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Which of these actions should a nurse take initially if a client who is diagnosed
with diabetes mellitus develops tremors and ataxia?
a. Measure the client's blood sugar level.
b. Administer a concentrated form glucose to the client.
c. Administer a prn dose of insulin.
d. Measure the client's urine for ketones.
A
An elderly client is at increased risk of developing drug toxicity to prescribed
medications due to declining hepatic and renal functioning. Which of these
strategies should a nurse plan to decrease this risk?
a. Increasing the time interval between medication doses.
b. Limiting the client's oral fluid intake.
c. Administering the medications with meals.
d. Encouraging the client to void every three to four hours.
A
A client has persistent paranoid delusions that the food on the unit is poisoned.
Which of these measures should a nurse include in the client's care plan?
,a. Explaining that staff does not poison clients.
b. Focusing on how the hospital staff helps clients.
c. Allowing the client to eat food from sealed containers.
d. Telling the client that not eating the food that is served will result in
privilege restrictions. C
Thrombophlebitis is a complication that may result due to surgery. Which of these
actions should a nurse take in the operating room to prevent this complication from
occurring?
a. Gatch the knee of the bed.
b. Administer anticoagulants preoperatively.
c. Apply sequential compression devices.
d. Maintain the legs in a dependent position.
C
When discussing weigh gain during pregnancy, a nurse should recommend that the
total weight gain for a pregnant client who is at ideal body weight for her height is:
a. at least 15 pounds.
b. 15 to 20 pounds.
c. 25 to 35 pounds.
d. at least 45 pounds.
C
,Which of these manifestations, if reported by a client who is 10-weeks-pregnant,
supports the diagnosis of ruptured tubal pregnancy.
a. Sharp unilateral abdominal pain.
b. Uncontrollable vomiting.
c. Marked abdominal distention.
d. Profuse vaginal bleeding.
A
Which of these assignments, if made by a nurse to a nursing assistant, indicates
that the nurse needs additional instructions regarding the principles of delegation?
a. "Please bathe the client in room 12, and then bring the client to the dining room
for breakfast by 9
A.M."
b. "Please bathe the client in room 10, administer a back rub, and then evaluate
if the back rub eased the client's discomfort."
c. "Please measure the intake and output for the client's in rooms 8. 9. and 10,
and record each on the intake/output sheets by 2 P.M."
d. "Please toilet the clients in rooms 11, 12, and 13 mid-morning and after
lunch." B
A client has the following order for regular insulin (Humulin R) on a sliding scale:
Blood sugar 150-180 mg: Give 2 units regular insulin
Blood sugar 181-200 mg: Give 4 units regular insulin
Blood sugar 201-220 mg: Give 6 units of regular insulin
Blood sugar above 220 mg: Call MD
, At 11 A.M., a nurse obtains a finger stick glucose of 198 mg. The only syringe is a
three milliliter one.
Regular insulin is available as 100 units per milliliter. How many milliliters should
the nurse administer?
a. 0.04
b. 0.4
c. 4
d. 40 A
Which of these nursing diagnosis is the priority for a client who is one-hour
postoperative after extensive abdominal surgery?
a. Risk for impaired physical mobility.
b. Risk for deficient fluid volume.
c. Risk for ineffective airway clearance.
d. Risk for infection.
C
A nurse should recognize that which of these occupations increases a person's risk
of developing hepatitis B?
a. Sanitation worker.
b. Nursery school teacher.
c. Hemodialysis nurse.
d. Fish market sales person.
C