STUDY THIS ONE
. If a client develops cor pulmonale (right-sided heart failure), the
nurse would expect to observe 1. increasing respiratory difficulty
seen with exertion. 2. cough productive of a large amount of thick,
yellow mucus. 3. peripheral edema and anorexia. 4. twitching of
extremities. - 3 . The nursing team includes two RNs, one
LPN/LVN, and one nursing assistant. The nurse should consider the
assignments appropriate if the nursing assistant is assigned to care
for 1. a client with Alzheimer's requiring assistance with feeding. 2.
a client with osteoporosis complaining of burning on urination. 3. a
client with scleroderma receiving a tube feeding. 4. a client with
cancer who has Cheyne-Stokes respirations. - 1 A 23-year-old
man is admitted with a subdural hematoma and cerebral edema
after a motorcycle accident. Which of the following symptoms
should the nurse expect to see INITIALLY? 1. Unequal and dilated
pupils. 2. Decerebrate posturing. 3. Grand mal seizures. 4.
Decreased level of consciousness. - 4 A 23-year-old woman at 32-
weeks gestation is seen in the outpatient clinic. Which of the
following findings, if assessed by the nurse, would indicate a possible
complication? 1. The client's urine test is positive for glucose and
acetone. 2. The client has 1+ pedal edema in both feet at the end
of the day. 3. The client complains of an increase in vaginal
discharge. 4. The client says she feels pressure against her
diaphragm when the baby moves. - 1 A 38-year-old woman is
returned to her room after a subtotal thyroidectomy for treatment
of hyperthyroidism. Which of the following, if found by the nurse at
the patient's bedside, is nonessential? 1. Potassium chloride for IV
,administration. 2. Calcium gluconate for IV administration. 3.
Tracheostomy set-up. 4. Suction equipment. - 1 A 59-year-old
woman with bipolar disorder is receiving haloperidol (Haldol) 2 mg
PO tid. She tells the nurse, "Milk is coming out of my breasts."
Which of the following responses by the nurse is BEST? 1. "You are
seeing things that aren't real." 2. "Why don't we go make some
fudge." 3. "You are experiencing a side effect of Haldol." 4. "I'll
contact your physician to change your medication." - 3 A 69-
year-old client is undergoing his second exchange of intermittent
peritoneal dialysis (IPD). Which of the following would require an
intervention by the nurse? 1. The client complains of pain during
the inflow of the dialysate. 2. The client complains of constipation.
3. The dialysate outflow is cloudy. 4. There is blood-tinged fluid
around the intra-abdominal catheter. - 3 A charge nurse is
discussing the responsibility of nurses carig for clients who have C.
difficile. Which of the following information should the nurse include
in the teaching? a) Assign the client to a room with a negative air-
flow system b) Use alcohol-based hand sanitizer when leaving the
clients room c) clean contaminated surfaces in the clients room
with a phenol solution d) have family members wear a gown and
gloves when visiting - D A client diagnosed with dementia wanders
the halls of the locked nursing unit during the day. To ensure the
client's safety while walking in the halls, the nurse should do which
of the following? 1. Administer PRN haloperidol (Haldol) to
decrease the need to walk. 2. Assess the client's gait for steadiness.
3. Restrain the client in a geriatric chair. 4. Administer PRN
lorazepam (Ativan) to provide sedation. - 2 A client has a history
of oliguria, hypertension, and peripheral edema. Current lab values
are: BUN -25, K+ -4.0 mEq/L. Which nutrient should be restricted
in the client's diet? 1. Protein. 2. Fats. 3. Carbohydrates. 4.
Magnesium. - 1 a client has a new prescription for spironilactone
( aldactone ) which of the following laboratory value should the
, nurse recognized as a reason to withhold the morning dose of the
medication and notify the provider - serum potassium 5.2 a client
has prescription for valproic ( Depakote) which of the following
laboratory value should the nurse anticipate monitor for the client
taking this medication - thrombocytes, amylase count and liver
function test A client is admitted with a diagnosis of acute
appendicitis. When assessing the abdomen, the nurse would expect
to find rebound tenderness at which location? a) Left lower
quadrant b) Left upper quadrant c) Right upper quadrant d) Right
lower quadrant - D A client is being discharged with sublingual
nitroglycerin (Nitrostat). The client should be cautioned by the
nurse to 1. take the medication five minutes after the pain has
started. 2. stop taking the medication if a stinging sensation is
absent. 3. take the medication on an empty stomach. 4. avoid
abrupt changes in posture. - 4 A client is given morphine 6 mg IV
push for postoperative pain. Following administration of this drug,
the nurse observes the following: pulse 68, respirations 8, BP
100/68, client sleeping quietly. Which of the following nursing
actions is MOST appropriate? 1. Allow the client to sleep
undisturbed. 2. Administer oxygen via facemask or nasal prongs. 3.
Administer naloxone (Narcan). 4. Place epinephrine 1:1,000 at the
bedside. - 3 A client is receiving total parenteral nutrition (TPN).
To determine the client's tolerance of this treatment, the nurse
should assess for which of the following? 1. A significant increase in
pulse rate. 2. A decrease in diastolic blood pressure. 3. Temperature
in excess of 98.6°F (37°C). 4. Urine output of at least 30 cc per
hour. - 4 A client is scheduled for a left lower lobectomy. The
physician has ordered diazepam (Valium) 2 mg IM for anxiety. The
nurse would determine that the medication is appropriate if the
client displays which of the following symptoms? 1. Agitation and
decreased level of consciousness. 2. Lethargy and decreased
respiratory rate. 3. Restlessness and increased heart rate. 4.