,When caring for a postsurgical client B
who has undergone multiple blood Rationale:
transfusions, which serum laboratory Multiple blood transfusions are a risk factor for
finding is of most concern to the hyperkalemia. A serum potassium level higher than
nurse? 5.0 mEq/L indicates hyperkalemia (B). The others
A.Sodium level, 137 mEq/L are normal findings (A, C, and D).
B.Potassium level, 5.5 mEq/L
C.Blood urea nitrogen (BUN) level,
18 mg/dL
D.Calcium level, 10 mEq/L
Which vaccination should the nurse A
administer to a newborn? Rationale:
A.Hepatitis B The hepatitis B vaccination should be given to all
B.Human papilloma virus (HPV) newborns before hospital discharge (A). HPV is not
C.Varicella recommended until adolescence (B). Varicella
D.Meningococcal vaccine immunization begins at 12 months (C).
Meningococcal vaccine is administered beginning
at 2 years (D).
The nurse is caring for a client on the B
medical unit. Which task can be Rationale:
delegated to unlicensed assistive Obtaining a fingerstick blood glucose level is a
personnel (UAP)? simple treatment and is an appropriate skill for UAP
A.Assess the need to change a to perform (B). (A, C, and D) are skills that cannot
central line dressing. be delegated to UAP.
B.Obtain a fingerstick blood glucose
level.
C.Answer a family member's
questions about the client's plan of
care.
D.Teach the client side effects to
report related to the current
medication regimen.
,The nurse is caring for a client with B,C,E
an ischemic stroke who has a Rationale:
prescription for tissue plasminogen Neurologic assessment, including the NIHSS, is
activator (t-PA) IV. Which action(s) indicated for the client receiving t-PA. This includes
should the nurse expect to close monitoring for bleeding during and after the
implement? (Select all that apply.) infusion; if bleeding or other signs of neurologic
A.Administer aspirin with tissue impairment occur, the infusion should be stopped
plasminogen activator (t-PA). (B, C, and E). Aspirin is contraindicated with t-PA
B.Complete the National Institute of because it increases the risk for bleeding (A). The
Health Stroke Scale (NIHSS). administration of t-PA within 6 hours of symptoms is
C.Assess the client for signs of concurrent with a diagnosis of a myocardial
bleeding during and after the infarction and within 4.5 hours of symptoms is
infusion. concurrent for a stroke (D).
D.Start t-PA within 6 hours after the
onset of stroke symptoms.
E.Initiate multidisciplinary consult for
potential rehabilitation.
When caring for a client in labor, B
which finding is most important to Rationale:
report to the primary health care A fetal heart rate (FHR) of 100 beats/min may
provider? indicate fetal distress (B) because the average FHR
A.Maternal heart rate, 90 beats/min. at term is 140 beats/min and the normal range is 110
B.Fetal heart rate, 100 beats/min to beats/min 160. The others (A, C, and D) are
C.Maternal blood pressure, 140/86 normal findings for a woman in labor.
mm Hg
D.Maternal temperature, 100.0° F
, The nurse is caring for a client with C
heart failure who develops Rationale:
respiratory distress and coughs up Positioning the patient in a high Fowler's position
pink frothy sputum. Which action with dangling feet will decrease further venous
should the nurse take first? return to the left ventricle (C). The other actions
A.Draw arterial blood gases. should be performed after the change in position
B.Notify the primary health care (A, B, and D).
provider.
C.Position in a high Fowler's position
with the legs down.
D.Obtain a chest X-ray.
A client who is prescribed A
chlorpromazine HCl (Thorazine) for Rationale:
schizophrenia develops rigidity, a Rigidity, shuffling gait, pill-rolling hand movements,
shuffling gait, and tremors. Which tremors, dyskinesia, and masklike face are
action by the nurse is most extrapyramidal side effects associated with
important?A.Administer a dose of Thorazine. It is most important for the nurse to
benztropine mesylate (Cogentin) administer an anticholinergic such as Cogentin to
PRN. reverse these effects (A). The others (B, C, D) may
B.Determine if the client has be appropriate interventions but are not as urgent
increased photosensitivity. as (A).
C.Provide comfort measures for sore
muscles.
D.Assess the client for visual and
auditory hallucinations.
who has undergone multiple blood Rationale:
transfusions, which serum laboratory Multiple blood transfusions are a risk factor for
finding is of most concern to the hyperkalemia. A serum potassium level higher than
nurse? 5.0 mEq/L indicates hyperkalemia (B). The others
A.Sodium level, 137 mEq/L are normal findings (A, C, and D).
B.Potassium level, 5.5 mEq/L
C.Blood urea nitrogen (BUN) level,
18 mg/dL
D.Calcium level, 10 mEq/L
Which vaccination should the nurse A
administer to a newborn? Rationale:
A.Hepatitis B The hepatitis B vaccination should be given to all
B.Human papilloma virus (HPV) newborns before hospital discharge (A). HPV is not
C.Varicella recommended until adolescence (B). Varicella
D.Meningococcal vaccine immunization begins at 12 months (C).
Meningococcal vaccine is administered beginning
at 2 years (D).
The nurse is caring for a client on the B
medical unit. Which task can be Rationale:
delegated to unlicensed assistive Obtaining a fingerstick blood glucose level is a
personnel (UAP)? simple treatment and is an appropriate skill for UAP
A.Assess the need to change a to perform (B). (A, C, and D) are skills that cannot
central line dressing. be delegated to UAP.
B.Obtain a fingerstick blood glucose
level.
C.Answer a family member's
questions about the client's plan of
care.
D.Teach the client side effects to
report related to the current
medication regimen.
,The nurse is caring for a client with B,C,E
an ischemic stroke who has a Rationale:
prescription for tissue plasminogen Neurologic assessment, including the NIHSS, is
activator (t-PA) IV. Which action(s) indicated for the client receiving t-PA. This includes
should the nurse expect to close monitoring for bleeding during and after the
implement? (Select all that apply.) infusion; if bleeding or other signs of neurologic
A.Administer aspirin with tissue impairment occur, the infusion should be stopped
plasminogen activator (t-PA). (B, C, and E). Aspirin is contraindicated with t-PA
B.Complete the National Institute of because it increases the risk for bleeding (A). The
Health Stroke Scale (NIHSS). administration of t-PA within 6 hours of symptoms is
C.Assess the client for signs of concurrent with a diagnosis of a myocardial
bleeding during and after the infarction and within 4.5 hours of symptoms is
infusion. concurrent for a stroke (D).
D.Start t-PA within 6 hours after the
onset of stroke symptoms.
E.Initiate multidisciplinary consult for
potential rehabilitation.
When caring for a client in labor, B
which finding is most important to Rationale:
report to the primary health care A fetal heart rate (FHR) of 100 beats/min may
provider? indicate fetal distress (B) because the average FHR
A.Maternal heart rate, 90 beats/min. at term is 140 beats/min and the normal range is 110
B.Fetal heart rate, 100 beats/min to beats/min 160. The others (A, C, and D) are
C.Maternal blood pressure, 140/86 normal findings for a woman in labor.
mm Hg
D.Maternal temperature, 100.0° F
, The nurse is caring for a client with C
heart failure who develops Rationale:
respiratory distress and coughs up Positioning the patient in a high Fowler's position
pink frothy sputum. Which action with dangling feet will decrease further venous
should the nurse take first? return to the left ventricle (C). The other actions
A.Draw arterial blood gases. should be performed after the change in position
B.Notify the primary health care (A, B, and D).
provider.
C.Position in a high Fowler's position
with the legs down.
D.Obtain a chest X-ray.
A client who is prescribed A
chlorpromazine HCl (Thorazine) for Rationale:
schizophrenia develops rigidity, a Rigidity, shuffling gait, pill-rolling hand movements,
shuffling gait, and tremors. Which tremors, dyskinesia, and masklike face are
action by the nurse is most extrapyramidal side effects associated with
important?A.Administer a dose of Thorazine. It is most important for the nurse to
benztropine mesylate (Cogentin) administer an anticholinergic such as Cogentin to
PRN. reverse these effects (A). The others (B, C, D) may
B.Determine if the client has be appropriate interventions but are not as urgent
increased photosensitivity. as (A).
C.Provide comfort measures for sore
muscles.
D.Assess the client for visual and
auditory hallucinations.
