1 A nurse is caring for an older adult client newly diagnosed with osteoarthritis. Which
of the following medications should the nurse anticipate giving as the primary
medication of choice?
Ketorolac (Toradol)
Celecoxib (Celebrex)
Propoxyphene (Darvon)
Acetaminophen (Tylenol)
2 A nurse is caring for a client who sustained a spinal cord injury. The client is
reporting a severe headache and has a blood pressure of 160/110 mm Hg. Which of
the following should the nurse do first?
Notify the primary care provider.
Monitor blood pressure every 15 min.
Check for urinary bladder distention.
Administer a prescribed analgesic.
3 A nurse is providing instructions to a client who is scheduled to undergo a
paracentesis. Which of the following instructions is appropriate at this time?
"You need to increase your intake of water after this procedure."
"You can expect to have a course of antibiotics after this procedure."
"You should find it easier to breathe after this procedure."
"You should empty your bladder after this procedure."
4 A nurse is teaching a client who has just had an acute episode of cholecystitis about
dietary changes that might help prevent future attacks. The nurse should teach the
client to avoid eating
steamed rice.
fried eggs.
, whole grain bread.
baked fish.
5 When providing care for a client with an AV graft, the nurse should assess the
affected extremity for
proximal pulses.
palpable thrill. ?
blood pressure.
lymph node enlargement.
6 A client has just returned from surgery with an external fixator to the left tibia.
Which of the following assessment findings requires immediate intervention by the
nurse?
The client has a pain rating of 7 at the operative site.
The client has 100 mL of blood in the Hemovac.
The client has an oral temperature of 38.3° C (101° F).
The client's capillary refill in the left toe is 6 sec.
7 A nurse is caring for four clients. Which of the following clients is at the highest risk
for developing metabolic alkalosis?
A client receiving laxatives and enemas for gastrointestinal surgery prep
A client with an AV fistula receiving hemodialysis
A client with a chest tube and a three-chamber drainage system
A client receiving mechanical ventilation via an endotracheal tube
8 A client is receiving continuous bladder irrigation following a transurethral resection
of the prostate. The nurse assesses decreased irrigation outflow, and the client reports
increased suprapubic discomfort. Which of the following is the appropriate nursing
intervention?
, Apply traction on the catheter to control bleeding.
Flush the catheter with sterile NS solution.
Administer a prescribed urinary antispasmodic.
Decrease the flow rate of the irrigant.
9 A young adult client is being evaluated in the emergency department for bacterial
meningitis. The nurse should do which of the following as part of the focused
assessment?
Gently elevate the head and note any nuchal rigidity.
Tap the client’s facial nerve and note any facial twitching.
Strike the patellar tendon with a percussion hammer and note any increase in
response.
Run a tongue blade on the outside of the client’s sole and note any flaring of
the toes.
10 Which of the following statements made by a client indicates a good understanding
of the discharge teaching the nurse provided regarding care of a tracheostomy?
"I'll cut a slit in a clean gauze pad to use as a stoma dressing."
"I'll deflate the cuff before I start eating and inflate it after I eat." ?
"I should suction my tracheostomy three times a day."
"I'll cleanse the stoma site with half-strength hydrogen peroxide and saline."
11 Which of the following orders by the primary care provider should a nurse question
related to the care of a client with a newly inserted chest tube?
Administer meperidine (Demerol) 25 mg IV push every 3 hr PRN.
Clamp the tube close to the client for 20 min each day.
Assist the client out of bed to the chair three times a day for 30 min.
Reinforce the dressing if it becomes soiled.
of the following medications should the nurse anticipate giving as the primary
medication of choice?
Ketorolac (Toradol)
Celecoxib (Celebrex)
Propoxyphene (Darvon)
Acetaminophen (Tylenol)
2 A nurse is caring for a client who sustained a spinal cord injury. The client is
reporting a severe headache and has a blood pressure of 160/110 mm Hg. Which of
the following should the nurse do first?
Notify the primary care provider.
Monitor blood pressure every 15 min.
Check for urinary bladder distention.
Administer a prescribed analgesic.
3 A nurse is providing instructions to a client who is scheduled to undergo a
paracentesis. Which of the following instructions is appropriate at this time?
"You need to increase your intake of water after this procedure."
"You can expect to have a course of antibiotics after this procedure."
"You should find it easier to breathe after this procedure."
"You should empty your bladder after this procedure."
4 A nurse is teaching a client who has just had an acute episode of cholecystitis about
dietary changes that might help prevent future attacks. The nurse should teach the
client to avoid eating
steamed rice.
fried eggs.
, whole grain bread.
baked fish.
5 When providing care for a client with an AV graft, the nurse should assess the
affected extremity for
proximal pulses.
palpable thrill. ?
blood pressure.
lymph node enlargement.
6 A client has just returned from surgery with an external fixator to the left tibia.
Which of the following assessment findings requires immediate intervention by the
nurse?
The client has a pain rating of 7 at the operative site.
The client has 100 mL of blood in the Hemovac.
The client has an oral temperature of 38.3° C (101° F).
The client's capillary refill in the left toe is 6 sec.
7 A nurse is caring for four clients. Which of the following clients is at the highest risk
for developing metabolic alkalosis?
A client receiving laxatives and enemas for gastrointestinal surgery prep
A client with an AV fistula receiving hemodialysis
A client with a chest tube and a three-chamber drainage system
A client receiving mechanical ventilation via an endotracheal tube
8 A client is receiving continuous bladder irrigation following a transurethral resection
of the prostate. The nurse assesses decreased irrigation outflow, and the client reports
increased suprapubic discomfort. Which of the following is the appropriate nursing
intervention?
, Apply traction on the catheter to control bleeding.
Flush the catheter with sterile NS solution.
Administer a prescribed urinary antispasmodic.
Decrease the flow rate of the irrigant.
9 A young adult client is being evaluated in the emergency department for bacterial
meningitis. The nurse should do which of the following as part of the focused
assessment?
Gently elevate the head and note any nuchal rigidity.
Tap the client’s facial nerve and note any facial twitching.
Strike the patellar tendon with a percussion hammer and note any increase in
response.
Run a tongue blade on the outside of the client’s sole and note any flaring of
the toes.
10 Which of the following statements made by a client indicates a good understanding
of the discharge teaching the nurse provided regarding care of a tracheostomy?
"I'll cut a slit in a clean gauze pad to use as a stoma dressing."
"I'll deflate the cuff before I start eating and inflate it after I eat." ?
"I should suction my tracheostomy three times a day."
"I'll cleanse the stoma site with half-strength hydrogen peroxide and saline."
11 Which of the following orders by the primary care provider should a nurse question
related to the care of a client with a newly inserted chest tube?
Administer meperidine (Demerol) 25 mg IV push every 3 hr PRN.
Clamp the tube close to the client for 20 min each day.
Assist the client out of bed to the chair three times a day for 30 min.
Reinforce the dressing if it becomes soiled.
