Practice Questions And Verified
Answers
\Q\.A nurse in a telemetry unit is collecting data from a client who has a newly-inserted
permanent pacemaker. Which of the following findings should the nurse report to the provider?
The client experiences hiccups when sitting.
The client's pulse rate is 5/min faster than the preset pacemaker rate.
There is the presence of a pacing spike before the P-wave on the ECG rhythm strip.
The dressing over the insertion site is dry and intact. - ANSWERS✔-The client experiences
hiccups when sitting.
\Q\.Click to highlight the findings the nurse should report to the charge nurse immediately. To
deselect a finding, click on the finding again. - ANSWERS✔-• Perineal pad is saturated with
blood, and large clots are present is correct. The presence of vaginal bleeding and blood clots is
a manifestation of vaginal hemorrhage.
Therefore, the nurse should report this finding to the charge nurse.
• Blood pressure 98/56 mm Hg is correct. Decreased
blood pressure is a manifestation of vaginal hemorrhage.
Therefore, the nurse should report this finding to the charge nurse.
• Heart rate 102/min is correct, Tachycardia is a manifestation of vaginal hemorrhage.
Therefore, the nurse should report this finding to the charge nurse.
,\Q\.A nurse is assisting with the care for a client who reports shortness of breath and has an
oxygen saturation
90%. Which of the following actions should the nurse take? - ANSWERS✔-Administer oxygen via
nasal cannula
R: The nurse should administer oxygen via nasal cannula to a client who reports shortness of
breath and has an oxygen saturation below the expected reference range. The nurse should
continue to monitor the client and adjust the oxygen flow rate as needed.
\Q\.A nurse is reinforcing teaching with the caregiver of a client who is terminally ill about
manifestations of impending death. Which of the following manifestations should the nurse
include? - ANSWERS✔-Incontinence of the bowel and bladder.
Rationale:The nurse should inform the caregiver that incontinence of the bowel and bladder is a
manifestation of impending death. Other manifestations include hypotension, bradycardia,
restlessness, and coolness of the skin.
\Q\.A nurse in a clinic is collecting data from a client who has hyperthyroidism and has been
taking methimazole for 4 weeks. Which of the following statements by the client indicates a
therapeutic response to the medication? - ANSWERS✔-"I have gained 3 lbs since my last
appointment"
R: Hyperthyroidism can cause weight loss. Therefore, the nurse should identify weight gain as
an indication that the methimazole therapy has been effective
\Q\.A nurse is contributing to the plan of care for a client who is postoperative following a total
knee arthroplasty.
The client is using a continuous passive motion (CPM) machine. Which of the following
interventions should the nurse recommend for the plan of care? - ANSWERS✔-Keep a sheepskin
pad between the client's extremity and the CPM machine.
, R: The nurse should plan to keep a sheepskin pad between the dient's extremity and the cOM
madhune to protect the client's skin. The nurse should check the client's skin condition
frequendy wile the cient is using the CPM machine.
\Q\.A nurse is reinforcing teaching with a client about testicular self-examination. Which of the
following instructions should the nurse include in the teaching? - ANSWERS✔-"Perform
testicular self-examination after taking a warm shower."
Rationale: The nurse should instruct the client to perform testicular self-examination after
taking a warm shower or bath. This causes relaxation of the scrotal skin, which allows for better
palpation of the testes.
\Q\.A nurse is reinforcing discharge teaching for the caregivers of a client who has Parkinson's
disease. Which of the following information should the nurse include in the teaching? -
ANSWERS✔-Remind the client to avoid watching their feet when walking.
R: The nurse should remind the client's caregivers to frequently remind the client to maintain
correct posture and prevent falls by not watching their feet when walking.
\Q\.A home health nurse is assisting with the care for a client who has COPD. The client reports
shortness of breath while eating, despite the use of home oxygen. Which of the following
recommendations should the nurse make? - ANSWERS✔-"Use a bronchodilator 30 minutes
before your meal."
R: The dient should use a bronchodilator 30 min before meals to prevent shortness of breath
while eating.