proc

Question 1

A nurse in an emergency department is preparing to perform an ocular irrigation for a client. Which of the following actions should the nurse plan to take?

a. Assess the client’s visual acuity prior to irrigation
b. Have the client turn their head toward the unaffected eye
c. Hold the irrigator syringe 3.81 cm (1.5 in) above the eye
d. Perform the irrigation with sterile water for irrigation

Answer 1

d. Perform the irrigation with sterile water for irrigation

Question 2

A nurse is preparing to administer lactated ringer’s via continuous IV infusion at 200 ml/hr. The IV tubing has a drop factor of 10 drops/ml. How many gtt/min should the
nurse set the IV pump to administer?
Round to near whole number.

A. 10
B. 22
C. 33
D. 4

Answer 2

C. 33

Question 3

A nurse is providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following client statements indicates an
understanding of the teaching?

a. I can keep my medications for 1 year before replacing it

b. I should lie down when I take this medication

c. I should discontinue this medication if I develop a headache

d. I can take up to five tablets in 15 minutes before seeking medical attention

Answer 3

b. I should lie down when I take this medication

Question 4

A nurse is providing discharge teaching to an older adult client following a left total hip arthroplasty. Which of the following instructions should the nurse include in the
teaching?

a. Clean the incision daily with hydrogen peroxide
b. You can cross your legs the ankles when sitting down
c. You should use an incentive spirometer every 8 hours
d. Install a raised toilet seat in your bathroom

Answer 4

d. Install a raised toilet seat in your bathroom

Question 5

A nurse is planning care for a client following a cardiac catheterization. Which of the
following actions should the nurse take?

a. Keep the client on bed rest for 24 hours
b. Limit the client’s fluid intake to 1 l per day
c. Maintain the client’s affected extremity in extension
d. Change the client’s dressing every 8 hour

Answer 5

c. Maintain the client’s affected extremity in extension

Question 6

A nurse is caring for a client who has a lower extremity fracture and a prescription for crutches. Which of the following client statements indicates that the client is adapting to their role change?

a. I will need to have my partner take over shopping for groceries and cooking the
meals for us
b. These crutches will make it impossible to care for my child
c. I feel bad that I have to ask my partner to keep the house clean
d. Its going to be difficult to tell my parents I cant take them to their appointments
anymore

Answer 6

a. I will need to have my partner take over shopping for groceries and cooking the meals for us

Question 7

A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration?

a. Pitting, dependent edema
b. Distended jugular veins
c. Increased BP
d. Decreased BP

Answer 7

d. Decreased BP

Question 8

A nurse is caring for a client who has a contusion of the brainstem and reports thirst.
The client’s urinary output was 4,000 ml over the past 24 hour. The nurse should
anticipate a prescription for which of the following IV medication?

a. Desmopressin
b. Epinephrine
c. Furosemide
d. Nitroprusside

Answer 8

a. Desmopressin

Question 9

A nurse in a clinic receives a phone call from a client who recently started therapy with
an ACE inhibitor and reports a nagging dry cough. Which of the following responses by
the nurse is appropriate?

a. “your cough may require that you stop or change your medication”
b. “Increasing your daily fluid intake may eliminate your cough”
c. “sucking on lozenge may reduce the frequency of your cough”
d. You cough should go away in time”

Answer 9

a. “your cough may require that you stop or change your medication”

Question 10

A nurse is taking an admission history from a client who reports Raynaud’s disease. Which of the following assessment findings should the nurse identify as a potential
trigger for exacerbations
of Raynaud’s?

a. Eating a strict vegetarian diet
b. A history of herpes zoster
c. Taking amlodipine for hypertension
d. Using a nicotine transdermal patch

Answer 10

d. Using a nicotine transdermal patch

Question 11

A nurse is caring for a client who has a central venous access device and notes the
tubing has become disconnected. The client develops dyspnea and tachycardia. Which
of the following actions should the nurse take first?

a. Perform an ECG
b. Obtain ABG values
c. Turn the client to his left side
d. Clamp the catheter

Answer 11

d. Clamp the catheter

Question 12

A nurse is completing an assessment of an older adult client and notes reddened areas over the bony prominences, but the client’s skin is intact. Which of the following
interventions should the nurse include in the plan of care?

a. Turn and reposition the client every 4 hr
b. Apply an occlusive dressing
c. Support bony prominences with pillows
d. Massage the reddened areas three times a day

Answer 12

c. Support bony prominences with pillows

Question 13

A home health nurse is making an initial visit to a client who has multiple sclerosis.
Which of the following actions is the priority for the nurse to take?

a. Discuss recommendations for eating and swallowing techniques
b. List strategies for family coping when dealing with possible role changes
c. Review the use of adaptive grooming devices to promote client independence
d. Give the client information about the local national multiple sclerosis society

Answer 13

a. Discuss recommendations for eating and swallowing techniques

Question 14

nurse in the emergency department is assessing a client. Which of the following
actions should the nurse take first?

a. Obtain a sputum sample for culture
b. Administer ondansetron
c. Initiate airborne precautions
d. Prepare the client for a chest x-ray

Answer 14

c. Initiate airborne precautions

Question 15

A nurse is reviewing the medical record of a client to identify risk factors for colorectal cancer. The nurse should identify which of the following findings as increasing the client’s risk?

a. History of Crohn’s disease
b. BMI of 24
c. Diet high in fiber
d. Age 46 years

Answer 15

a. History of Crohn’s disease

Question 16

A nurse is caring for a client who is scheduled for a mastectomy. The client tells the nurse, “I’m not sure I want to have a mastectomy.” Which of the following statements should the nurse make?

a. “I can give you a list of other people who had the same procedure”
b. “You will be cancer-free if you have the procedure”
c. “I can give you additional information about the procedure”
d. “You should should get a second opinion regarding the procedure”

Answer 16

c. “I can give you additional information about the procedure”

Question 17

A nurse is preparing to administer a unit of packed RBCs to a client who is anemic.
Identify the sequence of steps the nurse should follow.

a. Obtain venous access using 19-gauge needle
b. Obtain the unit of packed RBCs from blood bank
c. Verify blood compatibility with another nurse
d. Initiate transfusion of the unit of packed RBCs
e. Remain with the client for the first 15 to 30 min of the infusion

Answer 17

a. Obtain venous access using 19-gauge needle
b. Obtain the unit of packed RBCs from blood bank
c. Verify blood compatibility with another nurse
d. Initiate transfusion of the unit of packed RBCs
e. Remain with the client for the first 15 to 30 min of the infusion

Question 18

A nurse is preparing a teaching plan for a client who has mucositis related to
chemotherapy treatment. Which of the following instructions should the nurse include?

a. “rinse your mouth with hydrogen peroxide”
b. “brush your teeth for 60 seconds twice daily”
c. “wear your dentures only during meals”
d. “floss your teeth following each meals”

Answer 18

d. “floss your teeth following each meals”

Question 19

A critical care nurse is assessing a client who has severe head injury. In response to painful stimuli, the client does not open her eyes, displays decerebrate posturing, and makes incomprehensible sounds. Which of the following Glasgow Coma Scale scores
should the nurse assign the client?

a. 5
b. 2
c. 13
d. 10

Answer 19

a. 5

Question 20

A nurse is providing discharge teaching to a client who has heart failure and instructs
him to limit sodium intake to 2 g per day. Which of the following statements by the client indicates an understanding of the teaching?

a. “I can season my foods with garlic and onion salts”
b. “I can have mayonnaise on my sandwiches”
c. “I can have a frozen fruit juice bar for dessert”
d. “I can drink vegetable juice with a meal”

Answer 20

c. “I can have a frozen fruit juice bar for dessert”

Question 21

A nurse is preparing to perform ocular irrigation for a client following chemical splash to the eye. Which of the following actions should the nurse plan to take first?

Answer 21

Collect information about the irritant that caused the injury

Question 22

A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of the following findings should the nurse expect?

a. Hypothermia
b. Urine specific gravity 1.001 (<1.005)
c. Elevated blood pressure
d. BUN 15 mg/dl

Answer 22

b. Urine specific gravity 1.001 (<1.005)

Question 22

A nurse is assessing a client following extubation from a ventilator. For which of the
following findings should the nurse intervene immediately?

a. Rhonchi
b. SaO2 92%
c. Sore throat
d. Stridor

Answer 22

d. Stridor

Question 23

A nurse is reviewing the laboratory reports of a client who has acute pancreatitis. Which of the following findings should the nurse expect?

a. Elevated serum calcium
b. Elevated blood glucose
c. Decreased serum amylase
d. Decreased erythrocyte sedimentation rate

Answer 23

b. Elevated blood glucose

Question 24

A nurse is planning care for a client who has pulmonary embolism. Which of the following interventions should the nurse include? a. Initiate a continuous IV heparin infusion b. Instruct the client to massage the lower extremities c. Position the client on the left side d. Measure vital signs every 4 hour

Answer 24

a. Initiate a continuous IV heparin infusion

Question 25

A nurse is providing discharge teaching to a client who is recovering from a sickle cell crisis. Which of the following instructions should the nurse include? a. Avoid extremely hot or cold temperatures b. Limit fluids to 1.5 L per day c. Limit alcohol intake to one drink per day d. Avoid getting a flu vaccination

Answer 25

a. Avoid extremely hot or cold temperatures

Question 26

A nurse in the emergency department is caring for a client who is in hypovolemic shock. Which of the following actions should the nurse take first? a. Obtain a blood specimen for type and crossmatch b. Insert a large-bore IV catheter c. Administer IV therapy d. Monitor urine output

Answer 26

b. Insert a large-bore IV catheter

Question 27

A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft? a. Dilated appearance of the graft b. Absence of a bruit c. Normotensive blood pressure d. Palpable thrill

Answer 27

d. Palpable thrill

Question 28

A nurse is assessing a client who has heart failure and is receiving a loop diuretic. Which of the following findings indicates hypokalemia? a. Oliguria b. Hypertension c. Muscle weakness d. Positive chvostek's sign (CHEEK)

Answer 28

c. Muscle weakness

Question 29

A nurse is caring for a client who has a full-thickness burn injury covering 15% of their body. Which of the following actions should the nurse take? a. Weigh the client once per week b. Provide the client with a protein intake of 1g/kg/day c. Maintain a daily count of the client's calorie intake d. Place the client on a low-carb diet

Answer 29

c. Maintain a daily count of the client's calorie intake

Question 30

A nurse is providing discharge teaching to a client who has an ileostomy. Which of the following client statements indicates an understanding of the teaching? a. "I will expect my stools to be loose" b. "I will eat a high fiber diet' c. "I will take a laxative when I'm constipated" d. "I will empty my bag when it is full"

Answer 30

a. "I will expect my stools to be loose"

Question 31

A nurse is caring for a client who is receiving total parental nutrition through a central line. The current bag is nearly empty, and a new bag is unavailable from the pharmacy. Which of the following actions should the nurse take? a. Switch the infusion to a 10% dextrose solution b. Discontinue the infusion and flush the line c. Decrease the rate of infusion to last until the new bag is available d. Start an infusion of 0.45% sodium chloride solution

Answer 31

a. Switch the infusion to a 10% dextrose solution

Question 32

A nurse is caring for a client who is 6 hr postoperative following a thyroidectomy. The client reports tingling and numbness in the hands. The nurse should identify this as a sign of which of the following electrolyte imbalances? a. Hypocalcemia b. Hypokalemia c. Hypermagnesemia d. Hypernatremia

Answer 32

a. Hypocalcemia

Question 33

A nurse is caring for a client who is caregiver for a relative who has chronic disease. Which of the following statements indicates the client is adapting to the role change? a. "I had to reschedule my doctor's appointment last week" b. "I have lunch with my friends once a week" c. "I've lost 15 pounds in the past 2 months" d. "I need to get my blood pressure medicine refilled"

Answer 33

d. "I need to get my blood pressure medicine refilled"

Question 34

A nurse is reviewing medications taken at home with a client who has angina. Which of the following statements by the client indicates an understanding of the teaching? a. "I should withhold my metoprolol if my heart rate is above 100 bpm" b. "I should take my daily aspirin on an empty stomach" c. "I should lie down before taking dose of isosorbide dinitrate" d. "I should place a nitroglycerin tablet under my tongue every 10 minutes for up to four doses"

Answer 34

c. "I should lie down before taking dose of isosorbide dinitrate"

Question 35

A nurse in the post-anesthesia care unit is assessing a client following an appendectomy and finds a 2-cm (3/4in) area of blood on the postoperative dressing. Which of the following actions should the nurse take? a. Apply pressure b. Loosen the dressing c. Circle the drainage d. Apply a new dressing

Answer 35

c. Circle the drainage

Question 36

A nurse is caring for a client who is receiving mechanical ventilation. Which of following interventions should the nurse implement? a. Empty water from the ventilator tubing daily b. Suction the client's airway every 4 hour c. Maintain the client in supine position d. Perform oral care every 2 hour

Answer 36

a. Empty water from the ventilator tubing daily

Question 37

A nurse is a planning care for a client who has full-thickness burns on the lower extremities. Which of the following interventions should the nurse include? a. Apply new gloves when alternating between wound care sites b. Provide a diet of fresh fruits and vegetables for the client c. Limit visitation time for the client's children to 40 min per day d. Clean the equipment in the client's room once per week

Answer 37

a. Apply new gloves when alternating between wound care sites

Question 38

A nurse is providing teaching for a client who has tuberculosis and a new prescription for pyrazinamide. The nurse should instruct the client to notify the provider if which of the following adverse effects occurs? a. Hair loss b. Polyuria c. Weight gain d. Jaundice

Answer 38

d. Jaundice

Question 39

A nurse is planning care for a client who has left-sided hemiplegia following a stroke. Which of the following actions should the nurse include in the plan of care? a. Position the bedside table on the client's left side b. Place the plate guard on the client's meal tray c. Provide the client with a short handled reacher d. Remind the client to use a cane on left side while ambulating

Answer 39

b. Place the plate guard on the client's meal tray

Question 40

A nurse is performing an ear irrigation for a client. Which of the following actions should the nurse take? a. Use a cool fluid for irrigation b. Insert the tip of the syringe 2.5cm (1in) into the ear canal c. Tilt the client's head 45 degrees d. Point the tip of the syringe toward the top of the ear canal

Answer 40

d. Point the tip of the syringe toward the top of the ear canal

Question 41

A nurse is caring for a client who has a history of chemotherapy-induced nausea and vomiting. Which of the following medications should the nurse administer prior to chemotherapy? a. Ondansetron b. Sertraline c. Methylprednisolone d. Diphenhydramine

Answer 41

a. Ondansetron

Question 42

A nurse is preparing to discharge a client who has halo device and is reviewing new prescriptions from the provider. The nurse should clarify which of the following prescriptions with the provider? a. Increase intake of fiber-rich foods b. May place a small pillow under head when sleeping c. May operate a motor vehicle when no longer taking analgesics d. Take a tub bath instead of showers

Answer 42

c. May operate a motor vehicle when no longer taking analgesics

Question 43

A nurse is providing discharge teaching to a client who has tuberculosis. Which of the following information should the nurse include in the teaching? a. "You should wear an N95 respirator mask when you are at home" b. "You will need to return in 2 weeks to provide a sputum specimen" c. "You can drink alcohol after the first 6 weeks of treatment" d. "Your provider will discontinue your medications after 3 months of therapy

Answer 43

b. "You will need to return in 2 weeks to provide a sputum specimen"

Question 44

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? a. Flushed skin b. Frothy sputum/Hacking cough c. Jugular vein distention d. Bradycardia

Answer 44

b. Frothy sputum/Hacking cough

Question 45

A nurse is planning care for a client who has osteoarthritis of the knees. Which of the following interventions should the nurse include in the plan? a. Avoid using a topical salicylate cream b. Administer acetaminophen for pain management c. Place a large pillow under the client's knees when resting d. Apply an ice pack directly to client's knees

Answer 45

b. Administer acetaminophen for pain management

Question 46

A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The client reports sharp lower abdominal pain. Which of the following actions should the nurse first take? a. Increase the client's fluid intake b. Reposition the client in bed c. Check the client's urine output d. Administer PRN pain medication

Answer 46

c. Check the client's urine output

Question 47

A nurse is caring for a client who has Parkinson's disease and is prescribed a level 1 dysphagia diet. Which of the following items should the nurse remove from the client's tray? a. Vanilla milkshake b. Peanut butter c. Chocolate pudding d. Applesauce

Answer 47

b. Peanut butter

Question 48

A nurse in a provider's office is teaching a client about the self-management of GERD. Which of the following instructions should the nurse include? a. "eat a light meal 1 hour before bedtime" b. "sleep with head of your bed elevated 6 inches" c. "increase your caloric intake by 250 calories per day" d. "lie down for 30 min after each meal"

Answer 48

b. "sleep with head of your bed elevated 6 inches"

Question 49

A nurse is caring for a client who is postoperative following a partial thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider? a. Client report of pain at the incision site b. High-pitched sound on inspiration c. Hypoactive bowel sounds d. Loose tracheal secretions

Answer 49

b. High-pitched sound on inspiration

Question 50

A nurse is caring for a client who is 2 days postoperative following a below-the-knee amputation and asks about the purpose of maintaining an elastic bandage around the residual limb of the extremity. Which of the following is an appropriate response by the nurse? a. "the elastic bandage will prevent a post-op wound infection" b. "the elastic bandage will prevent excessive edema" c. "the elastic bandage will keep the sutures from loosening" d. "the elastic bandage will keep you from seeing the surgical site"

Answer 50

b. "the elastic bandage will prevent excessive edema"

Question 51

A nurse is planning care for a client who is 8 hour post-op following a coronary artery bypass grafting. Which of the following assessments should the nurse plan to perform first? a. Examine the surgical incision for drainage b. Auscultate breath sounds c. Palpate pulses distal to the graft donor site d. Measure the client's core body temperature

Answer 51

b. Auscultate breath sounds

Question 52

A nurse is providing instructions to a client who has primary syphilis. Which of the following instructions should the nurse include in the discharge plan? a. "you will need cryotherapy for 1 to 2 weeks" b. "you will need to take an antiviral medication for 6 months" c. "you will need 3 follow-up blood tests within 24 month period" d. "you will need to be monitored for 15 minutes after receiving each medication dose"

Answer 52

c. "you will need 3 follow-up blood tests within 24 month period"

Question 53

A nurse is caring for a client who has hypotension, cool clammy skin, tachycardia, and tachypnea. In which of the following positions should the nurse place the client? a. Reverse Trendelenburg b. Feet elevated c. High fowlers' d. Side lying

Answer 53

c. High fowlers'

Question 54

A nurse is teaching a client how to use a quad cane for ambulation following a right- hemispheric stroke. Which of the following client actions indicates an understanding of the teaching? a. Client takes a step before advancing the cane b. Client holds the cane with the left hand c. Client moves the cane 2 feet ahead d. Client advances the weaker leg forward first

Answer 54

d. Client advances the weaker leg forward first

Question 55

A nurse is providing discharge teaching for a client who has new tracheostomy. Which of the following statements by the client indicates an understanding of the teaching? a. "i'll remove the soiled tracheostomy ties prior to cleansing my stoma" b. "i'll cut a slit in a clean gauze pad to use as a stoma dressing" c. "I'll insert the obturator after cleaning my stoma" d. "I'll cleanse the cannula with half-strength hydrogen peroxide

Answer 55

c. "I'll insert the obturator after cleaning my stoma"

Question 56

A nurse is preparing to administer furosemide to a client who has acute heart failure. Which of the following laboratory results should the nurse identify as contraindications for receiving the medications? a. BUN 18 mg/dl b. Creatinine 0.8 mg/dl c. Potassium 3.2 mEq/l d. Sodium 136 meEq/l

Answer 56

c. Potassium 3.2 mEq/l

Question 57

A nurse is caring for a client admitted with a skull fracture. Which of the following assessment findings should be of greatest concern to the nurse? a. Bilateral pupil diameter changes from 4 to 2 mm b. WBC count changes from 9,000 to 16,000/mm3 c. Pulse pressure changes from 30 to 20 mm Hg d. Glasgow Coma Scale score changes from 14 to 9

Answer 57

d. Glasgow Coma Scale score changes from 14 to 9

Question 58

A nurse is assessing a client who has myasthenia gravis. Which of the following client statements should indicate to the nurse that the client needs a referral for occupational therapy? a. "I have a hard time with brushing my hair" b. "I would rather be in a wheelchair than use a walker to get around" c. "I've been having problems with bladder control" d. "I have difficulty swallowing food"

Answer 58

a. "I have a hard time with brushing my hair"

Question 59

A nurse is providing discharge teaching to a client who will be self-administering insulin at home. Which of the following information should the nurse include regarding needle disposal? a. "secure the cap tightly over the needle before you discard it" b. "remove the needle from the syringe before you place it in the trash" c. "you can discard needles in an empty bleach bottle with a lid" d. "place your storage container in a recycle bin when it is full"

Answer 59

c. "you can discard needles in an empty bleach bottle with a lid"

Question 60

A nurse is assessing a client who has arteriovenous (AV) graft in the left forearm. Which of the following findings should indicate to the nurse a complication of vascular access? a. 2+ left radical pulse b. Absence of a bruit c. Presence of a palpable thrill d. Dilated appearance of the AV site

Answer 60

b. Absence of a bruit

Question 61

A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take? a. Familiarize themselves with commonly used sign language b. Ask a family member to be present during the admission c. Obtain a board that uses colored pictures as communication d. Request an interpreter during the initial assessment

Answer 61

d. Request an interpreter during the initial assessment

Question 62

A nurse is planning care for a client who has unrepaired intertrochanteric fracture and has Buck's traction placed to the affected leg. Which of the following interventions should the nurse include? a. Situate the client's heel in the heel of the traction boot b. Apply weights of the traction to total 9.1 kg (20lb) c. Place the footplate against the foot of the bed d. Remove the boot for skin inspection every 12 hours.

Answer 62

a. Situate the client's heel in the heel of the traction boot

Question 63

A nurse is caring for a client who sustained a spinal cord injury in a diving accident. Which of the following actions should the nurse take? a. Assess the client's neurological status every 8 hour b. Monitor urine output hourly c. Provide the client with a low-fiber diet d. Log roll the client every 4 hour

Answer 63

b. Monitor urine output hourly

Question 64

A nurse is planning care for a client who has a central venous access device for intermittent infusions. Which of the following actions should the nurse include in the plan of care? a. Flush the catheter using a 10ml syringe b. Change the dressing every 24 hour c. Use clean technique when changing the dressing d. Cleanse the site with povidone-iodine

Answer 64

a. Flush the catheter using a 10ml syringe

Question 65

A nurse in the emergency department is caring for a client who has a gunshot wound to the abdomen. Which of the following actions should the nurse take first? a. Check the color of the client's skin b. Remove all of the client's clothing c. Administer an opioid analgesic d. Prepare the client for periorbital lavage

Answer 65

a. Check the color of the client's skin

Question 66

A nurse is caring for a client following a bronchoscopy. Which of the following actions should the nurse take first? a. Check the client's gag reflex b. Inform the client they might experience a low-grade fever c. Instruct the client to report bleeding d. Provide the client with sips of water

Answer 66

a. Check the client's gag reflex

Question 67

A nurse is developing a plan of care for a client who is returning from the PACU following a left below-the-knee amputation. Which of the following interventions should the nurse include in the plan? a. Provide the client with a firm mattress b. Wrap the client's residual limb with elastic bandage in a distal to proximal direction c. Place the client's residual limb in a dependent position when possible d. Keep the client in a supine position for 48 hours

Answer 67

a. Provide the client with a firm mattress

Question 68

A nurse is instructing a client who has a new diagnosis of type 1 diabetes mellitus about the sick-day rules. Which of the following statements by the client indicates an understanding of the teaching? a. "I will monitor my blood glucose every 8 hours" b. "I will consume 250 grams of carbs daily while I'm sick" c. "I will not take my diabetes medications while I am sick" d. "I will check urine for ketones if my blood glucose is greater than 240 mg/dl

Answer 68

d. "I will check urine for ketones if my blood glucose is greater than 240 mg/dl

Question 69

A nurse is reviewing ABG results for a client who has COPD. Which of the following findings should the nurse expect? a. pH 7.38 b. PaO2 85 mm Hg c. PaCO2 48 mm Hg d. HCO3- 25 mEq/l

Answer 69

c. PaCO2 48 mm Hg

Question 70

A nurse is admitting a client to a medical unit following placement of a permanent pacemaker. Which of the following findings requires further assessment by the nurse? a. Sneezing b. Hiccups c. Presence of a sharp spike prior to the QRS complex on the ECG d. Presence of intrinsic P waves following a QRS complex on the ECG

Answer 70

b. Hiccups

Question 71

A nurse is caring for a client who experienced extensive burns to the arms and torso. Which of the following actions should the nurse take regarding the client's oral nutritional intake? a. Adhere to scheduled meal times three times daily b. Encourage the client to eat as many calories as possible c. Limit the client's fluid intake to 1,500 ml/day d. Avoid the use of supplemental feedings throughout the day

Answer 71

b. Encourage the client to eat as many calories as possible

Question 72

A nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan of care? a. Place pillows under the client's knees b. Apply compression stockings to the lower extremities c. Avoid use of anticoagulants d. Discourage leg exercises while in bed

Answer 72

b. Apply compression stockings to the lower extremities

Question 73

A nurse is caring for a client who has duodenal ulcer. Which of the following actions should the nurse take? a. Restrict the client's fluid intake to 1,000 ml/day b. Infuse packed RBCs c. Administer the client's naproxen prescription d. Offer a snack before bedtime

Answer 73

b. Infuse packed RBCs

Question 74

A nurse is assessing an older adult client at a health fair. Which of the following statements by the client is the nurse's priority?? a. "I can't seem to get reading materials far enough away to see the words" b. "I'm having more difficulty telling the difference between blues and greens" c. "I've noticed that there is a gray ring around the colored part of my eye" d. "In the last day, I have had a severe headache and pain around my right eye"

Answer 74

d. "In the last day, I have had a severe headache and pain around my right eye"

Question 75

A nurse is caring for an adolescent client who has an acute kidney injury. Which of the following laboratory findings should the nurse anticipate? a. BUN 8 mg/dl b. Hgb 20 g/dl c. Potassium 6.8 mEq/l d. Creatinine 0.4 mg/dl

Answer 75

c. Potassium 6.8 mEq/l

Question 76

A nurse is planning care for an older adult client who has Meniere's disease. Which of the following interventions should the nurse include in the plan? a. Perform range-of-motion exercises to the client's neck every 4 hour b. Limit the client's fluid intake to 1,500 ml/day c. Encourage the client to change positions slowly d. Administer aspirin if the client reports a headache

Answer 76

c. Encourage the client to change positions slowly

Question 77

A nurse is preparing to receive a client from surgery following a transverse colon resection with colostomy placement. The nurse should expect to assess the stoma at which of the following locations? HOTZONE

Answer 77

a. Upper left abdomen (THIS ONE IS A DIAGRAM CHOOSE THE POINT ON THE TOP LEFT OF ABDOMEN)

Question 78

A nurse is admitting a client to the emergency department after a gunshot wound to the abdomen. Which of the following actions should the nurse take to help prevent the onset of acute kidney failure? a. Initiate beta blocker therapy b. Insert a urinary catheter c. Prepare the client for an intravenous pyelogram d. Administer IV fluids to the client

Answer 78

d. Administer IV fluids to the client

Question 79

A nurse is preparing to administer 1 unit of packed RBCs to an adult client. Which of the following actions should the nurse plan to take? a. Administer through a 22-gauge IV catheter b. Prime the IV tubing with 0.45% sodium chloride c. Complete the transfusion within 2 hour d. Slow the transfusion rate if the client reports itching

Answer 79

c. Complete the transfusion within 2 hour

Question 80

A nurse is planning care for a client who has developed nephrotic syndrome. Which of the following dietary recommendations should the nurse include? a. Increase phosphorus intake b. Decrease protein intake c. Increase potassium intake d. Decrease carbohydrate intake

Answer 80

b. Decrease protein intake

Question 81

A nurse is caring for an older adult client who has dementia. Which of the following questions should the nurse ask to assess the client's abstract thinking? a. "Can you count backwards from 100 intervals of 7?" b. "What is meant by the saying, don't beat around the brush? c. "What do you understand about your condition?" d. "Can you tell me the state where you were born?"

Answer 81

b. "What is meant by the saying, don't beat around the brush?

Question 82

A nurse is caring for a client who has cervical cancer and is receiving brachytherapy. Which of the following actions should the nurse take? a. Keep the soiled bed linens in the client's room b. Instruct visitors to remain 3 feet from the client c. Discard the radioactive device in the client's trash can d. Limit time for visitors to 2 hour per day

Answer 82

a. Keep the soiled bed linens in the client's room

Question 83

A nurse is preparing a client for a lumbar puncture. Which of the following images indicates the position should the nurse assist the client into for this procedure? (THIS IS A DIAGRAM CHOOSE)

Answer 83

a. Side-lying CHOOSE THE PERSON IN A FETAL POSITION

Question 84

A nurse is caring for a client who has cervical cancer and a sealed radiation implant. Which of the following actions should the nurse take? a. Place long-handled forceps at the client's bedside b. Attach a dosimeter badge to the client's gown c. Leave unused equipment in the client's room until discharge d. Move the client's soiled linens to a designated container outside the room

Answer 84

a. Place long-handled forceps at the client's bedside

Question 85

A nurse is teaching a client who has Graves' disease about recognizing the manifestations of the thyroid storm. Which of the following findings should the nurse include in the teaching? a. Increased temperature b. Decreased HR c. Hypotension d. Lethargy

Answer 85

a. Increased temperature

Question 86

A nurse is caring for a client who is postoperative following a complete thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider? a. Serosanguineous drainage b. Muscle twitching c. Client report of nausea d. Client report incisional pain

Answer 86

b. Muscle twitching

Question 87

A nurse is caring for a client who is receiving epidural analgesics. Which of the following assessment findings in the nurse's priority? a. Bladder distention b. Hypoactive bowel sounds c. Hypotension d. Weakness to lower extremities

Answer 87

c. Hypotension

Question 88

A nurse is planning care for a client who has status epilepticus. Which of the following interventions is the nurse's priority to include? a. Turn the client to the lateral position during seizure activity b. Provide the client oxygen at 6 l/min using a nasal cannula c. Administer phenytoin IV bolus to the client d. Administer diazepam intravenously to the client

Answer 88

a. Turn the client to the lateral position during seizure activity

Question 89

A nurse is caring for a client following a below-the knee amputation. The client states. "my life is over." Which of the following responses should the nurse make? a. "you are upset. We can talk about this later?" b. "would you like to meet with another client who is an amputee?" c. "why do you think your life is over?" d. "most people can adjust following this surgery"

Answer 89

b. "would you like to meet with another client who is an amputee?"

Question 90

A nurse in a clinic is providing preventive teaching to an older adult client during a well visit. The nurse should instruct the client that which of the following immunizations are recommended for healthy adults after the age of 60? Select All That Apply a. Herpes zoster b. Influenza c. Meningococcal d. Human papillomavirus e. Pneumococcal polysaccharide

Answer 90

a. Herpes zoster b. Influenza e. Pneumococcal polysaccharide

Question 91

A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse plan to include? a. Turn off all lights in the client's room at night b. Place the client's bed at the lowest height c. Request a prescription for a nightly sedative d. Assist the client with toileting at least once every 4 hour

Answer 91

b. Place the client's bed at the lowest height

Question 92

A nurse is assessing a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following findings indicates that the client is experiencing hypoglycemia? a. Abdominal cramping b. Increased perspiration c. Dehydration d. Fruity odor to breath

Answer 92

b. Increased perspiration

Question 93

A nurse in the PACU is assessing a client who is postoperative following general anesthesia. Which of the following findings is the priority to address? b. Decreased body temperature c. Indistinct, rambling speech d. Piloerection of the skin a. Vomiting upon arousal

Answer 93

a. Vomiting upon arousal

Question 94

A nurse is caring for a client who has hypervolemia. Which of the following is an expected assessment finding? a. Bradycardia b. Hypotension c. Loss of skin turgor d. Weight gain

Answer 94

d. Weight gain

Question 95

A nurse is teaching about measures to prevent recurring urinary tract infections with a female client. Which of the following information should the nurse include in the teaching? (SATA) a. Take a warm bubble bath daily b. Void every 6 hour during the day c. Drink low-fructose cranberry juice d. Wipe the perineal area from front to back after urinating e. Drink 3L of fluids daily

Answer 95

c. Drink low-fructose cranberry juice d. Wipe the perineal area from front to back after urinating e. Drink 3L of fluids daily

Question 96

A nurse is caring for a client following a cardiac catheterization who has hives and urticaria following administration of IV contrast dye. Which of the following medications should the nurse plan to administer? a. Spironolactone b. Desmopressin c. Metoclopramide d. Diphenhydramine

Answer 96

d. Diphenhydramine

Question 97

A home care nurse is planning to use nonpharmacological pain relief measures for an older adult client who has severe chronic back pain. Which of the following guidelines should the nurse use? a. Discontinue opioids before trying nonpharmacological methods of pain relief b. Use imagery with clients who have difficulty with focus and concentration c. Distraction changes the client's perception of pain, but does not affect the cause d. Pain relief from the use of heat and cold continues for several hours after removal of the stimulus.

Answer 97

c. Distraction changes the client's perception of pain, but does not affect the cause

Question 98

A nurse is caring for a female client who is receiving total parenteral nutrition without fat emulsion. Which of the following findings should the nurse report? a. Crackles in the bilateral lung bases b. Weight gain of 1.3 kg (3lb) over the past 7 days c. Triglyceride 110 mg/dl d. Bowel sounds absent in lower quadrants

Answer 98

a. Crackles in the bilateral lung bases