse (LPN) is assigned to care for all of these clients. Which client should the nurse assess first?
A 49-year-old client who has an acute myocardial infarction related to cocaine ingestion.
116
Which of these preventative measures should a nurse manager in a long-term care facility plan to institute to decrease clients' risks for falls?
Monitoring clients frequently for evidence of activity intolerance.
117
Which of these assessment findings, if present in a primigravida, indicates that the client is experiencing true labor?
There is a progressive increase in effacement and cervical dilatation.
118
A client is admitted for opiate detoxification for the fifth time. Which of these statements, if made by a staff member, indicates a biased view of the client?
"Addicts relapse because they don't try hard enough."
119
Which of these women, each of whom is in labor, should a nurse recognize as in need of immediate attention?
A woman who is in the active phase of labor and who insists she needs to use the bedpan to have a bowel movement.
120
A nurse has received a report on these assigned clients. Which client should the nurse follow-up first?
A client who is currently receiving cancer chemotherapy and who has a white blood cell count of 500 mm3 today.
121
Which of these statements, if made by a client who is taking a diuretic, should a nurse recognize as indicative of the need for additional instructions?
"I take all of my medications at bedtime so I don't forget them."
122
A nurse is monitoring a client who had a cystoscopy six hours ago. The nurse should inform the physician of which these manifestations?
The client's white blood cell count is 15,000 mm3.
123
Which of these actions should a nurse perform prior to a client's scheduled hemodialysis?
Weigh the client.
124
A client has been in bed for the past three days. Which of these measures should a nurse include before assisting the client out of bed?
Raising the head of the bed.
125
Which of these behaviors, if taken by a staff nurse on a psychiatric unit, indicates a correct understanding of therapeutic techniques?
A nurse sets consistent limits with manipulative clients.
126
A client who has insulin-dependent diabetes mellitus asks a nurse, "What should I do when I feel nervous, sweaty, and hungry?" The nurse should give the client which of these instructions?
"Eat a carbohydrate snack."
127
Which of these tasks should a licensed practical nurse (LPN) delegate to a nursing assistant?
Ambulating a client who had
a hip replacement three days ago.
128
A 36-week-pregnant woman awakens to find she is having profuse, red vaginal bleeding. A nurse should prepare the woman to have an immediate sonogram to determine the:
location of the placenta.
129
A nurse is planning to interview a client who speaks limited English. Which of these strategies should the nurse include?
Observe the client for indicators of confusion or not understanding questions.
130
A nurse takes the weight of a normal 2-year-old child who comes in to the pediatric clinic for a well-child visit. If the child weighted 7 lbs, 2 oz. at birth, how much should the nurse expect the child to weight at this visit?
28 lbs, 8 oz.
131
A nurse has been discussing the nutritional needs of children with a group of parents in a clinic. Which of these statements, if made by the parent of a 2-year-old child, should the nurse follow up?
"I give my child some popcorn as an afternoon snack."
132
Which of these client care situations has the greatest potential for presenting an ethical dilemma for a nurse?
Participating in pregnancy termination procedures.
133
Which assessment information should a nurse obtain first when a pregnant woman and her husband arrive at the Labor and Delivery Unit?
The frequency and intensity of labor contractions.
134
A client who has Parkinson's disease has been iden- tified as being at risk for falls. Which of these actions by a nurse is most likely to reduce the client's risk of falling?
Assign an assistant to remain with the client when ambulating.
135
A nurse determines that the therapeutic effectiveness of magnesium sulfate (MgSO4) for client who has preeclampsia is achieved when there is increased:
urinary output.
136
Which of these assessments is the initial priority of a client who is one-hour postoperative after an exploratory laparotomy?
The adequacy of the client's respiratory function.
137
Which of these client reports should a nurse recognize as suggestive of hypothyroidism?
"I feel cold and tired all the time."
138
A nurse is monitoring a client who is taking acetylsalicylic acid (Aspirin) 975 mg daily for adverse effects, which include:
occult blood in the stools.
139
Which of these rationales explains the purpose of nasogastric tube with suction for a client who had abdominal surgery?
Removal of secretions from the stomach.
140
A 75-year-old client who is newly admitted to a long-term care facility has all these nursing diag- noses. Which one is the priority?
Risk of injury.
141
A 12-month-old child is playing with the father. Which of these behaviors indicates that the child is demon- strating object permanence?
The child looks for a toy that the father has hidden under the table.
142
A nurse should recognize that a client's selection of which of these foods demonstrates a correct understanding of a high-fiber diet for colon cancer prevention?
Bran flakes.
143
Which of these discharge instructions should a nurse include for a client who has a ruptured tympanic membrane that occurred during a fall?
"Do not allow any water to enter the ear until healing is confirmed by direct visualization."
144
Which of these nursing measures is appropriate for a client who has recurrent renal calculi?
Encouraging a daily intake of three liters of flu- ids.
145
When auscultating the lungs of a woman who is ad- mitted for severe pregnancy-induced hypertension, a nurse notes the presence of crackles and moist respirations. These assessment findings most likely indicate which of these complications?
Pulmonary edema has developed.
146
A licensed practical nurse (LPN) is assigned to care for all of these clients. Which client should the nurse assess first?
A client who
is drowsy after falling out a third story window.
147
Which of these clients is at the highest risk of developing osteoporosis?
A thin, elderly Caucasian female who lives alone.
148
A nurse is obtaining the health history of a client who is admitted for surgical repair of an inguinal hernia. Which of these factors should the nurse recognize as having the greatest impact on the outcome of the surgery?
The client takes several acetylsali- cylic acid (Aspirin) tablets daily for knee pain.
149
A nurse should recognize that a client who has chronic obstructive pulmonary disease (COPD), needs additional instructions if the client makes which of these statements?
"I will turn up the oxygen flow rate if I have difficulty breathing."
150
A woman is treated in the emergency room for a broken arm and multiple facial bruises caused by her spouse. Which of these statements, if made by a nurse, is therapeutic?
"This type of abuse typically recurs after a period of remorse by the abuser."
