• 59-year-old male client is brought to the emergency room where he is
assessed to have a Glasgow Coma Scale of 3. Based on this assessment,
howshould the nurse characterize the client’s condition?
• The client has increased intracranial pressure
b . He has a good prognosis for recovery
c.This client is conscious, but is not oriented to time and place
d.He is in a coma, and has a very poor
prognosis Correct D
• A client who had a cerebral vascular accident (CVA)
Is paralyzed on the left side of the body and has developed a Stage II
pressure ulcer on the left hip. Which nursing diagnosis describes this
client’s current healthstatus?
• Risk for impaired tissue integrity related to impaired physical mobility
• Impaired skin integrity related to altered circulation and pressure
• Ineffective tissue perfusion related to inability to move self in bed.
• Impaired physical mobility related to the left side
paralysis Correct B
,• The nurse offers diet teaching to a female college student who was
diagnosedwith iron-deficiency anemia following her voluntary adoption
of a lacto-vegetarian diet. What nutrients should the nurse suggest this
client eat to best meet her nutritional needs while allowing her to
adhere to a lacto-vegetarian diet?
• Drink whole milk instead of skim milk to enhance the body’s
production ofamino acids
• Take vitamin K 10mg PO daily to enhance production of red blood cells
• Increase amounts of dark yellow vegetables such as carrots to fortify
ironstores
• Combine several legumes and grains such as beans and rice
to form complete proteins
Correct D
• The nurse is triaging clients from a train wreck. A client has multiple
open wounds, a blood pressure of 90/56, and a pulse of 112
beats/minute. Which triagetag color should the nurse place on this
client?
• Black
• Yellow
,• Green
• Red
Correc
tD
• Which action should the nurse include in the plan of care a
client who is receiving acyclovir (Zovirax) IV for treatment
of herpes zoster (shingles)?
• Initiate cardiac telemetry monitoring
• Maintain continuously pulse oximetry
• Perform capillary glucose measurements
• Monitor serum creatinine
levels Correct D
• A client receiving amlodipine (Norvasc), a calcium channel blocker,
develops 1+pitting edema around the ankles. It is most important for
the nurse to obtain what additional client data?
• Bladder distention
• Serum albumin level
• Abdominal girth
• Breath sounds
Correct D
• A male adult client is transferred to a psychiatric facility following
release from the hospital for treatment of a self-inflicted gunshot
, wound. In attempting to developa therapeutic relationship with this
client, which information is most important for thenurse to determine?
• The family’s reaction to this situation
• The nurse’s feeling about this client
• What losses the client recently experienced
• Why the client attempted to kill
himself Correct B
• Which client requires careful nursing assessment for signs and
symptoms of hypomagnesaemia?
• A young adult client with intractable vomiting from food poisoning
• A client who developed hyperparathyroidism in late adolescence
• A middle-age male client in renal failure following an
unsuccessful kidney transplant
• A female client who is overzealous with her intake of simple
carbohydrates Correct C
• While assessing a client who is experiencing Cheyne-Stokes
respirations, thenurse observes periods of apnea. What action
should the nurse implement?
• Elevate the head of the client’s head
• Auscultate the client’s breath sound
• Measure the length of the apneic periods
• Suction the client’s
oropharynx Correct C
assessed to have a Glasgow Coma Scale of 3. Based on this assessment,
howshould the nurse characterize the client’s condition?
• The client has increased intracranial pressure
b . He has a good prognosis for recovery
c.This client is conscious, but is not oriented to time and place
d.He is in a coma, and has a very poor
prognosis Correct D
• A client who had a cerebral vascular accident (CVA)
Is paralyzed on the left side of the body and has developed a Stage II
pressure ulcer on the left hip. Which nursing diagnosis describes this
client’s current healthstatus?
• Risk for impaired tissue integrity related to impaired physical mobility
• Impaired skin integrity related to altered circulation and pressure
• Ineffective tissue perfusion related to inability to move self in bed.
• Impaired physical mobility related to the left side
paralysis Correct B
,• The nurse offers diet teaching to a female college student who was
diagnosedwith iron-deficiency anemia following her voluntary adoption
of a lacto-vegetarian diet. What nutrients should the nurse suggest this
client eat to best meet her nutritional needs while allowing her to
adhere to a lacto-vegetarian diet?
• Drink whole milk instead of skim milk to enhance the body’s
production ofamino acids
• Take vitamin K 10mg PO daily to enhance production of red blood cells
• Increase amounts of dark yellow vegetables such as carrots to fortify
ironstores
• Combine several legumes and grains such as beans and rice
to form complete proteins
Correct D
• The nurse is triaging clients from a train wreck. A client has multiple
open wounds, a blood pressure of 90/56, and a pulse of 112
beats/minute. Which triagetag color should the nurse place on this
client?
• Black
• Yellow
,• Green
• Red
Correc
tD
• Which action should the nurse include in the plan of care a
client who is receiving acyclovir (Zovirax) IV for treatment
of herpes zoster (shingles)?
• Initiate cardiac telemetry monitoring
• Maintain continuously pulse oximetry
• Perform capillary glucose measurements
• Monitor serum creatinine
levels Correct D
• A client receiving amlodipine (Norvasc), a calcium channel blocker,
develops 1+pitting edema around the ankles. It is most important for
the nurse to obtain what additional client data?
• Bladder distention
• Serum albumin level
• Abdominal girth
• Breath sounds
Correct D
• A male adult client is transferred to a psychiatric facility following
release from the hospital for treatment of a self-inflicted gunshot
, wound. In attempting to developa therapeutic relationship with this
client, which information is most important for thenurse to determine?
• The family’s reaction to this situation
• The nurse’s feeling about this client
• What losses the client recently experienced
• Why the client attempted to kill
himself Correct B
• Which client requires careful nursing assessment for signs and
symptoms of hypomagnesaemia?
• A young adult client with intractable vomiting from food poisoning
• A client who developed hyperparathyroidism in late adolescence
• A middle-age male client in renal failure following an
unsuccessful kidney transplant
• A female client who is overzealous with her intake of simple
carbohydrates Correct C
• While assessing a client who is experiencing Cheyne-Stokes
respirations, thenurse observes periods of apnea. What action
should the nurse implement?
• Elevate the head of the client’s head
• Auscultate the client’s breath sound
• Measure the length of the apneic periods
• Suction the client’s
oropharynx Correct C
