116 odalys arregladas.Q&A

116 odalys arregladas.Q&A 116 arregladas por odalys 1. A client is admitted to the mental health unit with relationship distress with spouse and depressed mood. Finding of which diagnostic tests provide the most information for developing this client’s plan care? a- Urine drug screen b- Complete blood court c- Basic metabolic panel d- Electrocardiogram 2. An older woman who lives alone in two-story home admitted after falling while shopping. X rays reveal a fractured left hip. With no immediate family in the area, the client is concerned about her pets. Which interventions should the nurse implement? a- Palpate and mark pedal pulses b- Alert social worker of client’s concerns c- Asses ability to bear weight when standing d- Evaluate pain using standard pain scale e- Support left leg with two 3. A resident of a long-term care facility, who has moderate dementia, Is having difficulty Eating in the dining room. The client becomes frustrated when dropping utensils on the floor and then refuses to eat. What actions should the nurse implement? a- Allow client to choose foods from a menu b- Assign a staff member to feed the client c- Have meals brought to the to the client’s room d- Encourage the client to eat finger foods 4. A client is admitted to the mental health unit with a diagnosis of adjustment disorder and depressed mood. Which finding should be included when developing the client’s plan of care? a- Rapid Plasma regain (RPR) b- Electrocardiogram c- Urine drug screen d- Serum iron levels 5. A client with chronic kidney disease has an arteriovenous (AV) fistula in the left forearm. Which observation by the nurse indicates that the fistula is patent? a- Distended, tortuous veins in the left hand b- The left radial pulse is 2+ bounding c- Auscultation of a thrill on the left forearm d- Assessment of a bruit on the left forearm 6. When implementing a disaster intervention plan, which intervention should the nurse implement first? a- Initiate the discharge of stable clients from hospital units b- Identify a command center where activities are coordinated c- Assess community safety needs impacted by the disaster d- Instruct all essential off-duty personnel to report to the facility 7. The nurse is admitting a client from the postanesthesia unit to the postoperative surgical care unit. Which prescription should the nurse implement first? a- Advance from clear liquids as tolerated b- Straight catheterization if unable to void c- Cefazolin 1 gram IVPQ q6 hours d- Complete blood cell count (CBC) in AM 8. The nurse is caring for a client who is receiving continuous ambulatory peritoneal dialysis (CAPD) and notes that the output flow is 100ml less than the input flow. Which actions should the nurse implement first? a- Continue to monitor intake and output with next exchange b- Check the clients blood pressure and serum bicarbonate c- Irrigate the dialysis catheter d- Change the clients position 9. The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective? a- A tuna fish sandwich with chips and ice cream. b- A peanut butter sandwich with soda and cookies. c- A salad with three kinds of lettuce and fruit. d-Vegetable soup, crackers, and milk. 10. While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client’s laboratory values? a- Serum potassium and sodium levels. b- C-reactive protein level. c- Platelet count. d- Neutrophil count. 11. A client who is hypotensive is receiving dopamine, and adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication? a- Measure urinary output every hour b- Monitor serum potassium frequently c- Initiate seizure precautions d- Assess pupillary response to light hourly 12. A client with renal disease seems axious and presents with the onset of shortness of breath, lethargy, edema, and weight gain. Which action should the nurse implement first? a- Determine serum potassium level b- Calculate the clients daily fluid intake c- Assess client for signs of vertigo d- Review the client’s pulse oximetry reading 13. A client with eczema is experiencing severe pruritus. Which PRN prescriptions should the nurse administer? (Select all that apply) a- Topical corticosteroid. b- Topical scabicide. c- Topical alcohol rub. d- Transdermal analgesic. e- Oral antihistamine 14. A male client approaches the nurse with an angry expression on his face and raises his voice, saying, ´´ My roommate is the most selfish, self –centered, angry person I have ever met. If the loses his temper one more time with me, I am going to punch him out’’ The nurse recognizes that the client is using which defense mechanism? a- Denial b- Splitting c- Projection d- Rationalization 15. A male client is returned to the surgical unit following a left nephrectomy and is medicated with morphine. His dressing has a small amount of bloody drainage, and a Jackson-Pratt bulb surgical drainage device is in place. Which interventions is most important for the nurse to include in this clients plan of care? a- Monitor urine output hourly. b- Assess for back muscle aches c- Record drainage from drain d- Obtain body weight daily 16. The nurse assesses a client one hour after starting a transfusion of packed red blood cells and determines that there are no indications of a transfusion reaction. What instructions should the nurse provide the unlicensed assistive personnel (UAP) who is working with the nurse? a- Continue to measure the client’s vital signs every thirty minutes until the transfusion is complete b- Since a reaction did not occur, the priority is to maintain client comfort during the transfusion c- Monitor the client carefully for the next three hours and report the onset of a reaction immediately. d- Notify the nurse when the transfusion has finished, so further client assessment can be done. 17. The charge nurse is marking assignments on a psychiatric unit for a practical nurse (PN) and a newly licensed registered nurse (RN). Which client should be assigned to the RN ? a- An older male who tells the staff and other clients that he is superman and can fly. b- A young male with schizophrenia who says voices are telling him to kill his psychiatrist. c- A middle- aged client who is in the depressive phase of bipolar disease and is receiving lithium. d- An adult client who has been depressed for the past several months and denies social ideation. 18. What is the primary purpose for initiating nursing intervention that promote good nutrition, rest, and exercise, and stress reduction for clients diagnosed with an HIV infection? a- Prevent spread of infection to others b- Improve function of the immune system c- Increase ability to carry out activities of daily living d- Promote a feeling of general well-being 19. When preparing for a bone marrow aspiration, the nurse should place the client in which position to ensure access of the aspiration site? a- Prone with the posterior iliac crest draped b- Side-lying with the posterior chest exposed c- Sitting up and leaning across the over-bed table d- Supine with a pillow under the lumbar area. 20. An older male client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). He has facial paralysis and cannot move his left side. When entering the room, the nurse finds the client’s wife tearful and trying unsuccessfully to give him a drink of water. What action should the nurse take? a- Give the wife a straw to help facilitate the client’s drinking. b- Assist the wife and carefully give the client small sips of water c- Obtain a thickening powder before providing any more fluids d- Ask the wife to stop and assess the client’s swallowing reflex. 21. The mother of a 9-month-old infant o A client whith diabetic peripheral tells the nurse that her healthy “chubby” baby is irritable and not very active. After obtaining a dietary history, the nurse determines that the infant refuses to eat any infant cereals. Which finding is most important to report to the healthcare provider? a- Breast feeds 10 minutes at night to go to sleep. b- Has porcelain-like skin and tripled birth weight. c- Does not take an infant vitamin supplement. d- Ingests 6 ten-ounce bottles of cow’s milk daily. 22. A client with a severe prostatic infection that caused a blocked urethra is 3 days post-surgical urinary diversion. The healthcare provider directs the nurse to remove the suprapubic catheter to allow the client to void normally. Which intervention should the nurse implement first? a- Cleanse the site around the catheter b- Use a 20 ml syringe to deflate balloon c- Clamp catheter until a client voids naturally d- Empty urine from urinary drainage bag 23. The nurse assesses a client with new onset diarrhea. It is most important for the nurse to question the client about recent use of which type of medication? a. Antibiotics b. Anticoagulants c. Antihypertensive d. Anticholinergics 24. bebe de 2 dias de nacido le hacen TSH Y T4 • Para detectar los problemas metabólicos. (hypotiroidismo) 25. Enfermera va atomar la presion con un aparato electric • que lo tome con uno normal 26. La enfermera da teaching sobre el rotavirus • Lavar las manos antes de tocar los alimentos 27. Paciente con una hernia elective y habia comido que si la enfermera le podia dar los medicamentos. • Hold the medication 28. Paciente que tenia caposi sarcoma • Habia que buscar si tenia otro padecimiento 29. Dyalisis peritoneal que no salia lo mismo que entro • cambiarlo de position 30. Paciente que tenia hemoglotona bicocilada en 9 • Termina con postre de pera wine 31. Paciente que pario hace 5 horas y esta sangrando’’ • gravida 6 para 5 (multiparas) 32. la hija le esta poniendo gotas en lo sojos a la madre que le dice la enfermera que haga • Decirle a la mama que despues de las gotas lentamente 33. Paciente que le dan un medicamento en tableta y dice que no puede tomar pastillas que hace la enfermera • Llamar a la Farmacia para que cambien a liquido 34. Señalar carótida Carótida 35. paciente quemado 27% 36. Señalar el oído medio 37. A client is admitted following a motor vehicle collision. When assessing the clients level of consciousness, the nurse notes that the client no longer responds to commands. The nurse initiates a painful stimulus and the client responds by pulling the arms inward with elbow and wrist flexed and extending the legs with the toes pointed downward. What action should the nurse implement? a. Document the purposeful response to pain b. Administer a prescribed PRN analgesic c. Initiate seizure precaution immediately d. Report the finding to the healthcare provider 38. A client with diabetic peripheral tells the nurse that her healthy “chubby” baby is irritable and not very active. After obtaining a dietary history, the nurse determines that the infant refuses to eat any infant cereals. Which finding is most important to report to the healthcare provider? a- Breast feeds 10 minutes at night to go to sleep. b- Has porcelain-like skin and tripled birth weight. c- Does not take an infant vitamin supplement. d- Ingests 6 ten-ounce bottles of cow’s milk daily. 39. A client with renal disease seems anxious and presents with the onset of shortness of breath, lethargy, edema, and weight gain. Which action should the nurse implement first? a- Determine serum potassium level b- Calculate the client’s daily fluid intake c- Assess client for signs of vertigo d- Review the client’s pulse oximetry reading 40. A nurse working on an endocrine unit should see which client first? a- An adolescent male with diabetes who is arguing about his insulin dose. b- An older client with Addison’s disease whose current blood sugar level is 62mg/dl (3.44 mmol/l). c- An adult with a blood sugar of 384mg/dl (21.31mmol/l) and urine output of 350 ml in the last hour. d- A client taking corticosteroids who has become disoriented in the last two hours. Rational: meeting the client’s need for safety is a priority intervention. Mania and psychosis can occur during corticosteroids therapy, places the client at risk for injury, so the patient taking corticosteroids should be seen first. 41. What intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an IV site in the client's arm? a- Assess IV site frequently for signs of extravasation. b- Monitor capillary refill distal to the infusion site c- Apply a topical anesthetic at the infusion site for burning d- Explain that temporary burning at the IV site may occur 42. What instruction should the nurse provide to a client who is preparing to have a cystoscopy a. avoids strenuous activity and sport for a least 2 weeks b. Report any allergies to shellfish or iodine c. Lay prone for 24 horas after procedure c. Report any painful urination, blood urine, or fever 43. A client is admitted with multiple diarrheal stools, fever, and dehydration. Which assessment finding should be reported immediately to the health care provider? a- Oral temperature of 100° F b- Increased bowel sounds in all quadrants c- Dry, flaky skin that easily tents d- Mid-abdominal pulsating mass 44. The nurse auscultates a client's abdomen and hears a loud bruit near the umbilicus. What is the nurse's best action based on this assessment finding? a- Document the assessment finding in the medical record. b- Palpate the abdomen lightly in all four quadrants. c- Report the finding to the health care provider. d- Place the client in a semi-Fowler's position. 45. What instruction should the nurse provide to a client who is preparing to have a cystoscopy? a- Avoid strenuous activity and sports for a least 2 weeks b- Report any allergies to shellfish or iodine c- Lay prone for 24 hours after the procedure d- Report any painful urination, blood urine, or fever 46. A client’s catheter bag was left on the client’s bed for a prolonged period of time, and client develops a urinary tract infection. In evaluating the cause of the infection, what should the nurse identify as the client reservoir? a- Clients bladder b- Catheter tubing c- Urinary meatus d- the clients bed 47. Dopamine hydrochloride 2mcg/kg/minute is prescribed to promote renal perfusion for a client weighing 198lbs. the pharmacy sends a pre-mixed bag of dopamine 400 mg in 250 ml D5w. An IV pump is available that provides a precision infusion rate to a tenth of a ml. The nurse should set the IV pump to deliver how many ml/hours? (Enter numeric value only. If rounding is required, round to the nearest tenth.) • 6.75 = 6.8 48. An adult Woman who was recently diagnosed with type 2 diabetes mellitus (DM) is seen in the clinic for laboratory test. The clients height 5feet 2 inches and weight 165 pound (74.8kg) Her recent laboratory findings are describe above. In planning nutrition for this client. What diet modifications should the nurse recommend? (select all that apply) Esta pregunta tiene table (medical récord) a. Decrease presence carbohydrate in diet b. Increase dietary fiber such as whole grains c. Restrict protein in 10% of total calories in diet d. Reduce daily fat intake to 10% of total calories e. Eliminate alcohol intake except for especial occasions 49. The nurse is caring for a 3 years old child who is two hours postoperative from a cardiac catherization via the right femoral artery. Which assessment finding is an indication of arterial obstruction? a. Blood pressure trend is downward, and pulse is rapid and irregular b. The pressure dressing at right femoral area is moist and oozing blod c. Right foot is cool to the touch and appears pale and blanched d. Pulse distal to the femoral artery is weaker on left foot than right foot. 50. During a return demonstration of teaching provide by the nurse, the daughter of a client administers her mother eye drops by resting her dominant hand on her mother’s forehead and dropping the medication into conjunctival sac. What action should de nurse take in response to this medication a. Reminds the client to gently close her eyes after the eyedrops are instilled b. Offer to demonstrate the eye drop procedure to the daughter one more time c. Instruct the mother to gently rub the affected eye to distribute the drops d. Advise the daughter to keep her hand farther from her mother’s eyes 51. During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should the nurse take first? a- Give the client 4 ounces of orange juice b- Call 911 to summon emergency assistance c- Check the client for lacerations or fractures d-Asses clients blood sugar level 52. The nurse is caring for a 17-year-old male who fell 20 feet 5 months ago while climbing the side of a cliff and has been in a sustained vegetative state since the accident. Which intervention should the nurse implement? a. Inquire about food allergies and food likes and dislikes b. Talk directly to the adolescent while providing care c. Initiate open communication with the teen’s parents d. Monitor vital signs and neuro status every 2 hours 53. The nurse observes an unlicensed assistive personal (UAP) begin to provide oral care to an unresponsive client who is at risk for aspiration as seen in the picture. What instruction should the nurse provide the UAP? Select all that apply. a. Flex the client neck forward b. Turn the clients head to the side c. Remove the gloved finger from the mouth d. Elevate the head of the bed to semi fowlers e. Apply lubricant to the toothed 54. A client whit multiple sclerosis (MS) is receiving interferon beta-1b 0.1875 mg subcutaneously QOD. The nurse reconstitutes the vial by slowly injection 1.2 ml of diluent into the interferon vial for a reconstituted solution of 0.25mg/1ml. How many ml should the nurse administers? (Enter numeric value only. (If rounding is required round to the nearest hundred) 0.75 55. A 9-year-old is receiving vancomycin 400 mg IV every 6 hours for a methicillin resistant (Beta lactam resistant) Staphylococci aureus (MRSA) infection. The medication is diluted in a 100 ml bag of saline with instruction to infuse over one and half hours. How many ml/hours should the nurse program the infuse pump? If rounding is required, round to the nearest whole number. 66.6 = 67 56. A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and receiving lactate ringer’s solution at 75 ml/hours IV. One hour after admission to the unit, the nurse notes 300 ml of blood in the suction canister, the client heart rate is 155 beats/minute, and his blood pressure is 78/48mmHg. In addition to reporting the findings to the surgeon, which action the nurse implemented first? a. Measure and document the clients urinary output b. Request the clients reserved unit of a packed red blood cells c. Prepare for placement of a central venous catheter d. Increase the infusion rate of lactate ringer’s solution 57. The nurse is assessing a client who recently had an upper respiratory infection and now presents to the emergency department with lower extremity numbness and difficulty swallowing. Based on these finding, this client is at greatest risk for which pathophysiology condition? a. Epstein Bar Virus b. Cytomegalovirus c. Guillen Barre syndrome d. Mycoplasma Pneumonia 58. A client becomes increasingly lethargic and has a respiratory rate of 8 breaths per minute with 30 second periods of apnea. The health care provider is notified and STA arterial blood gases ABG are drawn. What ABG result should the nurse anticipate. a. Uncompensated metabolic acidosis b. Compensated metabolic acidosis c. Uncompensated respiratory acidosis d. Compensated respiratory alkalosis 59. A 2-month-old infant is brought to the clinic for routine immunizations. What plan should the nurse implement? a. Tell me mother to return in two weeks for IM polio vaccine (IPV), diphtheria, tetanus, pertussis (DTaP), hepatitis A (HA), and B (HB), H. influenzae type B (HIB), and pneumococcal (PCV vaccines b. Administer oral rotavirus vaccine (RV), polio vaccine (IPV), pertussis (DTaP), Hepatitis B (HB), Influenzae type B (HIB), and pneumococcal (PCV) vaccines IM in the gluteus maximus. c. Administer oral rotavirus vaccine (RV), and IM polio vaccine (IPV), diphtheria, tetanus, pertussis (DTaP), hepatitis A (HA), and B (HB), H. influenzae type B (HIB), and pneumococcal (PCV). d. Administer oral rotavirus vaccine (RV), and polio vaccine (IPV), pertussis (DTaP), Hepatitis B (HB), Influenzae type B (HIB), and pneumococcal (PCV) vaccines IM in the vastus lateralis 60. Two days after a syncopal episode, an adult woman is admitted to the telemetry unit Because of a new onset atrial fibrillation. The clients restless and complaining of shortness of breath at rest but insists on getting out of bed to go to the bathroom. Her vital signs are: blood pressure 90/40, heart rate 145 beats/minute, respiratory rate 22 breath/minute. While in the bathroom, the client begins to cough, producing frothy, pink tinged sputum. What action should the nurse take first? a. Obtain a heart rhythm strip from the telemetry monitor b. Auscultate the client’s breath sounds and heart sounds c. Assist the client back to the bed and into fowlers positions d. Encourage client to rinse mouth to moisten membranes 61. The nurse is caring for a male client with pyelonephritis who reports having cloudy, foul smelling urine, and a burning sensation whenever the urinate. The client is started on IV antibiotic therapy. The nurse should plan to carefully monitor which client parameter? a. Oliguria b. Ability to start a urinary stream c. Skin turgor fluid imbalance d. Flank pain 62. A client with bladder cancer had a surgical placement ureterileostomy (Ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately? a. Stoma output of 40 ml in last hour b. Mucous strings floating in the drainage c. Red edematous stomal appearance d. Liquid brown drainage from stoma 63. An alert older client with diabetes mellitus type 1 is admitted with a serum glucose of 420 mg/dl (23.31 mmol/L (SI)). As the nurse administers 10 units of regular insulin intravenous (IV), the client immediately begins to vomit. What action should the nurse implement first? a . Hang a bag of IV normal saline b. Check the client’s serum glucose level c. Turn the client to a lateral position d. Provide an emesis basin 64. In caring for a client with Cushing syndrome, which serum laboratory value is most important for the nurse to monitor? a- Lactate b- Glucose c- Hemoglobin d- Creatinine 65. The nurse is caring for a client who is experiencing a tonic-clonic seizure. Which actions should the nurse implement? (Select all that apply) a. Ease the client to the floor. b. Loosen restrictive clothing c. Note the duration of the seizure 66. A male client who had a small bowel resection acquired methicillin- resistant Staphylococcus aureus (MRSA) while hospitalized. He was treated and released but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention? • Maintain contact transmission precaution Esta le salió a juana pero con otras respuestas ella cree que es la que la familia se pusiera bata y mascara de isolation para estar con el paciente 67. Which type of Leukocyte is involved with allergic responses and the destruction of parasitic worms? a. Neutrophils b. Lymphocytes c. Eosinophils d. Monocytes Rationale: Eosinophils are involved in allergic responses and destruction of parasitic worms 68. A female client with chronic urinary retention explains double voiding technique to the nurse by stating she voids partially, hold the remaining urine in her bladder for three minutes, then voids again to empty her bladder fully. How should the nurse respond? • Advise the client to empty her bladder fully when she first voids 69. A young boy who is in a chronic vegetative state and living at home is readmitted to the hospital with pneumonia and pressure ulcers. The mother insists that she is capable of caring for her son and which action should the nurse implement next? a- Report the incident to the local child protective services. b- Find a home health agency that specializes in brain injuries. c- Determine the mother’s basic skill level in providing care. d- Consult the ethics committee to determine how to proceed. Rational: Although the mother states she is a capable caregiver, the client is manifesting disuse syndrome complications, and the mother’s skill in providing basic care should be determined. Further assessment is needed before implementing other nursing actions. 70. A client with eczema is experiencing severe pruritus. Which PRN prescriptions should the nurse administer? (Select all that apply) a- Topical corticosteroid. b- Topical scabicide. c- Topical alcohol rub. d- Transdermal analgesic. e- Oral antihistamine Rationale: anti-inflammatory actions of topical corticosteroids and oral antihistamines provide relief from severe pruritus (itching). Other options are not indicated. 71. A young adult female college student visits the health clinic in early winter to obtain birth control pills. The clinic nurse asks if the student has received an influenza vaccination. The student stated she did not receive vaccination because she has asthma. How should the nurse respond? a- Offer to provide the influenza vaccination to the student while she is at the clinic b- Encourage the student to obtain a vaccination prior to the next influenza season. c- Confirm that a history of asthma can increase risks associated with the vaccine. d- Advise the student that the nasal spray vaccine reduces side effects for people with asthma. Rationale: person with asthma are at increased risk related to influenza and should receive the influenza vaccination prior to or during influenza season. Waiting until the start of the next season places the student at risk for the current season. The vaccination does not increase risk for persons with asthma but the nasal spray may result in increased wheezing after receiving that form of the vaccination 72. A client who is admitted to the intensive care unit with a right chest tube attached to a THORA-SEAL chest drainage unit becomes increasingly anxious and complain of difficulty breathing. The nurse determine the client is tachypneic with absent breath sounds in the client’s right lungs fields. Which additional finding indicates that the client has developed a tension pneumothorax? • Continuous bubbling in the water seal chamber • Decrease bright red blood drainage • Tachypnea and difficulty breathing • Tracheal deviation toward the left lung. Rationale: Tracheal deviation toward the unaffected left lung with absent breath sounds over the affected right lung are classic late signs of a tension pneumothorax. EDUARDO 73. A 16 years old male client who has been treated in the past for a seizure disorder is admitted to the hospital immediately after admission he begins to have a grand mal seizure. Which action should the nurse implement? a. Observe the client carefully b. Place a padded tongue blade between client’s teeth c. Obtain assistance in holding him to prevent injury d. Call the rapid respond team 74. A female client is admitted for diabetic crisis resulting from inadequate dietary practice. After stabilization, the nurse talks to the client about her prescribed diet. What client characteristic is most important for successful adherence to the diabetic diet? a. Knows that insulin must be given 30 min before eating b- Frequently eats fruits and vegetables at meals and between meals/ c- Has someone available who can prepare and oversee the diet d- Demonstrates willingness to adhere to the diet consistently 75. A male client newly diagnosed with idiopathic epilepsy, is preparing for discharge from the hospital. Which instruction should the nurse provide to the client and his family prior to discharge a. Investigate resource that provide disability payments b. Investigate local state laws related to operating a motor vehicle c. When seizure free for 1 year, the medications may be discontinued d. Surgery may be indicated to remove the epileptogenic focus 76. A seriously ill male is transferred to a healthcare facility in a different state. Include in his records are an advanced directive and a “Physician orders for life sustaining treatment” (POLST). However, the state to which he transferred does not endorse POLST. The client lapses into a coma shortly after admission to the new facility. What action should the nurse take? a. Request that new healthcare provider co-sign POLST document b. Attach and advance directive copy to medical records prescription page c. Implement the clients wishes as described in his advance directive d. Ask the clients family to make life-sustaining treatment decision 77. Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention? a. Observe the appearance of the client urine b. Palpate the area above the pubic symphysis c. Measure the girth of the client’s lower abdomen d. Auscultate an area six inches below the umbilicus 78. After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the x-ray findings that indicate the CVC tip is in the client’s superior vena cava. Which action should the nurse implement? a. Initiate intravenous fluid as prescribed b. Notify the HCP of the need to reposition the catheter c. Remove the catheter and apply direct pressure for 5 minute d. Secure the catheter using aseptic technique Rationale: Venous blood return to the heart and drains from the subclavian vein into the superior vena cava. The X-ray findings indicate proper placement of the CVC, so prescribed intravenous fluid can be started. A and B are not indicated at this time. The catheter should be secure immediate following insertion (C) 79. The nurse is using a straight urinary catheter kit to collect a sterile urine specimen from a female client. After positioning am prepping this client, rank the actions in the sequence they should be implemented. (Place to first action on the top on the last action on the bottom.) • Correct : ODCP 1. Open the sterile catheter kit close to the client’s perineum. 2. Don sterile gloves and prepare to sterile field 3. Cleanse the urinary meatus using the solution, swabs, and forceps provided 4. Place distal end of the catheter in sterile specimen cup and insert catheter into meatus Rationale: First the kit should be open near the clients to minimize the risk of contamination during the collection of the sterile specimen. Once the kit is opened, sterile gloves should be donned to prepare the sterile field. Then the clients’ meatus should be cleansed, and the catheter inserted while to distal end of the catheter drains urine into the sterile specimen cup or receptacle. 80. The nurse assumes care of a postoperative adult client with type 2 diabetes mellitus and learns that the client has a current blood glucose level 750 mg/dl or 42 mmol/l (SI). When assessing the client, what is the priority? a. Determine when the client last ate b. Observer wound drainage characteristic c. Assess for signs of fluid volume deficit d. measure the level of acute pain 81. When preparing to administer and intravenous medication through a client’s triple lumen central venous catheter, the nurse observes that there are no continuous intravenous fluids infusing. What action should the nurse take? a. Position the clients head facing away from the site b. Aspirate for the presence of a blood return c. Initiate an infusion of 0,9% normal saline solution d. prepares a saline flush in a three ml syringe 82. Which statement by the mother of a toddler girl indicates to the nurse that a scheduled vaccine not be administered? a. “My child has been running a little fever and has a runny nose and cough” b. “Her throat closed up so bad she couldn’t breathe the las time she got this shot” c. “Her baby brother has a virus and has had diarrhea for three days now” d. “Her arm gets all red and hurts a lot every time she gets a vaccination” 83. A young adult who was injured during an explosion is not breathing. Which action should the nurse implement on immediate arrival at the rescue scene? a. Reposition the victim to access airway b. Evaluate degree of cyanosis c. Move victim to expectant zone d. Asses peripheral capillary refill time 84. The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing actions should the nurse assign to the PN? (Select all that apply.) a. Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM). b. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty c. Perform daily surgical dressing change for a client who had an abdominal hysterectomy d. Initiate patient-controlled analgesia (PCA) pumps for two clients immediately postoperative e. Start the second blood transfusion for a client twelve hour following a below knee amputation 85. A male client in the final stage of terminal cancer tell his nurse that he wishes he could just be allowed to die. The client states that he is tired of fighting this illness and is only continuing treatment action should the nurse take? a. Arrange a meeting with the family, physician, and client b. Request a consultation with the hospital social worker c. Ask the chaplain to discuss death issues with the client d. Notify the family that treatments have been discontinued 86. The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts? a. Express feelings of sadness and loneliness b. Neglects personal hygiene and has no appetite c. Lacks interest in the activity of the family and friends d. Begin to show signs of improvement in affect Rationale: when a depressed client begins to show signs of improvement, it can be because the client has "figured out" how to be successful in committing suicide. Depressed clients, particularly those who have shown signs of potentially becoming suicidal, should be watched with care for an impending suicide attempt might be greater when the client appear suddenly happy, begin to give away possessions, or becomes more relaxed and talkative 87. A female client with splenomegaly is discharged home and ask the nurse if she can work in her garden. What instruction should the nurse provide? a. No lifting of heavy objects b. Wear sunscreen and long sleeves outdoors c. Drink plenty of fluids and rest d. Avoid acetaminophen products 88. A client is admitted to the surgical unit with symptoms of a possible intestinal obstruction. When preparing to insert a nasogastric tube, which intervention should the nurse implement? a. Assess for a gag reflex b. Measure from corner of mouth to angle jaw c. Elevate the head of the bed 60 to 90 degrees d. Administer a PRN analgesic 89. A male client who is admitted to an adult alcohol rehabilitation program tell the nurse that he is a social drinker and usually has two drinks at brunch, a couple cocktails at the afternoon, wine at dinner, and a drink later in the evening. How should the nurse respond? a. “I think that you may be drinking even more than you report b. “Yes, go on”, that is followed with interested silence c. “You describe drinking rather steadily throughout the day and evening. Am I correct?” d. “A social drinker is someone who has a couple of alcoholic drinks once or twice a week” 90. Experiencing heartburn and a dull growing pain that is relieved when he eats. What is the best response by the nurse? a. Encourage the client to obtain a complete physical exam since these symptoms are consistent with an ulcer b. Instruct the client that these mild symptoms can generally be controlled with changes in his diet c. Assure the client that his symptoms may only reflect reflux, since ulcer pain is not relieved with food d. Advise the client that he needs to seek immediate medical evaluation and treatment of these symptom 91. A male client with heart failure (HF) reports heart palpations and difficulty breathing when Lying flat. When he requests additional pillows, the nurse determines that his heart rate is 125 beats/ minute, and respiratory rate is 22 breaths/ minute. Which intervention is most important for the nurse to implement? a- Listen to S1 and S2 heart sounds. b- Obtain manual blood pressure. c- Auscultate bilateral lung fields. d- Palpate the peripheral pulses. / 92. A client arrives on the surgical floor after major abdominal surgery. What intervention should the nurse perform first? a- Determine the client’s vital sign. b- Apply warmed blanked c- Administer prescribed pain medication d- Asses the surgical site 93. The mother of a child with cerebral palsy (CP) ask the nurse if her child’s impaired movements will worsen as the child grows. Which response provides the best explanation? a- Brain damage with CP is not progressive but does have a variable course b- continued development of the brain lesion determines the child’s outcome c- CP is one of the most common permanent physical disability in children d- Severe motor dysfunction determines the extent of successful habilitation 94. After receiving the Braden scale findings of residents at a long-term facility, the charge nurse should to tell the unlicensed assistive personnel (UAP) to prioritize the skin care for which client? a- An older adult who is unable to communicate elimination needs. b- An older man whose sheets are damped each time he is turned. c- A woman with osteoporosis who is unable to bear weight. d- A poorly nourished client who requires liquid supplement. Rational: a Braden score of less than 18 indicates a risk for skin breakdown, and clients with such score require intensive nursing care. Constant moisture places the client at a high risk for skin breakdown, and interventions should be implemented to pull moisture away from the client’s skin. Other options may be risk factors but do not have as high a risk as constant exposure to moisture. 95. The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which findings? Select all that apply: a-Restlessness b-Clenched Fist c-Increased pulse rate d-Increased respiratory rate. e-Increased temperature f-Peripheral pallor of the skin 96. A client is receiving intravenous (IV) fluids by gravity infusion and exhibits signs of fluid volume overload. When assessing the client’s IV delivery system, where should the nurse assess first? B 97. An adult male is brought to the emergency department by ambulance following a motorcycle accident. He was not wearing a helmet and presents with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse? a- Rebound abdominal tenderness b- nausea and projectile vomit c- rib pain with deep inspiration d- diminished bilateral breath sounds Rationale: Projective vomiting is indicative of increasing intracranial pressure, which can lead to ischemic brain damage or death, so this finding warrants immediate intervention. Rebound abdominal tenderness may indicate internal bleeding. Diminished breath sound may be related to pain. Rib pain with inspiration may indicate rib fracture. 98. An elderly female is admitted because of a change in her level of sensorium. During the evening shift, the client attempts to get out bed and falls, breaking her left hip. Buck’s skin traction is applied to the left leg while waiting for surgery. Which intervention is most important for the nurse to include in this client’s plan care? a. Asses the skin under the traction moleskin b. place a pillow under the involved lower left leg c. Evaluate her response to narcotic analgesia d. Ensure proper alignment of the leg in traction 99. A client with Addison’s disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client’s laboratory values include; sodium 129 mEq/l (129mmol/l SI), glucose 54 mg/dl (2.97mmol/l SI) and potassium 5.3 mmol/l SI). When reporting the findings to the HCP, the nurse anticipates a prescription for which intravenous medications? a- Regular insulin. b- Hydrocortisone c- Broad spectrum antibiotic d- Potassium chloride 100. A male client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the healthcare provider? a-Blood alcohol level of 0.09% b-Serum lithium level of 1.6 mEq/L or mmol/l (SI) c-Six hours of sleep in the past three days. d-Weight loss of 10 pounds (4.5 kg) in past month. Rationale: The therapeutic level of Serum lithium is 0.8 to 1.5 mEq/L or mmol/l (SI). Slurred speech and ataxia are sign of lithium toxicity. 101. A female client is admitted for diabetic crisis resulting from inadequate dietary practices. After stabilization, the nurse talks to the client about her prescribed diet. What client characteristic is most import for successful adherence to the diabetic diet? a- Knows that insulin must be given 30 min before eating b- Frequently eats fruits and vegetables at meals and between meals/ c- Has someone available who can prepare and oversee the diet d-Demonstrates willingness to adhere to the diet consistently 102. A male client with COPD smokes two packs of cigarettes per day and is admitted to the hospital for a respiratory infection. He complains that he has trouble controlling respiratory distress at home when using his rescue inhaler. Which comment from the client indicates to the nurse that he is not using his inhaler properly? a- “I have a hard time inhaling and holding my breath after I squeeze the inhaler, but I do my best” b- “I never use the inhaler unless I am feeling really short of breath” c- “I always shake the inhaler several times before I start” d- “After I squeeze the inhaler and swallow, I always feel a slight wave of nausea, bit it goes away” 102. A client is admitted with smoke inhalation, partial degree burns, and full thickness burns over the back and both posterior things first 24 hours of rapid fluid resuscitation, wich assessment finding warrants immediate intervention by the nurse? a- Average urine output of 28 ml per hour b- Inspiratory and expiratory bilateral crackles c- Diminished bibasilar breath sounds d- Central venous pressure of 12mm H2O 103. An adult female tells the nurse her grandmother was diagnosed with colorectal cancer at age 75 and the client is implement measures to reduce her own risk. Which of the client’s plans indicates the need for additional information? a- Yearly fecal occult blood testing b- Increased intake of fresh fruits, vegetables, and whole grains c- Annual sigmoidoscopy screening d- Reduced dietary intake of animal fat and protein 104. After traveling to a country with a tropical climate, a young male adult is diagnosed with a liver abscess and is taking antimicrobial therapy as an outpatient. During a follow-up visit at the community clinic, the nurse notes that the client has developed jaundice. What action should the nurse take? a- Explain the need to evaluate liver function b- Instruct the client to increase protein intake c- Arrange emergency transport to an inpatient facility d- Prepare the client for repeat blood cultures. 105. An older woman with a history of arterial fibrillation fell at home and fractures her left hip. She is currently taking war mg daily and has an international normalized ratio(INR) value of 0.5. upon admission, which prescription should the nurse expect to implement? complications related to end stage liver a- Transfuse unit of packed red blood cells b- Continue warfarin at same dose c- Administer Vitamin K injection d- Start continuous heparin infusion 106. Renal insufficiency is preparing for discharge from the hospital. Which information is most important for the nurse include in this client’s discharge teaching? a- Use of topical applications to manage pruritis b- Instructions regarding a restricted protein diet c- Strategies to promote independent self-care d- Need for maintaining good oral hygiene 107. A client with pancreatitis is receiving 0.9% normal saline, and the prescribed infusion rate was increased from 100ml/hour to 150 ml/hour. What assessment finding indicates to the nurse that the prescription has a therapeutic outcome? a- A decrease serum amylase from 240 Somogyi units/L to 120 units/L b- An increased in the hematocrit(HCT) from 42%to 52 % c- A decrease in blood urea nitrogen (BUN) from 36 mg/dl to 23 mg/dl d- An increase in the blood glucose level from 130 mg/dl 108. A 15-year-old male client was recently diagnoses with type 1 diabetes mellitus. He tells the nurse that he is having meal plan when he is with his friends. What nursing intervention is best for the nurse to implement? a- Advise him to take his own food with him when going to fast food restaurants with his friends b- Encourage him to find activities to do with his friends that do not involve eating. c- Assist him in identifying popular fast foods that are within his meal plan for diabetes. d- Recommend that he avoid fast food restaurants until he is familiar with his prescribed diet. 109. The nurse administers the osmotic diuretic mannitol to a client who has a closed head injury. Which assessment finding indicates immediate response to administration of the mannitol? a- A decrease in skin turgor b- A decrease in intracranial pressure c- An increase in serum sodium. d- An increase in serum osmolality values 110. The nurse should be most concerned about risk for injury(falls) after administering which medication? a- Promethazine(Phenergan) drowsiness b- Clarithromycin (Biaxin) antibiotic c- Pantoprazole) (Protonix) proton pump inhibitor d- Famotidine (Pepcid) blocker of h2 for ulcers 111. A laboring client, whose cervical dilatation is 7cm with100% effacement, grabs her husband’s shirt and tells him to leave the room because he is responsible for the pain she is experiencing. What action should the nurse take? a- Review the behavior common in the transition phase of labor with the client and her husband. b- Escort the husband to the waiting room and let him know when his wife wishes him to return c- Ask the husband how he feel about his wife’s request and encourage the woman to be more understanding. d- Provide comfort and role-model support measures for the laboring client and her husband. 112. The nurse is assisting the healthcare provider with a wound debridement at the bedside of a client who is mildly confused. The client is draped and sterile field is created. Which nursing intervention should the nurse implement client safety? a- Instruct the client to keep hands under the sterile field b- Verify that the client has given informed consent c- Assess for discomfort when procedure is completed d- Pour cleansing solution onto the sterile cloth field 113. An older client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The nurse notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the nurse to implement? a- Administer a prescribed PRN benzodiazepine at the of a confused state (mas effectivo) b- Ensure that the client is assigned to a room close to the nurses’ station. c- Postpone administration of night medication until after 2300pm d- Ask family member to remain with the client in the evenings from 1700 to 2100 pm 114. A client has a new prescription for the antiarrhythmic drug dronedarone. Which instruction is most important the nurse to include in the client’s discharge teaching plan? a- Report gastrointestinal distress b- Decrease fluid intake if gain 2 pounds c- Increase daily activity as tolerated d- Avoid use of any herbal supplements (Saint john warts) avoid 115. The nurse is teaching a client newly diagnosed with systemic lupus erythematosus(SLE). Which inform for the nurse to provide? a- The disease is characterized by alternating periods of flare-ups and remissions b- Once an acute attack subsides, the client can expect to feel fine again c- Systemic lupus erythematosus (SLE) is a chronic, incurable, terminal illness d- The client can expect to progressively lose function in a fairly predictable sequence. 116. The nurse is assessing a client who returns from surgery with a closed chest drainage system Pleur-Evac) after a lung lobectomy ding should the nurse verify to ensure the system is functioning properly? a- The drainage chamber does not drain more than 100 ml in 8 hours b- The suction control chamber bubbles vigorously when connected to suction c- The tubing remains looped below the level of the bed d- The fluid in the water-seal chamber rise from inspiration and falls with expiration