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1 A nurse is assessing for early signs of compartment syndrome for a client who has a short-leg fiberglass cast. Which of the following findings should the nurse expect? ---------CORRECT ANSWER-----------------Intense pain with movement 2 A nurse is monitoring a client who is receiving 2 units packed RBCs. Which of the following manifestations indicates a hemolytic transfusion reaction? ---------CORRECT ANSWER-----------------Chills 3 A nurse is caring for a client who had a total hip arthroplasty. Which of the following actions should the nurse take to prevent hip dislocation? ------- --CORRECT ANSWER-----------------Place two bed pillows between the legs when in bed 4 A nurse is assessing a client who is preoperative and reports an allergy to bananas. The nurse should recognize that the client is at risk for an allergic cross-reactivity to which of the following substances --------- CORRECT ANSWER-----------------Latex 5 A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching? ---------CORRECT ANSWER-----------------Hold breaths about 3 to 5 seconds before exhaling
6 A nurse is caring for a client who arrives at the emergency department and reports vomiting and diarrhea for the past 3 days. The client's serum potassium level is 2.8mEq/L. Which of the following interventions should the nurse implement first? ---------CORRECT ANSWER-----------------Initiate cardiac monitoring for the clients 7 A nurse is preparing to administer peritoneal dialysis to a client. Which of the following actions should the nurse take? ---------CORRECT ANSWER--- --------------Hang the drainage bag below the client's abdomen 8 A nurse is preforming a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)? ---------CORRECT ANSWER-----------------Disequilibrium with movement 9 A nurse is planning care for a client who is one day postoperative Following an open cholecystectomy. Which of the following interventions should the nurse include in the plan of care? ---------CORRECT ANSWER-- ---------------apply compression stockings to the lower extremities 10 A nurse is caring for a male client who has an exacerbation of heart failure. Which of the following prescriptions should the nurse expect to receive from the provider? (click on the "exhibit" button for additional information about the client. There are 3 tabs that contain separate categories of data.) ---------CORRECT ANSWER-----------------Furosemide 40mg IV bolus every 6 hr
16 A nurse is an emergency department is preparing a client for emergency surgery. The clients blood alcohol level is 180mg/dL. Which of the following actions is the nurse's priority? ---------CORRECT ANSWER----------------- Insert an NG tube 17 A nurse is assessing a client who has increased intracranial pressure. The nurse should recognize that which of the first sign of deteriorating neurological status? ---------CORRECT ANSWER-----------------Altered level of Consciousness 18 A nurse is performing skin cancer screening on a group of clients. Which of the following findings should the nurse Identify as an indication of melanoma? ---------CORRECT ANSWER-----------------Flat lesion with irregular borders 19 A nurse is caring for a client who has diabetes insipidus. Which Of the following medications should the nurse plan to administer. --------- CORRECT ANSWER-----------------Desmopressin 20 A nurse is preparing to assist with the insertion of a non-tunneled Central venous catheter for a client who is malnourished. Which of the following actions should the nurse plan to take. ---------CORRECT ANSWER-----------------Place the client's head on the bed lower than the foot. (Trendelenburg) 21 A nurse is caring for a client who had an arterial revascularization of the lower extremity. Which of the following is the priority action the nurse should plan to take after contacting the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)
a) Increase the insulin rate per protocol. ??? b) Increase the heparin infusion rate per protocol. c) Change the PCA timing of the patient control bolus to every 15 min. d) Start an IV fluid bolus of 0.9% sodium chloride 500mL to infuse over 1hr ---------CORRECT ANSWER-----------------Start an IV bolus 0.9% NS 500 mL to infuse over 1 hour 22 A nurse is providing discharge teaching to a client who has chronic urinary tract infections. The client has a prescription for ciprofloxacin 250 mg PO twice daily. Which of the following instructions should the nurse include in the teaching? ---------CORRECT ANSWER-----------------Drink 2 to 3 L of fluids daily. 23 A nurse is providing discharge teaching for a client who has HIV. Which of the following information is the priority for the nurse to review with the client? ---------CORRECT ANSWER-----------------"Describe your daily medication schedule." 24 A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first? ---------CORRECT ANSWER-----------------Stop the infusion. 25 A nurse is preparing to assist the provider with a thoracentesis for a client who has a left pleural effusion. Which of the following interventions is the priority for the nurse? ---------CORRECT ANSWER----------------- Determine whether the client has a allergy to local anesthetics. 26 A nurse is caring for a client who has bladder cancer and a WBC count of 900/mm3. Which of the following actions should the nurse take? ---------
32 A nurse is collecting data from a client who has toxoplasmosis and is HIV positive. Which of the following questions should the nurse ask to gather data about toxoplasmosis? ---------CORRECT ANSWER----------------
- "Do you have any household pets, such as a cat?" 33 A nurse in a long-term care facility is caring for a bedridden client. Which of the following findings should alert the nurse to a potential complication of the client's immobility? ---------CORRECT ANSWER---------- -------Confusion 34 A nurse is checking a client's ventilator settings. The nurse should understand that positive end- expiratory pressure has which of the following purposes? ---------CORRECT ANSWER-----------------To prevent alveolar collapse 35 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? ---------CORRECT ANSWER-----------------High- pitched sound on inspiration 36 A nurse on a medical unit is planning care for a group of clients. Which of the following clients should the nurse attend to first? ---------CORRECT ANSWER-----------------A client who has thrombocytopenia and reports a nosebleed. 37 A nurse is caring for a client who has a newly inserted chest tube. The nurse should clarify which of the following prescriptions with the provider ---
------CORRECT ANSWER-----------------Vigorously strip the chest tube twice daily. 38 A nurse is planning care for a client who has a newly implanted arteriovenous graft in the right arm. Which of the following actions should the nurse include in the pan of care? ---------CORRECT ANSWER------------- ----Palpate the site for a thrill 39 A nurse is providing discharge teaching for a client who has osteomyelitis in the left leg. Which of the following findings should the nurse identify as requiring a referral? ---------CORRECT ANSWER----------------- The client has a WBC count of 20,000/mm 40 A nurse is caring for a client who has an IV in the left forearm and whose infusion pump has alarmed several times. Which of the following actions should the nurse take first? ---------CORRECT ANSWER--------------- --Ensure the tubing connections are secure 41 A nurse is caring for a client who is 6hr postoperative following application of an external fixator for a tibial fracture. Which of the following actions should the nurse take? ---------CORRECT ANSWER----------------- Palpate the dorsalis pedis pulse. 42 A nurse is caring for a client following a total knee arthroplasty. The client reports a pain level on a scale of 0 to 10. Which of the following interventions should the nurse take? ---------CORRECT ANSWER------------- ----Apply ice pack to the client's knee
48 A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse? ---------CORRECT ANSWER-----------------Administer 0.9% sodium chloride 49 A nurse is preparing to administer levofloxacin 750 mg via intermittent over 90 min to a client. Available is levofloxacin 750 mg/150mL. How many mL/hr should the nurse set to the IV pump to administer? (Round to answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ---------CORRECT ANSWER-----------------100 mL/hr 50 A nurse is caring for a client who has been prescribed an antibiotic. The client tells the nurse. "I don't like taking medications because I don't think I need them." Which of the following responses should the nurse make? ----- ----CORRECT ANSWER-----------------*"I will tell your provider that you do not want to take this medication" 51 A nurse is teaching the family of a client who has Alzheimer's disease about caring for the client at home. Which of the following instructions should the nurse include? ---------CORRECT ANSWER-----------------Hang a monthly calendar in the client's bedroom 52 A nurse is assessing the pain status of a group of clients. Which of the following findings indicates a client is experiencing referred pain? --------- CORRECT ANSWER-----------------A client who has pancreatitis reports pain in the left shoulder. 53 a nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the following findings should the nurse report to the provider as a contraindication to receiving heparin? --------- CORRECT ANSWER-----------------Thrombocytopenia
54 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? ---------CORRECT ANSWER---------- -------History if Crohn's disease 55 A nurse is completing discharge teaching with a client who has a peripherally inserted central catheter (PICC) line in the left arm. Which of the following instructions should the nurse include in the teaching? --------- CORRECT ANSWER-----------------Use a 10-mL syringe to flush the line 56 A nurse is preparing to administer daily medications to a client who is undergoing a procedure at 1000 that requires IV contrast dye. Which of the following routine medications to give at 0800 should the nurse withhold? --- ------CORRECT ANSWER-----------------Metformin 57 A nurse is caring for a client who has developed a heart rate of 38/min and reports tremors and feeling faint. Which of the following medications should the nurse anticipate administering? ---------CORRECT ANSWER----- ------------Atropine sulfate 58 A nurse is reviewing the medical record of a client who has pneumonia. Which of the following serum laboratory values should the nurse expect? --- ------CORRECT ANSWER-----------------WBC count 15,000/mm 59 A nurse in an emergency department is caring for a client who has sinus bradycardia. Which of the following actions should the nurse take first? ----- ----CORRECT ANSWER-----------------Administer Atropine to the client
- A nurse on an oncology unit is caring for a client who is receiving internal radiation therapy. Which of the following actions should the nurse take? ---------CORRECT ANSWER-----------------Wear a lead around the apron when providing client care
- A nurse is assessing a client for a positive Chvostek's sign following a thyroidectomy. Which of the following areas on the clients head should the nurse tap to assess the client for tetany? ---------CORRECT ANSWER------- ----------? anterior to the earlobe and below the zygomatic arch or between the zygomatic arch and the corner of the mouth?
- A nurse is teaching a group of clients who have cancer about radiation therapy. Which of the following activities should the nurse include in the teaching? ---------CORRECT ANSWER-----------------Decrease time spent outdoors
- A nurse is planning care for a client who is receiving heparin IV to treat a pulmonary embolism. Which of the following medications should the nurse plan to have at the bedside? ---------CORRECT ANSWER--------------- --Protamine sulfate
- A nurse is providing discharge teaching to a client who has ileostomy. Which of the following client statements indicates an understanding of the teaching. ---------CORRECT ANSWER-----------------"I will expect my stools to be loose."
- A nurse is reviewing a client's cardiac monitor for dysrhythmias. Which of the following findings should the nurse identify as an indication for the placement of a permeant peacemaker? ---------CORRECT ANSWER--------- --------Complete AV block with rates slower than 40/mm
71 A nurse is caring for a client who is receiving chemotherapy and requests information about acupuncture to relive some of the side effects. Which of the following findings should the nurse identify as a contraindication to receiving this alternate therapy? ---------CORRECT ANSWER-----------------Lymphedema 72 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 take first? ---------CORRECT ANSWER-----------------Check the client's urine output 73 A nurse is assessing a client who has malnutrition. Which of the following findings should the nurse expect? ---------CORRECT ANSWER---- -------------Cachexia 74 A nurse is assessing a client who has a gravity drain in place following an open cholecystectomy. Which of the following images should the nurse identify as a gravity drain? ---------CORRECT ANSWER-----------------? Jackson-Pratt? 75 A home health nurse is assessing the home environment of a client who has cystic fibrosis. Which of the following equipment should the nurse plan to recommend? ---------CORRECT ANSWER-----------------Chest physiotherapy vest
82 A nurse is admitting a client who reports chest pain and has been placed on a telemetry monitor. Which of the following should the nurse analyze to determine whether the client is experiencing a myocardial infraction? ---------CORRECT ANSWER-----------------ST segment 83 A PACU nurse is monitoring the drainage from a client's NG tube following abdominal surgery. Which of the following findings in the first postoperative hour should the nurse report to the provider? --------- CORRECT ANSWER-----------------200 mL of brown drainage? 84 A nurse is caring for a client who understands a prescribed surgical procedure but cannot read or write. Which of the following actions should the nurse take? ---------CORRECT ANSWER-----------------Contact the client's power of attorney to sign the consent. 85 A nurse is providing dietary teaching to a client who has heart failure and a new prescription for a 2-g sodium diet. Which of the following client statements should the nurse identify as an understanding of the teaching? - --------CORRECT ANSWER-----------------"I can season my foods with lemon juice." 86 A nurse is reviewing ECG rhythm strips for a group of clients. The nurse should identify which of the following rhythms indicates bradycardia? --------
- CORRECT ANSWER-----------------? PR Interval area? 87 A nurse is planning care for a client who has Clostridium difficile gastroenteritis. Which of the following is an appropriate nursing action? ----- ----CORRECT ANSWER-----------------Clean surfaces with chlorhexidine?
88 A nurse is preparing to administer a unit of packed RBCs over 1 hr. Which of the following actions should the nurse plan to take? --------- CORRECT ANSWER-----------------Use Y tubing with 0.9% sodium chloride when administering the transfusion 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? ---------CORRECT ANSWER-----------------"Why do you think your life is over?"? 90 A nurse is assessing a client who has a pressure ulcer. Which of following findings should the nurse expect as an indication that the wound is healing? ---------CORRECT ANSWER-----------------Dark red granulation tissue? 91A nurse is providing teaching to a client who has left sided heart failure. Which of the following manifestations should the nurse include in the teaching. ---------CORRECT ANSWER-----------------Hacking cough 92A nurse in a providers office is caring for a client who has total vision loss and is the handler of a service dog. Which of the following actions should the nurse take to show consideration for the client in the service animal ---------CORRECT ANSWER-----------------consult the client before approaching the dog 93A nurse is reviewing laboratory results for 4 clients who are scheduled for surgery. Which of the following laboratory values should the nurse report to the surgeon ---------CORRECT ANSWER-----------------pallets 95.000/MM
99 A nurse is caring for a client who is experiencing an acute asthma attack Which of the following should the nurse identify as a contributing factor to the clients manifestations? ---------CORRECT ANSWER----------------- Inability to exhale retained carbon dioxide 100 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 take ---------CORRECT ANSWER---- -------------I can give you additional information about the procedure
