Questions + Answers |Actual Exam Q&A A+
**1. The nurse is reviewing medical prescriptions for newly admitted clients. It would
be a priority for the nurse to follow up with the physician if a client with?**
A) a potassium level of 4.0 mEq/L has kayexalate prescribed.
B) a dialantin level of 8 mcg/ml is placed on seizure precautions.
C) sensitivity to aspirin is prescribed Tylenol.
D) Sensitivity to penicillin Zithromax.
**Answer:**
B) The normal level is 3.5-5.0 mEq/L. Giving kayexalate in this situation may cause
the client to lose potassium, causing hypokalemia, therefore the drug is not
indicated; the therapeutic level for Dilantin is 10-20 mcg/ml, a level of 8 is
subtherapeutic thereby increasing the risk of seizure activity.
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**2. The nurse should intervene if the nurse notes a staff member?**
A) obtaining a client's consent prior to their operative procedure after receiving
Ativan.
B) Placing a client on the affected side following surgical repair of a retinal
detachment.
C) Handling a wet cast with the palms of the hands.
D) Using a broad base of support while transferring a client.
**Answer:**
A) Informed consent, explanation, and decision-making must occur before sedation
is given; therapeutic interventions for retinal detachment include bedrest with the
,area of detachment in a dependent position to promote healing; the cast should be
handled with the palms of the hands while wet to prevent denting; a broad base of
support is used during transfers to prevent muscle injury.
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**3. The community health nurse is caring for the following clients. It would be a
priority for the nurse to initiate a multidisciplinary conference for the client who**
A) 12 years old with Autism starting a new school and recently had an URI.
B) 17 years old, has type 1 DM, is unemployed, and had a recent Hemoglobin A1c of
13%.
C) 52 years old, with Myasthenia Gravis, recently prescribed Mestinon
(pyridostigmine), and employed as a mail carrier.
D) 70 years old, has schizophrenia, lives alone, and reports hearing non-threatening
voices.
**Answer:**
B) An adolescent with uncontrolled DM would require the greatest number of
disciplines (multidisciplinary) to manage their care, i.e., medicine, nursing, social
work, nutritionist. The other choices do not require as many providers of care to meet
their needs.
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**4. The nurse from the postpartum unit has been temporarily assigned to the
medical-surgical unit. It would be most appropriate to assign this nurse to the client
who**
A) has returned from right total hip replacement surgery four hours ago.
B) is being observed for increased intracranial pressure.
C) had surgery two hours ago to remove the appendix.
D) is two weeks postpartum and being maintained on a mechanical ventilator for
respiratory failure.
,**Answer:**
C) The management of a client following abdominal surgery is standard. The
postpartum nurse routinely cares for mothers following a C-section; therefore, it is
appropriate to assign this client.
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**5. The nurse in a well-baby clinic has assessed several children today. It would be
a priority for the nurse to suggest follow-up for the child who**
A) 2 months old with a positive Babinski reflex.
B) 5 months old and does not hold their own bottle.
C) 10 months old who cries around strangers.
D) 18 months old who needs support while ambulating.
**Answer:**
D) A child experiencing normal growth and development should be ambulating
independently by 12 months. The Babinski reflex disappears after 2 years of age. An
infant typically holds their own bottle by 6 months. Stranger anxiety usually develops
at approximately 7 months.
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**6. The nurse is caring for a mechanically ventilated client who was declared brain
dead. An advanced directive is not documented on the medical record. It would be
most appropriate to obtain consent for organ donation from the**
A) Client's primary care provider.
B) Client's nurse manager.
C) Closest living family member.
D) Hospital's ethics committee.
**Answer:**
, C) Consent for organ donation is given by a client's next of kin in the absence of an
advanced directive.
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**7. The nurse has received report on four clients. The nurse should first assess the
client who has**
A) COPD with O2 sat of 89%.
B) Parkinson's disease and is demanding to leave the hospital AMA.
C) Been admitted with suspected Guillain-Barré syndrome and has begun
plasmapheresis therapy.
D) CHF whose pitting edema increased to 2+.
**Answer:**
C) The client admitted with Guillain-Barré syndrome should be assessed first
because of the possibility of rapid progression of this illness and neuromuscular
respiratory failure.
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**8. It would be appropriate to assign which of these tasks to the CNA?**
A) Feeding a client who is experiencing dysphagia.
B) One-on-one client observation for safety.
C) Removal of an indwelling catheter.
D) Performing a simple dressing change.
**Answer:**
B) The CNA may be assigned to a client that requires one-on-one observation for
safety. The other choices require skilled nursing intervention by an LPN.
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