Q & A FULLY ANSWERED
A nurse is caring for a client who is receiving a blood transfusion. the client becomes
restless, dyspneic, and has crackles noted to the lung bases. Which of the following
actions should the nurse anticipate taking?
a. administer an antihistamine
b. slow the infusion rate.
c. give the client a corticosteroid
d. elevate the clients lower extremities - (CORRECT ANSWER)B. slow the infusion
rate
A nurse is caring fro a client who is 4 hr postoperative following an open reduction
internal fixation of the right ankle. Which of the following assessment findings should
the nurse report to the provider?
a. extremity cool upon palpation
b. serosanguineous drainage on the dressing
c. capillary refill of 2 seconds
d. client report of discomfort when moving toes - (CORRECT ANSWER)A. extremity
cool upon palpation
A nurse is caring for a client who has increased ICP and is receiving mannitol via
continuous IV infusion. The nurse should report which of the following adverse
effects of this medication to the provider?
a. Rhinitis
b. crackles heard on auscultation
c. increased urinary output
d. decreased deep tendon reflexes - (CORRECT ANSWER)B. crackles heard on
auscultation
a nurse is providing teaching to a client who take ginkgo biloba as an herbal
supplement. Which of the following statements should the nurse make?
a. "ginkg biloba relieves nausea for people who hace vertigo."
b."taking ginkgo biloba will help relieve your joint pain.
c. ginkgo biloba can cause an increased risk for bleeding
d. taking ginkgo biloba decreased the risk of migraine headahce - (CORRECT
ANSWER)C. risk for bleeding
a nurse is teaching a client who has a cardiac dysrhythmia about the purpose of
undergoing continuous telemetry monitoring. Which of the following statements by
the client reflects an understand of the teaching?
a. this measures how much blood my heart is pumping
b. this identifies if i have a defective heart valve
c. this identifies if the pacemaker cells of my heart are working properly
d. this measures the blood circulating to my heart muscle - (CORRECT ANSWER)c.
this identifies if the pacemaker cells of my heart are working properly
a nures is caring for a client who has a potassium level of 3 mEq/L. Which of the
following assessment finding should the nurse expect?
a. postivie trousseau's sign
b. 4+ deep tendon reflexes
c. deep respirations
, d. hypoactive bowel sounds - (CORRECT ANSWER)D. hypoactive bowel sounds
a nurse is caring fro a client who is receiving TPN and is NPO. When reviewing the
chart, the nurse notes the following prescription: capillary blood glucose AC and HS.
Which of the following actions should the nurse take?
a. check the clients blood glucose according to facility mealtimes
b. contact the primary care provider to clarify the prescription
c. request for meal to be provided for the client
d. hold the prescription until the client is no longer NPO - (CORRECT ANSWER)B.
contact the primary care provider to clarify the prescription
a nurse is reviewing the lab results of a client who has AIDS and is taking
amphotericin B for fungal infection. The nurse should identify that which of the
following values is an indication of an adverse effect of the medication
a. potassium 4.8
b. magnesium 1.7
C. BUN 34
D. hematocrit 45% - (CORRECT ANSWER)C. BUN 34
a nurse is assessing a client who has Cushing's disease. Which of the following
findings should the nurse expect?
a. muscle atrophy
b. ataxia
c. weight loss
d. hypotension - (CORRECT ANSWER)a. muscle atrophy
a nurse is caring fro a clinet who has DKA. Which of the following should the nurse
plan to administer
a. 240 mL (8oz) of orange juice
b. 1 ampule of 50% dextrose IV bolus
c. NPH insulin 60 units subq
D. regular insulin 20 units IV bolus - (CORRECT ANSWER)D. regular insulin 20
units IV bolus
A nurse is providing teaching to a client who has esophageal cancer and is to
undergo radiation therapy. Which of the following statements should the nurse
identify as an indication that the client understand the teaching?
a. I will wash the ink markings off the radiations area after each treatment
b. I will use my hands rather than a washcloth to clean the radiation area
c. I will be able to be out in the sun 1 month after my radiation treatment are over
d. I will use a heating pad on my neck if it becomes sore during the radiation therapy
- (CORRECT ANSWER)B i will use my hands rather than a washcloth to clean the
radiation area
a nurse is caring for a client who has amymtrophic lateral sclerosis (ALS) and is
being admitted tot he hospital with pneumonia. Which of the following assessment
findings is the nurses priority?
a. temp 38.4 (101.1)
b. increased respiratory secretions
c. fluid intake of 200 mL in the prior 8 hr
A nurse is caring for a client who is receiving a blood transfusion. the client becomes
restless, dyspneic, and has crackles noted to the lung bases. Which of the following
actions should the nurse anticipate taking?
a. administer an antihistamine
b. slow the infusion rate.
c. give the client a corticosteroid
d. elevate the clients lower extremities - (CORRECT ANSWER)B. slow the infusion
rate
A nurse is caring fro a client who is 4 hr postoperative following an open reduction
internal fixation of the right ankle. Which of the following assessment findings should
the nurse report to the provider?
a. extremity cool upon palpation
b. serosanguineous drainage on the dressing
c. capillary refill of 2 seconds
d. client report of discomfort when moving toes - (CORRECT ANSWER)A. extremity
cool upon palpation
A nurse is caring for a client who has increased ICP and is receiving mannitol via
continuous IV infusion. The nurse should report which of the following adverse
effects of this medication to the provider?
a. Rhinitis
b. crackles heard on auscultation
c. increased urinary output
d. decreased deep tendon reflexes - (CORRECT ANSWER)B. crackles heard on
auscultation
a nurse is providing teaching to a client who take ginkgo biloba as an herbal
supplement. Which of the following statements should the nurse make?
a. "ginkg biloba relieves nausea for people who hace vertigo."
b."taking ginkgo biloba will help relieve your joint pain.
c. ginkgo biloba can cause an increased risk for bleeding
d. taking ginkgo biloba decreased the risk of migraine headahce - (CORRECT
ANSWER)C. risk for bleeding
a nurse is teaching a client who has a cardiac dysrhythmia about the purpose of
undergoing continuous telemetry monitoring. Which of the following statements by
the client reflects an understand of the teaching?
a. this measures how much blood my heart is pumping
b. this identifies if i have a defective heart valve
c. this identifies if the pacemaker cells of my heart are working properly
d. this measures the blood circulating to my heart muscle - (CORRECT ANSWER)c.
this identifies if the pacemaker cells of my heart are working properly
a nures is caring for a client who has a potassium level of 3 mEq/L. Which of the
following assessment finding should the nurse expect?
a. postivie trousseau's sign
b. 4+ deep tendon reflexes
c. deep respirations
, d. hypoactive bowel sounds - (CORRECT ANSWER)D. hypoactive bowel sounds
a nurse is caring fro a client who is receiving TPN and is NPO. When reviewing the
chart, the nurse notes the following prescription: capillary blood glucose AC and HS.
Which of the following actions should the nurse take?
a. check the clients blood glucose according to facility mealtimes
b. contact the primary care provider to clarify the prescription
c. request for meal to be provided for the client
d. hold the prescription until the client is no longer NPO - (CORRECT ANSWER)B.
contact the primary care provider to clarify the prescription
a nurse is reviewing the lab results of a client who has AIDS and is taking
amphotericin B for fungal infection. The nurse should identify that which of the
following values is an indication of an adverse effect of the medication
a. potassium 4.8
b. magnesium 1.7
C. BUN 34
D. hematocrit 45% - (CORRECT ANSWER)C. BUN 34
a nurse is assessing a client who has Cushing's disease. Which of the following
findings should the nurse expect?
a. muscle atrophy
b. ataxia
c. weight loss
d. hypotension - (CORRECT ANSWER)a. muscle atrophy
a nurse is caring fro a clinet who has DKA. Which of the following should the nurse
plan to administer
a. 240 mL (8oz) of orange juice
b. 1 ampule of 50% dextrose IV bolus
c. NPH insulin 60 units subq
D. regular insulin 20 units IV bolus - (CORRECT ANSWER)D. regular insulin 20
units IV bolus
A nurse is providing teaching to a client who has esophageal cancer and is to
undergo radiation therapy. Which of the following statements should the nurse
identify as an indication that the client understand the teaching?
a. I will wash the ink markings off the radiations area after each treatment
b. I will use my hands rather than a washcloth to clean the radiation area
c. I will be able to be out in the sun 1 month after my radiation treatment are over
d. I will use a heating pad on my neck if it becomes sore during the radiation therapy
- (CORRECT ANSWER)B i will use my hands rather than a washcloth to clean the
radiation area
a nurse is caring for a client who has amymtrophic lateral sclerosis (ALS) and is
being admitted tot he hospital with pneumonia. Which of the following assessment
findings is the nurses priority?
a. temp 38.4 (101.1)
b. increased respiratory secretions
c. fluid intake of 200 mL in the prior 8 hr
