LATEST EXAM MARKED A+ QUESTIONS
AND ANS GRADED A+
. A client is admitted for first and second degree burns on the face, neck, anterior
chest and hands. The nurse's priority should be - answer Assess for dyspnea or
stridor
. The nurse assesses a 72 year-old client who was admitted for right sided
congestive heart failure. Which of the following would the nurse anticipate
finding? - answer Jugular vein distention
A 10 year-old child has a history of epilepsy with tonic-clonic seizures. The school
nurse should instruct the classroom teacher that if the child experiences a seizure
in the classroom, the most important action during the seizure would be to -
answer Place the hands or a folded blanket under the head of the child
A 14 year-old with a history of sickle cell disease is admitted to the hospital with a
diagnosis of vaso-occlusive crisis. Which statements by the client would be most
indicative of the etiology of this crisis - answer "I went to the health care provider
last week for a cold and I have gotten worse."
A 2 day-old child with spina bifida and meningomyocele is in the intensive care
unit after the initial surgery. As the nurse accompanies the grandparents for a first
visit, which response should the nurse anticipate of the grandparents? - answer
Disbelief
,A 20 year-old client has an infected leg wound from a motorcycle accident, and
the client has returned home from the hospital. The client is to keep the affected
leg elevated and is on contact
precautions. The client wants to know if visitors can come. The appropriate
response from the home health nurse is that: - answer Visitors should wash their
hands before and after touching the client
A 4 year-old has been hospitalized for 24 hours with skeletal traction for
treatment of a fracture of the right femur. The nurse finds that the child is now
crying and the right foot is pale with the absence of a pulse. What should the
nurse do first? - answer Notify the health care provider
A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is
awake and alert, but has not been able to void since he returned from surgery 6
hours ago. He received 1000 mL of IV fluid. Which action would be most likely to
help him void? - answer Assist him to stand by the side of the bed to void
A 65-year-old Catholic Hispanic-Latino client with prostate cancer adamantly
refuses pain medication because the client believes that suffering is part of life.
The client states "everyone's life is in God's hands." The next action for the nurse
to take is to - answer Ask the client if talking with a priest would be desired
A child is admitted to the pediatric unit with a diagnosis of suspected
meningococcal meningitis. Which admission orders should the nurse do first? -
answer Place in respiratory/secretion precautions
A client asks the nurse to call the police and states: "I need to report that I am
being abused by a nurse." The nurse should first - answer Obtain more details of
the client's claim of abuse
, A client continuously calls out to the nursing staff when anyone passes the client's
door and asks them to do something in the room. The best response by the
charge nurse would be to - answer Assign 1 of the nursing staff to visit the client
regularly
A client diagnosed with anorexia nervosa states after lunch, "I shouldn't have
eaten all of that sandwich, I don't know why I ate it, I wasn't hungry." The client's
comments indicate that the client is likely experiencing - answer Guilt
A client diagnosed with cirrhosis of the liver and ascites is receiving
Spironolactone (Aldactone). The nurse understands that this medication spares
elimination of which element? - answer Potassium
A client expresses anger when the call light is not answered within 5 minutes. The
client demanded a blanket. The best response for the nurse to make is client
demanded a blanket. - answer "I see this is frustrating for you. I have a few
minutes so let's talk."
A client frequently admitted to the locked psychiatric unit repeatedly
compliments and invites one of the nurses to go out on a date. The nurse's
response should be to - answer Discuss the boundaries of the therapeutic
relationship with the client
A client has a chest tube in place following a left lower lobectomy inserted after a
stab wound to the chest. When repositioning the client, the nurse notices 200 cc
of dark, red fluid flows into the collection chamber of the chest drain. What is the
most appropriate
nursing action? - answer Continue to monitor the rate of drainage