The nurse prepares a teaching plan for a client who experienced anaphylaxis after receiving
a dose of penicillin. Which steps will the nurse inform the client to take if anaphylaxis occurs
in the future? (Please arrange in order. All options must be used.)
Have 2 epinephrine autoinjectors available a all times
Administer one injection of epinephrine
Leave the epinephrine injector in place for 10 seconds
Call 911 for transport to the emergency department
Bring the used autoinjector to the emergency department
Two nurses, who work together on an orthopedic unit, are involved in a disagreement. The
disagreement has caused tension among all staff members resulting in decreased morale on
the unit. Which initial action by the unit manager is appropriate when handling this
situation? (Select all that apply.)
1 Speak with both nurses individually.
.
2 Place both nurses on a performance plan.
.
3 Suggest one nurse transfer to another unit.
.
4 Serve as a mediator in a meeting with both nurses.
.
5 Speak to all staff members to gather facts about the
. disagreement.
6 Consult with risk management.
.
4 Distract and redirect to a different activity.
.
The nurse teaches a client about the use of a walker following hip replacement surgery.
Which statement, if made by the client, requires follow-up by the nurse? (Select all that
apply.)
1 “I will stand and hold on to my walker until I feel steady.”
.
2 “I will back up to the chair until it touches the back of my legs and then
. sit down.”
3 “I will lean over the handles of the walker while moving my feet forward.”
.
4 “I will remove all throw rugs from my house.”
.
, 5 “I will wear shoes with leather soles.”
.
A client is terminally ill and days away from death. The hospice nurse wants to help
the client cope by discussing end-of-life needs. Which topic is appropriate to
discuss at the end of life? (Select all that apply.)
1 Who should inherit the client’s estate.
.
2 The client’s interest in active euthanasia.
.
3 The client’s desire for a cure from current
. illness.
4 The effects of dehydration.
.
5 The possibility of hallucinations.
.
6 Fears of the unknown.
.
A client who is reporting persistent lower back pain requests a pain medication.
After reviewing the client’s medication administration record, the nurse informs the
client that the next dose of pain medication is not due for several hours. Which
non-pharmacological intervention is appropriate for the nurse to offer? (Select all
that apply.)
1 A lidocaine patch to place on the painful area.
.
2 A heating pad to place on the painful area.
.
3 A gentle massage with a muscle-relaxing cream on the painful
. area.
4 Repositioning in bed to relieve pressure from the painful area.
.
5 Aromatherapy to provide a distraction from the pain.
.
A nurse provides care for a client who was admitted to the mental health unit
following a suicide attempt. When talking to the sibling of the client, which
,question is appropriate for assessing the family dynamics? (Select all that
apply.)
1.
“How long has your family lived at the current address?”
2.
“Who would you describe as the leader of the family?”
3.
“How did you react to your sibling’s suicide attempt?”
4.
“What do you think caused your sibling’s suicidal intentions?”
5.
“What would you describe as a strength of the family?”
6.
“What is something you think should change in your family?”
The nurse provides care for a client who has undergone an abdominal
hysterectomy. Which interventions will the nurse include in the client’s plan of
care? (Select all that apply.)
1.
Changing the client’s position at least every 2 hours.
2.
Monitoring the client’s urine output.
3.
Eliminating food and fluid intake for 24 hours.
4.
Assessing the client’s perineal pads for bleeding.
5.
, Encouraging the client to perform leg exercises.
The nurse receives a phone call from a caller who states a bomb is in the hospital.
Which action does the nurse take when handling this situation? (Select all that
apply.)
1 Ask the caller about the location of the device.
.
2 Hang up and notify security.
.
3 Inquire about what will make it explode.
.
4 Talk firmly, demanding respect from the caller.
.
5 Move any suspicious package.
.
The nurse provides care to a client diagnosed with Paget disease. Which findings
are anticipated by the nurse as characteristic of this disorder? (Select all that
apply.)
1 A vitamin D deficiency.
.
2 An elevated serum alkaline phosphatase.
.
3 A pathologic fracture.
.
4 A loss of total bone mass and substance.
.
5 An abnormal remodeling and resorption of bone.
.
The nurse prepares to administer newly prescribed clonazepam and meloxicam to
the client. Upon assessment, the client reports hives and difficulty breathing after
taking midazolam and oxycodone years ago. Which actions will the nurse
implement? (Select all that apply.)
1 Holds the clonazepam.
a dose of penicillin. Which steps will the nurse inform the client to take if anaphylaxis occurs
in the future? (Please arrange in order. All options must be used.)
Have 2 epinephrine autoinjectors available a all times
Administer one injection of epinephrine
Leave the epinephrine injector in place for 10 seconds
Call 911 for transport to the emergency department
Bring the used autoinjector to the emergency department
Two nurses, who work together on an orthopedic unit, are involved in a disagreement. The
disagreement has caused tension among all staff members resulting in decreased morale on
the unit. Which initial action by the unit manager is appropriate when handling this
situation? (Select all that apply.)
1 Speak with both nurses individually.
.
2 Place both nurses on a performance plan.
.
3 Suggest one nurse transfer to another unit.
.
4 Serve as a mediator in a meeting with both nurses.
.
5 Speak to all staff members to gather facts about the
. disagreement.
6 Consult with risk management.
.
4 Distract and redirect to a different activity.
.
The nurse teaches a client about the use of a walker following hip replacement surgery.
Which statement, if made by the client, requires follow-up by the nurse? (Select all that
apply.)
1 “I will stand and hold on to my walker until I feel steady.”
.
2 “I will back up to the chair until it touches the back of my legs and then
. sit down.”
3 “I will lean over the handles of the walker while moving my feet forward.”
.
4 “I will remove all throw rugs from my house.”
.
, 5 “I will wear shoes with leather soles.”
.
A client is terminally ill and days away from death. The hospice nurse wants to help
the client cope by discussing end-of-life needs. Which topic is appropriate to
discuss at the end of life? (Select all that apply.)
1 Who should inherit the client’s estate.
.
2 The client’s interest in active euthanasia.
.
3 The client’s desire for a cure from current
. illness.
4 The effects of dehydration.
.
5 The possibility of hallucinations.
.
6 Fears of the unknown.
.
A client who is reporting persistent lower back pain requests a pain medication.
After reviewing the client’s medication administration record, the nurse informs the
client that the next dose of pain medication is not due for several hours. Which
non-pharmacological intervention is appropriate for the nurse to offer? (Select all
that apply.)
1 A lidocaine patch to place on the painful area.
.
2 A heating pad to place on the painful area.
.
3 A gentle massage with a muscle-relaxing cream on the painful
. area.
4 Repositioning in bed to relieve pressure from the painful area.
.
5 Aromatherapy to provide a distraction from the pain.
.
A nurse provides care for a client who was admitted to the mental health unit
following a suicide attempt. When talking to the sibling of the client, which
,question is appropriate for assessing the family dynamics? (Select all that
apply.)
1.
“How long has your family lived at the current address?”
2.
“Who would you describe as the leader of the family?”
3.
“How did you react to your sibling’s suicide attempt?”
4.
“What do you think caused your sibling’s suicidal intentions?”
5.
“What would you describe as a strength of the family?”
6.
“What is something you think should change in your family?”
The nurse provides care for a client who has undergone an abdominal
hysterectomy. Which interventions will the nurse include in the client’s plan of
care? (Select all that apply.)
1.
Changing the client’s position at least every 2 hours.
2.
Monitoring the client’s urine output.
3.
Eliminating food and fluid intake for 24 hours.
4.
Assessing the client’s perineal pads for bleeding.
5.
, Encouraging the client to perform leg exercises.
The nurse receives a phone call from a caller who states a bomb is in the hospital.
Which action does the nurse take when handling this situation? (Select all that
apply.)
1 Ask the caller about the location of the device.
.
2 Hang up and notify security.
.
3 Inquire about what will make it explode.
.
4 Talk firmly, demanding respect from the caller.
.
5 Move any suspicious package.
.
The nurse provides care to a client diagnosed with Paget disease. Which findings
are anticipated by the nurse as characteristic of this disorder? (Select all that
apply.)
1 A vitamin D deficiency.
.
2 An elevated serum alkaline phosphatase.
.
3 A pathologic fracture.
.
4 A loss of total bone mass and substance.
.
5 An abnormal remodeling and resorption of bone.
.
The nurse prepares to administer newly prescribed clonazepam and meloxicam to
the client. Upon assessment, the client reports hives and difficulty breathing after
taking midazolam and oxycodone years ago. Which actions will the nurse
implement? (Select all that apply.)
1 Holds the clonazepam.
