and Answers
A nurse is preparing a client who speaks limited English for surgery. What is the most appropriate
nursing action in obtaining informed consent from this client? - Correct answer Seek the assistance of a
nurse on the floor who is fluent in the client's language (nurse is responsible for ensuring client
understands information regarding procedure)
What is the focus of the agency for Healthcare Research and Quality? - Correct answer To improve
quality of health care services for all populations, including low-income groups and minorities
What is the focus of the National Institutes of Health? - Correct answer Biomedical research to improve
the prevention, diagnosis, and treatment of specific diseases
A nurse is caring for a school-age child who is taking valprioc acid. The nurse should expect the provider
to order what test? - Correct answer Serum enzyme levels b/c valproic acid can cause hepatic toxicity
What should the nurse instruct a client when preparing for a thoracentesis? - Correct answer Avoid
coughing during procedure and lie still to avoid puncturing the pleura
What is pleurisy (pleuritis)? - Correct answer inflammation of the pleura
What is ginger tea used for in pregnant women? - Correct answer Decreasing episodes of nausea
A nurse is preparing to administer an IM injection to a client who is obese. What action should the nurse
take? - Correct answer Use the ventrogluteal site because it has a thick area of muscle
What does a sudden relief of pain in a client scheduled for an appendectomy indicate? - Correct answer
Peritonitis from a ruptured appendix
A nurse is teaching about adverse effects to a client starting captopril. What adverse effect should be
reported to provider? - Correct answer Cough, develops d/t buildup of bradykinin in lungs
,A nurse is caring for a client who has a Mg level of 2.7 mEq/L. What intervention should the nurse do? -
Correct answer Initiate continuous cardiac monitoring b/c client is hypermagnesemic and at risk for
cardiac dysrhythmias
What type of thyroidism are tremors a manifestation of? - Correct answer Hyperthyroidism
What is dry, coarse hair a manifestation of? - Correct answer hypothyroidism
What is periorbital edema a manifestation of? - Correct answer hypothyroidism
A nurse is planning care for a client who has RA and has moderate-severe pain in multiple joints. What
actions should the nurse take? - Correct answer -Take frequent rest periods throughout day (while also
exercising regularly to maintain muscle strength, joint function, and ROM)
-Use ice to reduce inflammation and pain
-
What is the expected reference range for urine osmolality? - Correct answer 50-1200 mOsm/kg
A nurse is preparing to teach about dietary management to a client who has Crohn's disease and an
enteroenteric fistula. What nutrient should the nurse tell the client to decrease in diet? - Correct answer
Fiber. To help reduce diarrhea and inflammation
What are rhonchi? - Correct answer Dry, low-pitched, snore-like noises produced in the throat or
bronchial tube d/t a partial obstruction such as by secretions
What is thrombophlebitis? - Correct answer inflammation of a vein with clot formation. Common
complication of immobility often showing up in calf
Dilated pupils are a manifestation of what type of withdrawal? - Correct answer Opioid withdrawal
, Is it possible for you to get rheumatic fever twice? - Correct answer Yes, so prophylactic treatment with
monthly IM injections of benzathine penicillin G or dialy oral doses of penicillin or sulfadiazine will be
needed
A nurse is caring for a client who is prescribed lithium (Eskalith). What clinical finding should be
immediately reported to the provider? - Correct answer Slurred speech (can precipitate seizures or
coma)
What characterizes antisocial personality disorder? - Correct answer Reckless disregard for self and
others, impulsivity, deceitfulness, lack of remorse, consistent irresponsibility
What is the Romberg test? - Correct answer Tests the client's equilibrium, client stands with feet
together and arms at sides eyes open and then closed. Client should be able to maintain the position for
20 secs with minimal or no swaying
What does paradoxical chest movement indicate? - Correct answer flail chest
When should an ileostomy pouch be emptied? - Correct answer When it is 1/3 to 1/2 full to prevent
stool leakage and skin irritation
What does an albumin level of 2.8 indicate? - Correct answer malnutrition and need for nutritional
supplementation (albumin level below 3.5 g/dL)
What is the expected reference range for albumin? - Correct answer 3.5-5 g/dL
A nurse is caring for a client who is taking valproic acid for seizure control. For what adverse effect
should the nurse monitor and report? - Correct answer Jaundice b/c med places client at risk for liver
damage
Chest tube drainage should be how much per hour? - Correct answer <70 mL/hr
What does acute confusion, fatigue, lethargy, and anorexia indicate? - Correct answer Acute confusion