AND ANSWERS
A client has bipolar disorder and has just begun a regimen of lithium, 600 mg tid. Which is the
most critical management issue for the client during the first 2 weeks of treatment?
A. Ascertaining that the client is taking a full dose daily
B. Ensuring the client's blood levels reach a therapeutic and safe dose
C. Educating the client about the side effects of lithium
D. Monitoring the client's cardiac status - ANS B. Ensuring the client's blood levels reach a
therapeutic and safe dose
A client suffers from depression following the accidental death of a child. After a suicide
attempt, the client is admitted to the psychiatric unit. During the admission interview, the
nurse learns that the client no longer wants to die. The nurse should:
A. suggest that the client no longer requires close observation.
B. place the client in a private room, away from the nurses' station, so that she has privacy to
work through the stages of the grieving process.
C. inspect the client's personal belongings for potentially dangerous objects.
D. avoid any further discussion of suicide unless the client brings up the topic. - ANS C.
inspect the client's personal belongings for potentially dangerous objects.
A client is returned to his room after a subtotal thyroidectomy. Which piece of equipment is
most important for the nurse to keep at the client's bedside?
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,A. Indwelling urinary catheter kit
B. Tracheostomy set
C. Cardiac monitor
D. Humidifier - ANS B. Tracheostomy set
Which is the most reliable and accurate method for delivering precise concentrations of oxygen
through noninvasive means?
A. Nasal cannula
B. Venturi mask
C. T-piece
D. Partial-rebreathing mask - ANS B. Venturi mask
A client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window
undergoes a stapedectomy to remove the stapes and replace the impaired bone with a
prosthesis. After the stapedectomy, the nurse should provide which client instruction?
A. "Lie in bed with your head elevated, and refrain from blowing your nose for 24 hours."
B. "Try to ambulate independently after about 24 hours."
C. "Shampoo your hair every day for 10 days to help prevent ear infection."
D. "Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose
yourself to loud sounds for 30 days." - ANS D. "Don't fly in an airplane, climb to high
altitudes, make sudden movements, or expose yourself to loud sounds for 30 days."
A 4-year-old child diagnosed with Wilms tumor is admitted for surgery. What information
would be most important for the nurse to include in the child's preoperative plan of care?
A. Avoiding further abdominal palpation
B. Performing dressing changes to the affected area
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,C. Administering analgesics for pain
D. Preparing the child for amputation - ANS A. Avoiding further abdominal palpation
A client is receiving nitroglycerin ointment to treat angina pectoris. The nurse evaluates the
therapeutic effectiveness of this drug by assessing the client's response and checking for
adverse effects. Which vital sign is most likely to reflect an adverse effect of nitroglycerin?
A. pulse rate of 84 beats/minute
B. respiration 26 breaths/minute
C. blood pressure 84/52 mm Hg
D. temperature of 100.2° F (37.9° C) - ANS C. blood pressure 84/52 mm Hg
When promoting client safety on an inpatient psychiatric unit, which interventions would be
used as the measure of last resort?
A. Surveillance
B. Seclusion
C. Room restriction
D. Four-point restraint - ANS D. Four-point restraint
Which zone of the surgical area only requires attire in the form of scrub clothes and caps?
A. Unrestricted zone
B. Semi-restricted zone
C. Restricted zone
D. Operative zone - ANS B. Semi-restricted zone
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, Which term refers to the inability to coordinate muscle movements, resulting difficulty
walking?
A. Agnosia
B. Ataxia
C. Spasticity
D. Rigidity - ANS B. Ataxia
Which are true of nonprescription drugs? (Select all that apply.)
1. They require a prescription to obtain.
2. They are referred to as over-the-counter drugs.
3. They can be taken without risk to the client.
4. They have certain labeling requirements.
5. They should be taken only as directed on the label. - ANS 2. They are referred to as over-
the-counter drugs.
4. They have certain labeling requirements.
5. They should be taken only as directed on the label
After an instructor has posted assignments, a person claiming to be a nursing student arrives on
a unit and asks a nurse for access to the medication records of a client to whom the student
nurse has been assigned. The student's only identification (ID) is a laboratory coat with the
school's name on it. What is the nurse's most appropriate response?
A. Allow the student access to the medication record because the instructor has posted an
assignment sheet.
B. Ask the student to provide a photo ID for comparison with the names on the assignment
sheet.
C. Ask the student to contact the instructor by phone to verify the student's identification.
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