A client who has partial-thickness burns on the chest, abdomen, and right side arrives in
the emergency department. Which action will the nurse take first?
A. Remove the client's clothing.
B. Evaluate whether the client has inhaled smoke.
C. Insert a venous access device in an unaffected arm.
D. Determine the extent of the burns, using the rule of nines. -ANSWER-B;A client is
admitted to the hospital, and benazepril is prescribed for hypertension. Which is an
appropriate nursing action for clients taking this medication?
A.Assess for dizziness.
B.Assess for dark, tarry stools.
C.Administer the medication after meals.
D.Monitor the electroencephalogram (EEG). -ANSWER-A;A construction worker sustains
a puncture wound from a rusty nail and the last immunization for tetanus in unknown.
The primary health care provider prescribes tetanus immune globulin. Which type of
protection does this immunization offer?
A. Lifelong passive immunity
B. Long-lasting active protection
C. Stimulation of antibody production
D. Immediate passive short-term immunity -ANSWER-D;A hospice client who has severe
pain asks for another dose of oxycodone. Which consideration is the nurse's primary
concern when responding to the client's request?
A. Prevent addiction.
B. Determine why the medication is needed.
C. Provide alternative comfort measures.
D. Reduce the client's pain. -ANSWER-D;A nurse receives an order to administer
cefazolin 2 g/100 mL NS IV every 8 hours. Pharmacy suggests infusing the cefazolin
over 30 minutes. How many milliliters per hour would the nurse set the IV infusion
device? -ANSWER-200 mL/hr;The nurse has administered sublingual nitroglycerin.
, Which outcome would the nurse use to determine the effectiveness of sublingual
nitroglycerin?
A.Relief of anginal pain
B.Improved cardiac output.
C.Decreased blood pressure
D.Ease in respiratory effort -ANSWER-A;After a subtotal gastrectomy, a client
demonstrates signs of dumping syndrome. About 90 minutes after the initial attack, the
client reports feeling shaky. Which would the nurse determine is the cause of the latter
effect?
A. A second, more extensive rise in glucose
B. An overwhelmed insulin-adjusting mechanism
C. A distention of the duodenum from an excessive amount of chyme
D. An overproduction of insulin that occurs in response to the rise in blood glucose. -
ANSWER-D;Which type of immunity will clients acquire through immunizations with live
or killed vaccines?
A. Natural active immunity
B. Artificial active immunity
C. Natural passive immunity
D. Artificial passive immunity -ANSWER-B;Which situations accurately represent
superego in a client, per Freud? (Select all that apply)
A. Controlling the urge to eat candy because he or she knows it will affect blood sugar
levels.
B. Having a craving for fruit but not stealing it form the next client because that client
needs it more.
C. Urinating beside the bed instead of waiting for the nurse to assist him or her.
D. Experiencing a stomachache but refraining from stealing medications from a friend
because it is illegal.
E. Feeling the urge to run away from the hospital but refraining from doing so because
the security guard is watching. -ANSWER-A B D;An older client is treated in the
emergency department for soft tissue injuries that the medical team suspect might be
caused by physical abuse. An adult child states that the client is confused and often
falls. A mini-mental examination indicates that the client is oriented to person, place,
and time. Which action would the nurse take next?
A.Interview the client without the presence of family members.
B.Suggest that the client call law enforcement officers if threatened by family members.
C.Accept the adult child's explanation until more data can be collected.
D.Refer the client's clinical record to the hospital ethics committee for review. -ANSWER-
A;•A test dose of amphotericin is ordered. The order reads to infuse 1 mg in 20 mL over
15 minutes. How many milliliters per hour would the nurse set the IV infusion device? -
ANSWER-80 ML/HR;Which important step would the nurse take to evaluate lifestyle
change in the client?
A. Ask which barriers the client perceives with the planned lifestyle change.
B. Instruct the client to include family members to support the lifestyle change.
C. Advise the client to refrain from discussing the time spent in activity or actual number
of fruits and vegetables eaten.
the emergency department. Which action will the nurse take first?
A. Remove the client's clothing.
B. Evaluate whether the client has inhaled smoke.
C. Insert a venous access device in an unaffected arm.
D. Determine the extent of the burns, using the rule of nines. -ANSWER-B;A client is
admitted to the hospital, and benazepril is prescribed for hypertension. Which is an
appropriate nursing action for clients taking this medication?
A.Assess for dizziness.
B.Assess for dark, tarry stools.
C.Administer the medication after meals.
D.Monitor the electroencephalogram (EEG). -ANSWER-A;A construction worker sustains
a puncture wound from a rusty nail and the last immunization for tetanus in unknown.
The primary health care provider prescribes tetanus immune globulin. Which type of
protection does this immunization offer?
A. Lifelong passive immunity
B. Long-lasting active protection
C. Stimulation of antibody production
D. Immediate passive short-term immunity -ANSWER-D;A hospice client who has severe
pain asks for another dose of oxycodone. Which consideration is the nurse's primary
concern when responding to the client's request?
A. Prevent addiction.
B. Determine why the medication is needed.
C. Provide alternative comfort measures.
D. Reduce the client's pain. -ANSWER-D;A nurse receives an order to administer
cefazolin 2 g/100 mL NS IV every 8 hours. Pharmacy suggests infusing the cefazolin
over 30 minutes. How many milliliters per hour would the nurse set the IV infusion
device? -ANSWER-200 mL/hr;The nurse has administered sublingual nitroglycerin.
, Which outcome would the nurse use to determine the effectiveness of sublingual
nitroglycerin?
A.Relief of anginal pain
B.Improved cardiac output.
C.Decreased blood pressure
D.Ease in respiratory effort -ANSWER-A;After a subtotal gastrectomy, a client
demonstrates signs of dumping syndrome. About 90 minutes after the initial attack, the
client reports feeling shaky. Which would the nurse determine is the cause of the latter
effect?
A. A second, more extensive rise in glucose
B. An overwhelmed insulin-adjusting mechanism
C. A distention of the duodenum from an excessive amount of chyme
D. An overproduction of insulin that occurs in response to the rise in blood glucose. -
ANSWER-D;Which type of immunity will clients acquire through immunizations with live
or killed vaccines?
A. Natural active immunity
B. Artificial active immunity
C. Natural passive immunity
D. Artificial passive immunity -ANSWER-B;Which situations accurately represent
superego in a client, per Freud? (Select all that apply)
A. Controlling the urge to eat candy because he or she knows it will affect blood sugar
levels.
B. Having a craving for fruit but not stealing it form the next client because that client
needs it more.
C. Urinating beside the bed instead of waiting for the nurse to assist him or her.
D. Experiencing a stomachache but refraining from stealing medications from a friend
because it is illegal.
E. Feeling the urge to run away from the hospital but refraining from doing so because
the security guard is watching. -ANSWER-A B D;An older client is treated in the
emergency department for soft tissue injuries that the medical team suspect might be
caused by physical abuse. An adult child states that the client is confused and often
falls. A mini-mental examination indicates that the client is oriented to person, place,
and time. Which action would the nurse take next?
A.Interview the client without the presence of family members.
B.Suggest that the client call law enforcement officers if threatened by family members.
C.Accept the adult child's explanation until more data can be collected.
D.Refer the client's clinical record to the hospital ethics committee for review. -ANSWER-
A;•A test dose of amphotericin is ordered. The order reads to infuse 1 mg in 20 mL over
15 minutes. How many milliliters per hour would the nurse set the IV infusion device? -
ANSWER-80 ML/HR;Which important step would the nurse take to evaluate lifestyle
change in the client?
A. Ask which barriers the client perceives with the planned lifestyle change.
B. Instruct the client to include family members to support the lifestyle change.
C. Advise the client to refrain from discussing the time spent in activity or actual number
of fruits and vegetables eaten.
