CAT 2
A 12 year old boy who is 54" tall is scheduled for x-rays of his hands and wrist to determine
growth patterns. The mother asked the RNY. A set of these x-rays is being taken. What
explanation is best for the nurse to provide this mother? - ANS-Hormonal influences on the
phone at this age can be determined by x-ray
A 2-year-old child with celiac disease experience a relapse of symptoms. In developing a
teaching plan for the child's family, which topic should be the nurse's primary focus? -
ANS-Dietary management
A client at 32 weeks gestation reports to the clinic nurse that she has a new onset of bright
red, painless, vaginal, bleeding. Which intervention should the nurse implement? -
ANS-Position the client in the side-lying position.
A client has started long-term maintenance therapy with a cardiotonic medication that has a
narrow therapeutic index. Teaching the client, the signs and symptoms of which adverse
effect is most important? - ANS-Toxicity
A client in the first trimester of pregnancy calls the nurse to report she has symptoms of a
cold and wants to know if it is safe for her to take the herb Echinacea. What instruction
should the nurse provide this client? - ANS-Avoid using herbs during the first trimester of
pregnancy
A client is admitted to the rehab center after having a stroke involving the Broca's area of
the left cerebral cortex. Based on the location of this stroke, which limitation should the
nurse anticipate this client will have? - ANS-Difficulty in speech articulation
A client is receiving morphine sulfate 1 mg q10 minutes with a lockout dose of 24 mg per 4
hours via an intravenous PCA pump. Which record, found on the PCA pump history,
indicates that the client has used the PCA pump effectively during the previous hour? -
ANS-5 attempts: 5 mg administered
A client receiving O2 at 2L/minute per nasal cannula has a change in oxygen saturation
from 92% at 0800 to 88% at 1200, but there is no change in respiratory rate during this same
time period. What action should the nurse take first? - ANS-Apply the pulse oximeter to a
different finger
A client who was in a house fire is brought to the ED. Which assessment findings should
the nurse respond to first? - ANS-The clients voice is hoarse and nasal hair is singed
A chest tube connected to a section at 20 cm H2O pressure is in the fourth intercostal
space for a patient with a hemothorax. Which patient should the nurse consider to be within
normal limits four hours after insertion? - ANS-Fluctuation with Respiration in the pleuravac's
waterseal chamber A client with a peptic ulcer disease (PUD) is admitted to the emergency
room, complaining of sudden severe upper abdominal pain. Assessment indicates an
extremely tender and rigid admin, blood pressure of 90/60 mmHg, and a pulse of 110 bpm.
The emergency department nurse should've dissipate implementation of which intervention?
- ANS-Preparing the client for emergency abdominal surgery
A client with an exacerbation of systemic lupus erythematous (SLE) is admitted for
parenteral corticosteroid therapy. What factor is most important for the nurse to consider
when assigning a room for this client? The client - ANS-Should not share a room with a
client who has an infection
, A client with depression remains in bed most of the day, declines activities, and refuses
meals. Which nursing diagnosis is most important to this client? ANS - Deficit in self-care A
female client is admitted to the psychiatric department on an emergency commitment. The
client's husband asks the RN, "What is going to happen to my wife? Can I take her home
now?" Which information should the RN provide? - ANS-Hospitalization is mandated until a
mental health court hearing is held
A female client who had a kidney transplant five hours ago is receiving replacement IV fluids
to match your an output. She has had 950 milliliters, urine output over the last hour, and has
a weak, irregular pulse. The electrocardiogram indicates occasional preventricular
contractions (PVC), what is the highest priority nursing action? - ANS-Assess serum
electrolytes
A high fluid intake is prescribed for a client with your urolithiasis. The client wishes to know
what the chief purpose for this intervention. What should the nurse tell the client about this
prescription? - ANS-The purpose is to increase the hydrostatic pressure behind the stone to
assist in its downward passage
A male client had a thyroidectomy 24 hours ago, and I'm now complains of cramping in the
hand of the arm where his BP is being taken. The nurse knows that his hand is twitching.
What intervention should the nurse implement first? - ANS-Review the client serum calcium
level
Morning cardiac catheterization is scheduled for a male patient. Which interventions should
the nurse plan to implement prior to this procedure? - ANS-Inform the client that he may
experience a flushed feeling throughout his body when the dye is injected
A male client, who is in end stage renal disease and has been on a waiting list for a
transplant for over one year, is told his condition is now terminal. He tells the nurse that he
found a website with a kidney for sale and asks the nurse where he can a tissue match
analysis. What is the nurses' ethical responsibility? - ANS-Inform the client that it is a
criminal offense to purchase organs in the United States
A male college student returns to the student health center one week after receiving a
positive mono spot for mononucleosis I request a prescription for amoxicillin. He has a
febrile and complains of fatigue, a sore throat, dysphasia, and extremely swollen glands.
What response to the nurse provide? - ANS-Clarify that these symptoms will not respond to
antibiotic therapy
An educational program on healthy eating for high school students was created by a nurse.
The program consisted of a series of four classes. What finding is indicative of a a program
outcome? - ANS-Overweight student lost an average of often pounds by the program's end
A nurse is interviewing a client with a history of COPD, who is dyspneic and has a
respiratory rate of 36 breaths per minute. Which nursing diagnosis has the highest priority? -
ANS-Impaired verbal communication
A nurse manager at a long-term facility is concerned about the health for the nursing staff.
Which program should the nurse-manager institute first? - ANS-Provide lift devices for
immobile clients
A nurse seeks to alter a provision of a state's Nurse Practice regarding nurse-client ratios,
which the nurse believes to be unsafe. What action is most likely to impact a ruling by the
state's Board of Nursing? - ANS-Meet with the nurse's representative to the state legislature
A one-year-old with neuroblastoma is crying continuously and is curled into a fetal position.
What action is most important for the nurse to implement? - ANS-Give a prescribed
analgesic
A 12 year old boy who is 54" tall is scheduled for x-rays of his hands and wrist to determine
growth patterns. The mother asked the RNY. A set of these x-rays is being taken. What
explanation is best for the nurse to provide this mother? - ANS-Hormonal influences on the
phone at this age can be determined by x-ray
A 2-year-old child with celiac disease experience a relapse of symptoms. In developing a
teaching plan for the child's family, which topic should be the nurse's primary focus? -
ANS-Dietary management
A client at 32 weeks gestation reports to the clinic nurse that she has a new onset of bright
red, painless, vaginal, bleeding. Which intervention should the nurse implement? -
ANS-Position the client in the side-lying position.
A client has started long-term maintenance therapy with a cardiotonic medication that has a
narrow therapeutic index. Teaching the client, the signs and symptoms of which adverse
effect is most important? - ANS-Toxicity
A client in the first trimester of pregnancy calls the nurse to report she has symptoms of a
cold and wants to know if it is safe for her to take the herb Echinacea. What instruction
should the nurse provide this client? - ANS-Avoid using herbs during the first trimester of
pregnancy
A client is admitted to the rehab center after having a stroke involving the Broca's area of
the left cerebral cortex. Based on the location of this stroke, which limitation should the
nurse anticipate this client will have? - ANS-Difficulty in speech articulation
A client is receiving morphine sulfate 1 mg q10 minutes with a lockout dose of 24 mg per 4
hours via an intravenous PCA pump. Which record, found on the PCA pump history,
indicates that the client has used the PCA pump effectively during the previous hour? -
ANS-5 attempts: 5 mg administered
A client receiving O2 at 2L/minute per nasal cannula has a change in oxygen saturation
from 92% at 0800 to 88% at 1200, but there is no change in respiratory rate during this same
time period. What action should the nurse take first? - ANS-Apply the pulse oximeter to a
different finger
A client who was in a house fire is brought to the ED. Which assessment findings should
the nurse respond to first? - ANS-The clients voice is hoarse and nasal hair is singed
A chest tube connected to a section at 20 cm H2O pressure is in the fourth intercostal
space for a patient with a hemothorax. Which patient should the nurse consider to be within
normal limits four hours after insertion? - ANS-Fluctuation with Respiration in the pleuravac's
waterseal chamber A client with a peptic ulcer disease (PUD) is admitted to the emergency
room, complaining of sudden severe upper abdominal pain. Assessment indicates an
extremely tender and rigid admin, blood pressure of 90/60 mmHg, and a pulse of 110 bpm.
The emergency department nurse should've dissipate implementation of which intervention?
- ANS-Preparing the client for emergency abdominal surgery
A client with an exacerbation of systemic lupus erythematous (SLE) is admitted for
parenteral corticosteroid therapy. What factor is most important for the nurse to consider
when assigning a room for this client? The client - ANS-Should not share a room with a
client who has an infection
, A client with depression remains in bed most of the day, declines activities, and refuses
meals. Which nursing diagnosis is most important to this client? ANS - Deficit in self-care A
female client is admitted to the psychiatric department on an emergency commitment. The
client's husband asks the RN, "What is going to happen to my wife? Can I take her home
now?" Which information should the RN provide? - ANS-Hospitalization is mandated until a
mental health court hearing is held
A female client who had a kidney transplant five hours ago is receiving replacement IV fluids
to match your an output. She has had 950 milliliters, urine output over the last hour, and has
a weak, irregular pulse. The electrocardiogram indicates occasional preventricular
contractions (PVC), what is the highest priority nursing action? - ANS-Assess serum
electrolytes
A high fluid intake is prescribed for a client with your urolithiasis. The client wishes to know
what the chief purpose for this intervention. What should the nurse tell the client about this
prescription? - ANS-The purpose is to increase the hydrostatic pressure behind the stone to
assist in its downward passage
A male client had a thyroidectomy 24 hours ago, and I'm now complains of cramping in the
hand of the arm where his BP is being taken. The nurse knows that his hand is twitching.
What intervention should the nurse implement first? - ANS-Review the client serum calcium
level
Morning cardiac catheterization is scheduled for a male patient. Which interventions should
the nurse plan to implement prior to this procedure? - ANS-Inform the client that he may
experience a flushed feeling throughout his body when the dye is injected
A male client, who is in end stage renal disease and has been on a waiting list for a
transplant for over one year, is told his condition is now terminal. He tells the nurse that he
found a website with a kidney for sale and asks the nurse where he can a tissue match
analysis. What is the nurses' ethical responsibility? - ANS-Inform the client that it is a
criminal offense to purchase organs in the United States
A male college student returns to the student health center one week after receiving a
positive mono spot for mononucleosis I request a prescription for amoxicillin. He has a
febrile and complains of fatigue, a sore throat, dysphasia, and extremely swollen glands.
What response to the nurse provide? - ANS-Clarify that these symptoms will not respond to
antibiotic therapy
An educational program on healthy eating for high school students was created by a nurse.
The program consisted of a series of four classes. What finding is indicative of a a program
outcome? - ANS-Overweight student lost an average of often pounds by the program's end
A nurse is interviewing a client with a history of COPD, who is dyspneic and has a
respiratory rate of 36 breaths per minute. Which nursing diagnosis has the highest priority? -
ANS-Impaired verbal communication
A nurse manager at a long-term facility is concerned about the health for the nursing staff.
Which program should the nurse-manager institute first? - ANS-Provide lift devices for
immobile clients
A nurse seeks to alter a provision of a state's Nurse Practice regarding nurse-client ratios,
which the nurse believes to be unsafe. What action is most likely to impact a ruling by the
state's Board of Nursing? - ANS-Meet with the nurse's representative to the state legislature
A one-year-old with neuroblastoma is crying continuously and is curled into a fetal position.
What action is most important for the nurse to implement? - ANS-Give a prescribed
analgesic
