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A nurse is caring for a client who is at 33 weeks of gestation following an D. Administer epinephrine - ANSWER-B. Defibrillate
amniocentesis. The nurse should monitor the client for which of the following
complications? A. Vomiting A nurse is admitting a client who 1 week postpartum and reports excessive
vaginal bleeding. The nurse does not speak the same language as the client. The
B. Hypertension
client's partner and 10-year-old child are accompanying her. Which of the
C. Epigastric pain following actions should the nurse take to gather the client's admission data?
D. Contractions - ANSWER-D. Contractions
A. Have the client's child translate
B. Allow the client's partner to translate
A nurse is providing teaching to an older adult client about methods to promote
C. Request a female interpreter through the facility
nighttime sleep. Which of the following instructions should the nurse include?
D. Ask a nursing student who speaks the same language as the client to translate -
A. Stay in bed at least 1 hr if unable to fall asleep ANSWER-C. Request a female interpreter through the facility
B. Take a 1 hr nap during the day
C. Perform exercises prior to bedtime A nurse is caring for a client who is febrile. To reduce the client's fever, the nurse
applies a cooling blanket. Which of the following findings indicates the client is
D. Eat a light snack before bedtime - ANSWER-D. Eat a light snack before bedtime having an adverse reaction to the cooling?
a. Flushing
A nurse on a telemetry unit is caring for a client who becomes unconscious and b. Tachycardia
whose monitor displays ventricular tachycardia. Which of the following actions
should the nurse take first after determining the client does not have a palpable c. Restlessness
pulse?
d. Shivering - ANSWER-d. Shivering
A. Assess heart sounds
B. Defibrillate
C. Establish IV access
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A nurse is caring for a client who has deep-vein-thrombosis of the left lower Consume foods high in potassium- restrict - ANSWER-a. Eat 1 g/kg of protein per
extremity. Which of the following actions should the nurse take? (Exhibit) A. day
Position the client with the affected extremity lower than the heart
B. Withhold heparin IV infusion PTT- 30-40 seconds; x2 if on heparin A nurse is caring for a client who is receiving intermittent enteral tube feedings.
C. Administer acetaminophen Which of the following places the client at risk for aspiration?
D. Massage the affected extremity every 4 hr - ANSWER-B. Withhold heparin IV A. Sitting in a high-Fowler's position during the feeding
infusion PTT- 30-40 seconds; x2 if on heparin B. A history of gastroesophageal reflux disease
C. Receiving a high osmolarity formula
A nurse is reviewing assessment data from several clients. For which of the D. A residual of 65 mL 1 hr postprandial? - ANSWER-B. A history of
following clients should the nurse recommend referral to a dietitian? gastroesophageal reflux disease
A. An older adult client who has a BMI of 24
B. A client who has a nonhealing leg ulcer ?A nurse is providing prenatal teaching to a client who is at 12 weeks of gestation.
C. An older adult client who has presbyopia The nurse should tell the client that she will undergo which of the following
screening tests at 16 weeks of gestation?
D. A client who has an albumin level of 3.7 g/dL (normal 3.4-5.4) - ANSWER-B. A
client who has a nonhealing leg ulcer A. Chorionic villus sampling- as early as 8 weeks
B. Cervical cultures for chlamydia- 1st appointment.
8. A nurse is providing discharge teaching to a client who has a chronic kidney C. Nonstress test -28 weeks
disease and is receiving hemodialysis. Which of the following instructions should D. Maternal serum alpha-fetoprotein- 16 to 18 weeks - ANSWER-D. Maternal
the nurse include in the teaching? serum alpha-fetoprotein- 16 to 18 weeks
a. Eat 1 g/kg of protein per day
b. Take magnesium hydroxide for indigestion A nurse is caring for a client who is on bed rest. The nurse should recognize that
c. Drink at least 3 L of fluid daily- which of the following findings is a complication of immobility?
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A. Decreased serum calcium levels- increased serum calcium C "Limit your child's potassium intake while she is taking this medication."
B. Increased blood pressure- hypotension D "Have your child drink a small glass of water after swallowing the
medication." - ANSWER-D "Have your child drink a small glass of water after
C. Swollen area on calf swallowing the medication."
D. Urinary frequency- - ANSWER-C. Swollen area on calf
A nurse is providing teaching to a client who has a depressive disorder and a new
12. A nurse in acute care mental health facility is participating in a prescription for phenelzine. Which of the following foods should the nurse
medicationeducation group. The leader of the group uses a laissez-faire instruct the client to avoid?
leadership style. Which of the following actions should the nurse expect from the
leader during the session? A. Grapefruit
A .The leader encourages group members to remain silent until questions are B. Spinach
called for
C. Cottage cheese- cream cheese ok.
B. The leader lecture about medication adverse effects to the group members
D. Smoked salmon - ANSWER-D. Smoked salmon
c. The leader allows the group to discuss whatever they would like to
regarding their medications
A nurse is planning care for a client who has COPD and weighs 99 lb. The provider
d. The leader has group members vote on what they would like to learn has prescribed a diet of a 1.5 g protein/kg/day. How many grams of protein per
about during the session - ANSWER-d. The leader has group members vote on day should the nurse include in the client's dietary plan? (Round to the nearest
what they would like to learn about during the session whole number - ANSWER-a. 68
A nurse is providing teaching about digoxin administration to the parents of a A nurse is planning care for a client who has bipolar disorder and is experiencing
toddler who has heart failure. Which of the following statements should the nurse mania. Which of the following interventions should the nurse include in the plan?
include in the teaching?
A. Encourage the client to spend time in the day room
A "You can add the medication to a half-cup of your child's favorite juice."
B. Withdraw the client's TV privileges if he does not attend group therapy X
B "Repeat the dose if your child vomits within 1 hour after taking medication." X
C. Encourage the client to take frequent rest periods
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D. Place the client in seclusion when he exhibits signs of anxiety X - ANSWER-C. d. Place documentation of the nurses' actions in the personnel file - ANSWER-a
Encourage the client to take frequent rest periods Instruct the nurses to close the client's computer record
A parish nurse is leading a support group for clients whose family members have A nurse is reviewing the medical record of a client who has schizophrenia and is
committed suicide. Which of the following strategies should the nurse plan to use taking clozapine. Which of the following findings should the nurse identify as a
during the group session? contraindication to the administration of clozapine?
a Encourage clients to establish a timeline for their own grieving process
a. Heart rate 58/min
b. Initiate a discussion with clients about ways to cope with changes in family
b. Fasting blood glucose 100 mg/dL
dynamics
c. Hgb 14 g/dL
d. WBC count 2,900/mm3- also agranulocytosis same thing or soar throat. -
c Discourage clients from sharing negative aspects of their relationship with ANSWER-d. WBC count 2,900/mm3- also agranulocytosis same thing or soar
the deceased persons throat.
d Assist clients in identifying ways suicide could have been prevented -
ANSWERb. Initiate a discussion with clients about ways to cope with changes in A nurse is caring for several clients on a medical-surgical unit. For which of the
family following nurses activities is it required that the nurse use sterile gloves?
a. Inserting an NG tube
A nurse manager observes two staff nurses reviewing the computer records of a b. Administering total parenteral nutrition through a central venous access device
client who is not under their care. Which of the following actions should the nurse c. Initiating IV access
manager take first?
a Instruct the nurses to close the client's computer record b d. Performing tracheostomy care - ANSWER-d. Performing tracheostomy care
Request the nurses present an in-service on client confidentiality
A nurse is caring for a client who is at 11 weeks of gestation. Which of the
c. Advise the nurses to read the facility's confidentiality policyd.
following immunizations should the nurse give?