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1. A nurse is reviewing the laboratory results for a client who is at 32 gesta-
tions. For which of the following results should the nurse notify the provider?
a. Hgb 12 g/dL
b. Platelet count 90,000/mm2
c. Hematocrit 37%
d. Creatinine 0.7 mg/dl: b. Platelet count 90,000/mm2
2. After receiving change-of-shift report, which of the following clients should
the nurse collect data from first? a. A client who has a history of pancreatitis
and reports severe abdominal pain b. A client who has heart failure and
reports severe dyspnea c. A client who is scheduled for abdominal surgery in
1 hrs d. A postoperative client who has diabetes mellitus and a blood glucose
of 280 mg/dK: b. A client who has heart failure and reports severe dyspnea
3. A nurse is preparing a client for surgery. The client tells the nurse that he
is concerned about the safety of a large sum of money in his wallet. Which of
the following actions is appropriate for the nurse to take?
a. Place the money in an envelope and lock it in the client's medication drawer
b. Contact security personnel to place the money in the facility safe c. Hold
the money for the client until he returns from surgery
d. Label the money and leave it with the unit secretary.: b. Contact security
personnel to place the money in the facility safe
4. A nurse is preparing to instill an optic suspension into an adult client' ear.
Which of the following methods should the nurse plan to use?
a. Pull the auricle upward and outward.
b. Pull the auricle downward and backward.
c. Pull the auricle upward and backward.
d. Pull the auricle downward an outward: c. Pull the auricle upward and backward.
5. 5. A nurse is caring for an older adult client who has pneumonia. When
reinforcing teaching about the diagnosis age- related changes with the client's
family, which of the following alterations should the nurse include?
a. Increased inflation of the basilar lungs
b. Increased elasticity of the thoracic cage
c. Hypertrophy of the bronchial mucous gland
d. Hyperactive cough reflex: b. Increased elasticity of the thoracic cage
6. A client is participating in an anger management session explain that his
recent behavior is related to his job loss. Which of the following mechanism
is the client using?
a. Projection
b. Rationalism
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c. Repression
d. Sublimation: b. Rationalism
7. A nurse is reinforcing teaching with the client who is about to undergo
a thoracentesis. Which if the following statement by the client indicates an
understanding of the information?
a. "I will have general anesthesia during the procedure."
b. "I will lie flat for 6 hours before the procedure."
c. "I will have the chest x-ray following the procedure."
d. "I will breathe deeply through my nose during the procedure.: c. "I will have
the chest x-ray following the procedure."
8. A nurse is reviewing the medical record of a client who is requesting an oral
contraceptive. Which of the following findings should the nurse identify as a
contraindication to the use of oral contraceptive? a. History of renal calculi
b. Migraines with aura
c. BMI of 26
d. History of cholecystectomy: a. History of renal calculi
9. . A nurse is reinforcing discharge teaching about transmission precautions
with a client who has Hepatitis C. Which of the following information should
the nurse include?
a. Avoid sharing razors with other family members.
b. clean toilet surfaces with bleach after each use
c. Advice family members to receive a hepatitis c immunization
d. Do not prepare food for other family member s while infectious: a. Avoid
sharing razors with other family members.
10. A nurse is preparing to administer an IM injection to a client. To reduce
the risk of a needle stick injury, the nurse should take which of the following
actions?
a. Place a cap holds securely on the used needle a before disposal. b. Recap
the needle using a one-handed scoop approach before proper disposal.
c. Dispose of the used needle immediately in a puncture proof sharps contain-
er.
d. Detach and dispose of the use needle promptly following injection: c. Dis-
pose of the used needle immediately in a puncture proof sharps container.
11. A nurse is reinforcing teaching with a client who has new prescription for
levothyroxine. Which of the following statements indicates understanding of
the instructions?
a. "I should take this medication with meals."
b. This medication will take 2 weeks to reach full effectiveness."
c. "I need to take this medication for the rest of my life."
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d. "If I forget to take the medication, I can double the next dose.": c. "I need to
take this medication for the rest of my life."
12. A nurse is caring for a client who is receiving prazosin. The client's blood
pressure is 100/60 mm Hg. which of the following actions should the nurse
take?
a. Administer a reversal agent
b. Initiate cardiac monitoring
c. Instruct the client to stand up slowly
d. Inform the client to report urinary retention: c. Instruct the client to stand up
slowly
13. A nurse is reinforcing teaching about colostomy care with a client. Which
of the following client statements indicate an understanding of how to care
for the colostomy?
a. I will cleanse the stoma site gently with an antiseptic solution.
b. I will contact my doctor right away if my stoma is red
c. I will cut the water opening 1 inch bigger than my stoma.
d. I will empty the colostomy bag when one half is full: d. I will empty the
colostomy bag when one half is full
14. A nurse is reinforcing teaching with a client who has a permanent pace-
maker in place. Which of the following statements by the client indicates an
understanding of the teaching?
a. "I should have my doctor replace the battery in the pacemaker in a year."
b. "I need to record my pulse rate daily."
c. "I should avoid taking tub baths."
d. "I will remove my microwave oven from my house.": b. "I need to record my
pulse rate daily."
15. A nurse is collecting data from a parent of a preschooler at a well-child vis-
it. Which of the following findings is a contraindication to a measles, mumps
and rubella (MMR) immunization?
a. Family history of allergies to penicillin
b. Erythema at injection site with previous immunization.
c. Long-term use of immunosuppressants
d. Current use of antimicrobial therapy.: c. Long-term use of immunosuppres-
sants
16. . A nurse is reinforcing teaching with a client who has a vitamin C defi-
ciency. Which of the following foods should the nurse include as having the
highest vitamin C content?
a. 1 cup yogurt
b. 1 cup raw broccoli
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c. 1 large baked potato
d. 1 cup boiled carrots: b. 1 cup raw broccoli
17. A nurse is checking the home environment of a client for safety hazards.
Which of the following items require intervention by the nurse?
a. The television set is turned to a loud volume
b. The dining room table has low chairs with no armrests
c. The bedroom extension cord is placed under a heavy nightstand
d. The living room contains wall to wall carpeting.: a. The television set is turned
to a loud volume
18. 18. A nurse is caring for a 17-yr. old client who is admitted for an emergency
appendectomy. Which of the following is an appropriate action by the nurse in
obtaining informed consent?
a. Have the client's older sibling give consent if parent is not available.
b. Delay the procedure if the provider cannot contact the parents.
c. Witness the signature of the client's parents when he arrives.
d. Obtain verbal consent from the client while waiting for the parents to
arrive: a. Have the client's older sibling give consent if parent is not available.
19. A nurse is reinforcing teaching with a parent about appropriate snacks for
a toddler. Which of the following food should the nurse include?
a. Marshmallows
b. Graham crackers
c. Almonds
d. Carrot sticks: b. Graham crackers
20. A nurse is preparing to catheterize a client's bladder to check for residual
urine. The nurse should schedule this procedure at which of the following
times?
a. Right after the client void
b. When the client feels an urge to void
c. While voiding on a bedpan
d. Before obtaining a bladder scan.: a. Right after the client void
21. A nurse is caring for a client who has viral pneumonia. Which of the
following actions should the nurse take?
a. Place the client in a private room
b. Administer azithromycin
c. Recommend a pneumococcal immunization.
d. Limit fluid intake to 1L per day: a. Place the client in a private room
22. 22. A nurse is collecting data from a client who has diabetes mellitus.
Which of the following indicates the client might be experiencing diabetic
ketoacidosis?
Study online at https://quizlet.com/_c5wl5l
1. A nurse is reviewing the laboratory results for a client who is at 32 gesta-
tions. For which of the following results should the nurse notify the provider?
a. Hgb 12 g/dL
b. Platelet count 90,000/mm2
c. Hematocrit 37%
d. Creatinine 0.7 mg/dl: b. Platelet count 90,000/mm2
2. After receiving change-of-shift report, which of the following clients should
the nurse collect data from first? a. A client who has a history of pancreatitis
and reports severe abdominal pain b. A client who has heart failure and
reports severe dyspnea c. A client who is scheduled for abdominal surgery in
1 hrs d. A postoperative client who has diabetes mellitus and a blood glucose
of 280 mg/dK: b. A client who has heart failure and reports severe dyspnea
3. A nurse is preparing a client for surgery. The client tells the nurse that he
is concerned about the safety of a large sum of money in his wallet. Which of
the following actions is appropriate for the nurse to take?
a. Place the money in an envelope and lock it in the client's medication drawer
b. Contact security personnel to place the money in the facility safe c. Hold
the money for the client until he returns from surgery
d. Label the money and leave it with the unit secretary.: b. Contact security
personnel to place the money in the facility safe
4. A nurse is preparing to instill an optic suspension into an adult client' ear.
Which of the following methods should the nurse plan to use?
a. Pull the auricle upward and outward.
b. Pull the auricle downward and backward.
c. Pull the auricle upward and backward.
d. Pull the auricle downward an outward: c. Pull the auricle upward and backward.
5. 5. A nurse is caring for an older adult client who has pneumonia. When
reinforcing teaching about the diagnosis age- related changes with the client's
family, which of the following alterations should the nurse include?
a. Increased inflation of the basilar lungs
b. Increased elasticity of the thoracic cage
c. Hypertrophy of the bronchial mucous gland
d. Hyperactive cough reflex: b. Increased elasticity of the thoracic cage
6. A client is participating in an anger management session explain that his
recent behavior is related to his job loss. Which of the following mechanism
is the client using?
a. Projection
b. Rationalism
, vati finals
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c. Repression
d. Sublimation: b. Rationalism
7. A nurse is reinforcing teaching with the client who is about to undergo
a thoracentesis. Which if the following statement by the client indicates an
understanding of the information?
a. "I will have general anesthesia during the procedure."
b. "I will lie flat for 6 hours before the procedure."
c. "I will have the chest x-ray following the procedure."
d. "I will breathe deeply through my nose during the procedure.: c. "I will have
the chest x-ray following the procedure."
8. A nurse is reviewing the medical record of a client who is requesting an oral
contraceptive. Which of the following findings should the nurse identify as a
contraindication to the use of oral contraceptive? a. History of renal calculi
b. Migraines with aura
c. BMI of 26
d. History of cholecystectomy: a. History of renal calculi
9. . A nurse is reinforcing discharge teaching about transmission precautions
with a client who has Hepatitis C. Which of the following information should
the nurse include?
a. Avoid sharing razors with other family members.
b. clean toilet surfaces with bleach after each use
c. Advice family members to receive a hepatitis c immunization
d. Do not prepare food for other family member s while infectious: a. Avoid
sharing razors with other family members.
10. A nurse is preparing to administer an IM injection to a client. To reduce
the risk of a needle stick injury, the nurse should take which of the following
actions?
a. Place a cap holds securely on the used needle a before disposal. b. Recap
the needle using a one-handed scoop approach before proper disposal.
c. Dispose of the used needle immediately in a puncture proof sharps contain-
er.
d. Detach and dispose of the use needle promptly following injection: c. Dis-
pose of the used needle immediately in a puncture proof sharps container.
11. A nurse is reinforcing teaching with a client who has new prescription for
levothyroxine. Which of the following statements indicates understanding of
the instructions?
a. "I should take this medication with meals."
b. This medication will take 2 weeks to reach full effectiveness."
c. "I need to take this medication for the rest of my life."
, vati finals
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d. "If I forget to take the medication, I can double the next dose.": c. "I need to
take this medication for the rest of my life."
12. A nurse is caring for a client who is receiving prazosin. The client's blood
pressure is 100/60 mm Hg. which of the following actions should the nurse
take?
a. Administer a reversal agent
b. Initiate cardiac monitoring
c. Instruct the client to stand up slowly
d. Inform the client to report urinary retention: c. Instruct the client to stand up
slowly
13. A nurse is reinforcing teaching about colostomy care with a client. Which
of the following client statements indicate an understanding of how to care
for the colostomy?
a. I will cleanse the stoma site gently with an antiseptic solution.
b. I will contact my doctor right away if my stoma is red
c. I will cut the water opening 1 inch bigger than my stoma.
d. I will empty the colostomy bag when one half is full: d. I will empty the
colostomy bag when one half is full
14. A nurse is reinforcing teaching with a client who has a permanent pace-
maker in place. Which of the following statements by the client indicates an
understanding of the teaching?
a. "I should have my doctor replace the battery in the pacemaker in a year."
b. "I need to record my pulse rate daily."
c. "I should avoid taking tub baths."
d. "I will remove my microwave oven from my house.": b. "I need to record my
pulse rate daily."
15. A nurse is collecting data from a parent of a preschooler at a well-child vis-
it. Which of the following findings is a contraindication to a measles, mumps
and rubella (MMR) immunization?
a. Family history of allergies to penicillin
b. Erythema at injection site with previous immunization.
c. Long-term use of immunosuppressants
d. Current use of antimicrobial therapy.: c. Long-term use of immunosuppres-
sants
16. . A nurse is reinforcing teaching with a client who has a vitamin C defi-
ciency. Which of the following foods should the nurse include as having the
highest vitamin C content?
a. 1 cup yogurt
b. 1 cup raw broccoli
, vati finals
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c. 1 large baked potato
d. 1 cup boiled carrots: b. 1 cup raw broccoli
17. A nurse is checking the home environment of a client for safety hazards.
Which of the following items require intervention by the nurse?
a. The television set is turned to a loud volume
b. The dining room table has low chairs with no armrests
c. The bedroom extension cord is placed under a heavy nightstand
d. The living room contains wall to wall carpeting.: a. The television set is turned
to a loud volume
18. 18. A nurse is caring for a 17-yr. old client who is admitted for an emergency
appendectomy. Which of the following is an appropriate action by the nurse in
obtaining informed consent?
a. Have the client's older sibling give consent if parent is not available.
b. Delay the procedure if the provider cannot contact the parents.
c. Witness the signature of the client's parents when he arrives.
d. Obtain verbal consent from the client while waiting for the parents to
arrive: a. Have the client's older sibling give consent if parent is not available.
19. A nurse is reinforcing teaching with a parent about appropriate snacks for
a toddler. Which of the following food should the nurse include?
a. Marshmallows
b. Graham crackers
c. Almonds
d. Carrot sticks: b. Graham crackers
20. A nurse is preparing to catheterize a client's bladder to check for residual
urine. The nurse should schedule this procedure at which of the following
times?
a. Right after the client void
b. When the client feels an urge to void
c. While voiding on a bedpan
d. Before obtaining a bladder scan.: a. Right after the client void
21. A nurse is caring for a client who has viral pneumonia. Which of the
following actions should the nurse take?
a. Place the client in a private room
b. Administer azithromycin
c. Recommend a pneumococcal immunization.
d. Limit fluid intake to 1L per day: a. Place the client in a private room
22. 22. A nurse is collecting data from a client who has diabetes mellitus.
Which of the following indicates the client might be experiencing diabetic
ketoacidosis?
