CC PROCTOR 4 (C)

1. A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the client's coccyx and abrasions around the wrists. Which of the following actions should the nurse take to address the suspicions of elder abuse? A. Inform the transferring agency of the client's condition. B. Privately interview the client about her condition. C. Notify risk management D. Contact the family regarding the client's condition. - B. Privately interview the client about her condition. 2. A nurse is caring for a client following a stroke. The client has right-sided weakness and facial drooping. Which of the following nursing actions is the priority? a. Maintain NPO status for client(ABC) b. Change client's position every 2 hours c. Perform range-of-motion exercises to client's extremities. d. Place the clients right hand in supination position. - a. Maintain NPO status for client(ABC) 3. A community health nurse is teaching a client who has type 1 diabetes mellitus and is 10 weeks of gestation about managing diabetes during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? A. "I will decrease my protein intake during the third trimester"( increase protein for basic growth) B. "I will need to increase my insulin doses later in my pregnancy" C. "I will increase my carbs at breakfast and limit them the rest of the day" D. "I will decrease my calorie consumption during the first trimester"(increase calorie) - B. "I will need to increase my insulin doses later in my pregnancy" 4. A home health nurse is preparing to assess a client who reports tingling around the mouth and laxative use at least once daily. Which of the following assessments should the nurse perform first? a. Test the client for Trousseau's sign b. Assess the client's skin turgor c. Check the client's motor strength d. Measure the client's pupil size - a. Test the client for Trousseau's sign 5. A nurse is teaching a client who has an ileostomy about the care of his stoma site. Which of the following statements by the client requires further teaching? A. "I should clean my stoma with warm water"( can use low ph soap and water) B. " My stoma should be bright pink or red"(pink,red and moist) C. "I should change the stoma pouch every day" D. "I should cut my pouch opening 1⁄8 inch larger than my stoma"(allow expansion) - C. "I should change the stoma pouch every day" 6. A nurse is assessing a client who is receiving magnesium sulfate by continuous IV infusion. Which of the following findings should the nurse recognize as a result of magnesium sulfate toxicity? A. Hyporeflexia B. Tachypnea( bradypnea, less than 12/min) C. Pruritus( sign of allergic reaction) D. Polyuria (oliguria, less than 30 ml/hr) - A. Hyporeflexia 7. A nurse is planning to administer ampicillin 100 mg/kg/day in divided doses every 12 hours to a newborn who weighs 4.34 kg(9.5 lbs). Available is ampicillin 125mg/ml. How many milliliters should the nurse administer per dose? ( Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero) - 1.7 mL per dose 100mg X 4.34 kg= 434 mg/day 434mg/125mgX1=3.472/day 3.472/2= 1.736 8. A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make? A. "Your desire to be an organ donor must be documented in writing" B. "I cannot be a witness for your consent to donate" C. "You must be at least 21 years of age to become an organ donor" D. "Your name cannot be removed once you are listed on the organ donor list - A. "Your desire to be an organ donor must be documented in writing" 9. A nurse is admitting a client who has acute heart failure. Which of the following prescriptions from the provider should the nurse anticipate? A. Administer enalapril 2.5 mg PO twice daily B. Ambulate the client every 4 hr while awake(bedrest) C. Provide the client with 4 g sodium diet( D. Infuse 0.9% sodium chloride 500 mL IV bolus over 1 hr - A. Administer enalapril 2.5 mg PO twice daily 10. A nurse is collecting a specimen for urinalysis and culture from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take during collection? A. Drain the specimen from the drainage bag(not sterile use the port for culture and UA) B. Clamp the catheter distal to the injection port C. Collect 2 mL of urine for each specimen D. Obtain the urinalysis specimen before the culture specimen - B. Clamp the catheter distal to the injection port 11. A nurse is caring for a client who reports diarrhea for 3 days. The nurse should monitor the client for which of the following manifestations? A. Orthostatic Hypertension B. Dependent Edema C. Decreased Hematocrit D. Neck Vein Distension - A. Orthostatic Hypertension 12. A nurse is devdeloping an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder? A. The client is overly concerned about minor details. B. The client exhibits impulsive behavior. C. The client is exceptionally clingy to others. D. The client may act seductively.- histrionic - B. The client exhibits impulsive behavior. 13. A nurse is assessing a client who is 36 weeks of gestation. Which of the following findings should the nurse report to the provider? A. 3+ deep tendon reflexes (common finding in women with preeclampsia and does not require action unless there are symptoms of magnesium toxicity.) B. Protruding Hemorrhoids C. Urinary Frequency (expected) D. Supine Hypotension - B. Protruding Hemorrhoids 14. A nurse is administering an analgesic to a client who has a chest tube. The provider is preparing to discontinue the chest tube before the medication has taken affect. Which of the following actions should the nurse prepare to take first? A. Inform the provider of the time of the last dose of pain medication. B. Document the sequence of events as they occur. C. Provide non-pharmacological pain management interventions. D. Instruct the client about the steps of the procedure. - A. Inform the provider of the time of the last dose of pain medication. 15. A nurse in a PACU is transferring care of a client to a nurse on the medicalsurgical unit. Which of the following statements should the nurse include in the hand-off report? A. The client was intubated without complications. B. The estimated blood loss was 250 milliliters. C. There was a total of 10 sponges used during the procedures. D. The client is a member of the board of directors. - B. The estimated blood loss was 250 milliliters.