Exam 160 Questions and Verified Correct
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The nurse is providing care for a client with severe peripheral arterial disease (PAD). The
client reports a history of rest ischemia, with leg pain that occurs during the night. Which
action should the nurse take in response to this finding?
A. Elevate the legs to assess for color changes
B. Provide a heating pad for PRN use
C. Offer cold packs when the pain occurs
D. Suggest dangling the legs when pain occurs - answer>>>C. Offer cold packs when the
pain occurs
The nurse assess a client being treated for Herpes zoster (shingles). Which assessments
should the nurse include when evaluating the effectiveness of the the treatment? (Select
all that apply)
A. Functional ability
B. Skin integrity
C. Pain scale
D. Bowel sounds
E. heart sounds - answer>>>A. Functional ability
B. Skin integrity
A heparin infusion is prescribed for a client who weighs 220 pounds. After administering a
bolus dose of 80 units/kg, the nurse calculates the infusion rate for the heparin solution
at 18 units/kg/hr. The available solution is Heparin Sodium 25,000 units in 5% Dextrose
injection 250mL. The nurse should program the infusion pump to deliver how many
mL/hour? - answer>>>18
When providing client care the nurse identifies a problem and develops a related clinical
question. Next, the nurse intends to gather evidence so that the decision-making process
in response to the problem and clinical question is evidence-based. When gathering
evidence, which consideration is most important?
A. Past experience with similar problems
B. Relevance to the situation
C. Related personal values
,D. Frequency that the problem occurs - answer>>>B. Relevance to the situation
A client diagnosed with calcium kidney stones has a history of gout. A new prescription
for aluminum hydroxide is scheduled to begin at 0730. Which client medication should
the nurse bring to the healthcare provider's attention?
A. Esinapril
B. Allopurinol
C. Furosemide
D. Aspirin, low dose - answer>>>B. Allopurinol
A client with urge incontinence was treated with onabotuilinumtoxinA injections and is
now experiencing urinary retention. Which action should the nurse include in the client's
plan of care?
A. Provide a bedside commode for immediate use in the client's room
B. Teach the client techniques for performing intermittent catheterization
C. Explain the need to limit intake of oral fluids to reduce client discomfort
D. Remind the client to practice pelvic floor (Kegel) exercises regularly - answer>>>D.
Remind the client to practice pelvic floor (Kegel) exercises regularly
After a spider bite on the lower extremity, a client is admitted for treatment of an
infection that is spreading up the leg. Which admission assessment findings should the
nurse report to the healthcare provider? (Select all that apply)
A. Location of the initial IV site
B. Red blood cell count (RBC)
C. Swollen lymph nodes in the groin
D. White blood cell count (WBC)
E. Core body temperature - answer>>>C. Swollen lymph nodes in the groin
D. White blood cell count (WBC)
E. Core body temperature
The home care nurse visits a client who has cancer. The client reports having a good
appetite but experiencing nausea when smelling food cooking. Which action should the
nurse implement?
A. Encourage family members to cook meals outdoors and bring the cooked food inside
B. Assess the client's mucous membranes and report the findings to the healthcare
provider
C. Advise the client to replace cooked foods with a variety of different nutritional
supplements
,D. Instruct the client to take an antiemetic before every meal to prevent excessive
vomiting - answer>>>A. Encourage family members to cook meals outdoors and bring the
cooked food inside
The nurse is wearing personal protective equipment (PPE) while caring for a client. When
exiting the room, which PPE should be removed first?
A. Gloves
B. Mask
C. Eyewear
D. Gown - answer>>>A. Gloves
An older male client, who is a retired chef, is hospitalized with a diabetic ulcer on his foot.
His daughter tells the nurse that her father has become increasingly obsessed with the
way his food is prepared in the hospital. The nurse's response should be based on what
information?
A. The client probably has an organic brain disease and will likely have Alzheimer's disease
within a few years
B. The family needs a social worker to talk to them about how to handle their father when
he becomes annoying
C. The daughter is under stress and should be encouraged to think about happier times
D. If the client was compulsive about food when he was younger, the aging process can
magnify this - answer>>>D. If the client was compulsive about food when he was
younger, the aging process can magnify this
A client is receiving enoxaparin 30mg subcutaneously twice a day. In assessing for adverse
effects of the medication, which serum laboratory value is most important for the nurse
to monitor?
A. Glucose
B. Calcium
C. Platelet count
D. White blood cell count - answer>>>C. Platelet count
The nurse is caring for a 24-month-old toddler who has sensory sensitivity, difficulty
engaging in social interactions, and has not yet spoken two-word phrases. Which
assessment should the nurse administer?
A. The modified checklist for autism in toddlers (M-CHAT)
B. Psychology Systems Questionnaire (PHQ-2)
C. Behavioral Style Questionnaire (BSQ)
, D. The Ages and Stages Questionnaire (ASQ) - answer>>>A. The Modified Checklist for
Autism in Toddlers (M-CHAT)
Prior to surgery, written consent must be obtained. Which is the nurse's legal
responsibility with regard to obtaining written consent?
A. Explain the surgical procedure to the client and ask the client to sign the consent form
B. Ask the client or a family member to sign the surgical consent form
C. Determine that the surgical consent form has been signed and is included in the client's
record.
D. Validate the client's understanding of the surgical procedure to be conducted -
answer>>>C. Determine that the surgical consent form has been signed and is included in
the client's record
A client with hyperthyroidism is admitted to the postoperative unit after a subtotal
thyroidectomy. Which of the client's serum laboratory values requires intervention by the
nurse?
A. T3- uptake at 50%
B. Glucose 150 mg/dL
C. Total calcium 5.0 mg/dL
D. Thyroxine 12 mcg/dL - answer>>>C. Total calcium 5.0 mg/dL
A client in the third trimester of pregnancy reports that she fells some "lumpy places" in
her breasts and that her nipples sometimes leak a yellowish fluid. She has an
appointment with her healthcare provider in two weeks. What action should the nurse
take?
A. Tell the client to begin nipple stimulation to prepare for breast feeding.
B. Reschedule the client's prenatal appointment for the following day
C. Explain that this normal secretion can be assessed at the next visit
D. Recommend that the client start wearing a supportive brassiere - answer>>>C. Explain
that this normal secretion can be assessed at the next visit
While the nurse is assessing an older client's fall risk, the client reports living at home
alone and never falling. Which action should the nurse take?
A. Inform the client that falls occur more often in the hospital than at home
B. Record a minimal risk for falls, documenting the client's statement
C. Continue to obtain client data needed to complete the fall risk survey
D. Place the client on a high fall risk protocol because of advanced age - answer>>>C.
Continue to obtain client data needed to complete the fall risk survey