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. When walking past a client's room, the nurse hears 1
unlicensed assistive personnel (UAP) talking to another UAP.
Which statement requires follow-up intervention? - correct
answer- "Since I am late for lunch, would you do this one
client's glucose test?"
A 1 year-old child is receiving temporary total parental nutrition
(TPN) through a central venous line. This is the first day of TPN
therapy. Although all of the following nursing actions must be
included in the plan of care of this child, which one would be a
priority at this time? - correct answer- Monitor serum
glucose levels
A 6 year-old child diagnosed with acute glomerulonephritis
(AGN) is experiencing anorexia, moderate edema and elevated
blood urea nitrogen (BUN) levels. The child requests a peanut
butter sandwich for lunch. What would the nurse's best
response to this request? - correct answer- "I know
that is your favorite, but let me help you pick another lunch."
,A 9 year-old is taken to the emergency room with right lower
quadrant pain and vomiting. When preparing the child for an
emergency appendectomy, what must the nurse expect to be
the child's greatest fear? - correct answer- Perceived
loss of control
A 24 year-old male is admitted with a diagnosis of testicular
cancer. The nurse would expect the client to have - correct
answer- Heaviness in the affected testicle
A 25 year-old client, unresponsive after a motor vehicle
accident, is being transferred from the hospital to a long term
care facility. To which o staff members should the charge nurse
assign the client? - correct answer- RN
A 52 year-old client is being transfused with one unit of packed
cells. A half hour after the transfusion was initiated, the client
complains of chills and headache. Which action should the nurse
implement first? - correct answer- Stop the
transfusion
A 64 year-old client scheduled for surgery with a general
anesthetic refuses to remove a set of dentures prior to leaving
the unit for the operating room. What would be the most
appropriate intervention by the nurse? - correct answer-
,Ask the client if the preference would be to remove the
dentures in the operating room receiving area
A charge nurse working in a long term care facility is making out
assignments. Which assignment to an unlicensed assistive
personnel (UAP), if made by the nurse, requires intervention by
the supervisor? - correct answer- Teaching a family
intermittent (bolus) feedings via G-tube before discharge
A child is sent to the school nurse by a teacher who has a written
note that Fifth's disease is suspected. Which characteristic would
the nurse expect to find? - correct answer- Erythema
on the face, primarily on cheeks giving a "slapped face"
appearance
A child is treated with edetate calcium disodium (Calcium EDTA)
for lead poisoning. Which of these should the nurse assess first ?
- correct answer- Urinary output
A client admits to benzodiazepine dependence for several years.
She is now in an outpatient detoxification program. The nurse
must understand that a priority during withdrawal is -
correct answer- Avoid alcohol use during this time
, A client being treated for hypertension returns to the
community clinic for follow up. The client says, "I know these
pills are important, but I just can't take these water pills
anymore. I drive a truck for a living, and I can't be stopping every
20 minutes to go to the bathroom." Which of these is the best
nursing diagnosis? - correct answer- Noncompliance
related to medication side effects
A client calls the nurse with a complaint of sudden deep
throbbing leg pain. What is the appropriate first action by the
nurse? - correct answer- Maintain the client on bed
rest
A client experiences intense anxiety after the home was
destroyed by a fire. The client escaped from the fire with only
minor injuries. The nurse knows that the most important initial
intervention would be to: - correct answer- Determine
available community and personal resources
A client has been admitted with complaints of lower abdominal
pain, difficulty swallowing, nausea, dizziness, headache and
fatigue. The client is agitated, fearful, tachycardic and complains
of being "too sick to return to work." The client is diagnosed as
having somatoform disorder. In formulating a plan of care, the