Exam Questions and Verified Correct Answers
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A client has returned from a cardiac catheterization. Which one of the following assessments
would indicate the client is experiencing a complication from the procedure?
A) Increased blood pressure
B) Increased heart rate
C) Loss of pulse in the extremity
D) Decreased urine output - answer>>>C) Loss of pulse in the extremity
A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and
alert, but has not been able to void since he returned from surgery 6 hours ago.He received
1000 mL of IV fluid. Which action would be most likely to help him void?
A) Have him drink several glasses of water
B) Crede' the bladder from the bottom to the top
C) Assist him to stand by the side of the bed to void
D) Wait 2 hours and have him try to void again - answer>>>C) Assist him to stand by the side of
the bed to void
In planning care for a 6 month-old infant, what must the nurse provide to assist in the
development of trust?
A) Food
B) Warmth
C) Security
D) Comfort - answer>>>C) Security
The nurse is caring for a client who requires a mechanical ventilator for breathing.The high
pressure alarm goes off on the ventilator. What is the first action the nurse should perform?
A) Disconnect the client from the ventilator and use a manual resuscitation bag
,B) Perform a quick assessment of the client's condition
C) Call the respiratory therapist for help
D) Press the alarm re-set button on the ventilator - answer>>>B) Perform a quick assessment of
the client's condition
The nurse is preparing a client who will undergo a myelogram. Which of the following
statements by the client indicates a contraindication for this test?
A) "I can't lie in 1 position for more than thirty minutes.
"B) "I am allergic to shrimp."
C) "I suffer from claustrophobia.
"D) "I developed a severe headache after a spinal tap." - answer>>>"B) "I am allergic to
shrimp."
The health care provider order reads "aspirate nasogastric feeding (NG) tuber every 4 hours
and check pH of aspirate." The pH of the aspirate is 10. Which action should the nurse take?
A) Hold the tube feeding and notify the provider
B) Administer the tube feeding as scheduled
C) Irrigate the tube with diet cola soda
D) Apply intermittent suction to the feeding tube - answer>>>A) Hold the tube feeding and
notify the provider
To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must
A) Apply suction for no more than 10 seconds
B) Maintain sterile technique
C) Lubricate 3 to 4 inches of the catheter tip
D) Withdraw catheter in a circular motion - answer>>>A) Apply suction for no more than 10
seconds
An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection
equals 2.0 ml The correct action is to
A) Administer the medication in 2 separate injections
,B) Give the medication in the dorsal gluteal site
C) Call to get a smaller volume ordered
D) Check with pharmacy for a liquid form of the medication skip - answer>>>A) Administer the
medication in 2 separate injections
The nurse receives an order to give a client iron by deep injection. The nurse know that the
reason for this route is to
A) Enhance absorption of the medication
B) Ensure that the entire dose of medication is given
C) Provide more even distribution of the drug
D) Prevent the drug from tissue irritation Skip - answer>>>D) Prevent the drug from tissue
irritation Skip
A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find
when evaluating for the therapeutic effectiveness of this drug?
A) Diaphoresis with decreased urinary output
B) Increased heart rate with increase respirations
C) Improved respiratory status and increased urinary output D) Decreased chest pain and
decreased blood pressure - answer>>>C) Improved respiratory status and increased urinary
output
While providing home care to a client with congestive heart failure, the nurse is asked how long
diuretics must be taken. What is the nurse's best response?
A) "As you urinate more, you will need less medication to control fluid.
"B) "You will have to take this medication for about a year."
C) "The medication must be continued so the fluid problem is controlled.
"D) "Please talk to your health care provider about medications and treatments." -
answer>>>C) "The medication must be continued so the fluid problem is controlled.
, A client is being discharged with a prescription for chlorpromazine (Thorazine).Before leaving
for home, which of these findings should the nurse teach the client to report? A) Change in
libido, breast enlargement
B) Sore throat, fever
C) Abdominal pain, nausea, diarrhea
D) Dsypnea, nasal congestion - answer>>>B) Sore throat, fever
A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's
office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the
bottom of the child's foot. Which action should the nurse implement first?
A. Cleanse the foot with soap and water and apply an antibiotic ointment
B. Provide teaching about the need for a tetanus booster within the next 72 hours.
C. have the mother check the child's temperature q4h for the next 24 hours
D. transfer the child to the emergency department to receive a gamma globulin
injection - answer>>>A. Cleanse the foot with soap and water and apply an antibiotic ointment
A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and
levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the
prescribed dosage is too high for this client? The client experiences:
A. Bradycardia and constipation
B. Lethargy and lack of appetite
C. Muscle cramping and dry, flushed skin
D. Palpitations and shortness of breath - answer>>>D. Palpitations and shortness of breath
A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow
vision and palpitations. Which finding is most important for the nurse to assess to the client? -
answer>>>Obtain a list of medications taken for cardiac history
The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all
that apply) - answer>>>A. Fluid shifts from intravascular to interstitial area due to decreased
serum