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An obese female client with a high serum cholesterol level comes to the clinic for a follow-up
evaluation. She tells the nurse that she is now walking 30 minutes three times per week and is
eating a carbohydrate free, high protein diet in order to lose weight. What response is best for the
nurse to provide?
A. Explain to the lcient that her diet choice is not helpful in lowering cholesterol levels
B. Discuss the importance of maintaining a target heart rate during each excercise period
C. Teach the client additional ways to lower cholesterol, including stress management
D. Praise the client for her excercise and dieting efforts and encourage her to continue with this
program - Answer>>> A. Explain to the lcient that her diet choice is not helpful in lowering
cholesterol levels
In counting a client's radial pulse, the nurse notes the pulse is weak and irregular. To record the
most accurate heart rate, what should the nurse take?
A. Recheck the radial pulse in thirty minutes
B. Palpate the radial pulse for thiry seconds and double the rate
C. Count the apical pulse rate for sixty seconds
D. Compare the radial pulse rate bilaterally and record the higher rate. - Answer>>> C. Count
the apical pulse rate for sixty seconds
,When the nurse asks a male client with Bipolar Disorder if he is going to group session, he
responds, "there is no use in me going to that group because all they talk about is Schizophrenia,
which doesn't apply to me." Which response is best for the nurse to provide this client?
A. "Tell me what medications you are taking right now"
B. "You are probably right. The group really does not apply to your condition."
C. "It sounds to me like it may be better for you that you stay here"
D. "Let's talk about what you may have in common with the other group members." -
Answer>>> D. "Let's talk about what you may have in common with the other group members."
A 3 year-old admitted with fever of unknown origin (FUO) has begun vomiting in the past half
hour. The child's temperature is 101.80 F, and the last dose of antipyretic medication was given 5
hours ago. The child has prescriptions of acetaminophen (Tylenol) 160 MG per 5 mL elixir or
160 mg suppositories PRN fever or pain. What action should the nurse take at this time?
A. Make the child NPO and hold all medications untill the vomiting has stopped
B. Give acetaminophen elixir to ensure the child's cooperation with swallowing
C. Notify the healthcare provider that the child's fever has become dangerously high
D. Use an acetaminophen suppository for the fever since the child is vomiting - Answer>>> A.
Make the child NPO and hold all medications untill the vomiting has stopped
The nurse is monitoring a client with an IV infusion in the left antecubital fossae. The infusion
pump is functioning without alarms at the prescribed rate of 100mL/hour. The site is warm, red
and without swelling. What conclusion should these findings indicate to the nurse?
A. The IV fluids are infusing into the subcutaneous tissues and the pump should be stopped
B. The infusion pump is functioning properly and the IV site is healthy
,C. The insertion date should be verified and the IV discontinued
D. The site is inflamed and should be reported to the RN for placement in another site. -
Answer>>> D. The site is inflamed and should be reported to the RN for placement in another
site.
A client is having Radical Masectormy. What is the position of choice during the immediate
postoperative period?
A. Side-lying on the operative side with the bed flat
B. Supine with the arm on the operative side in a dependant position
C. Semi-Fowler's position with the arm on the operative side elevated
D. Sim's position with the arm on the operative side in a dependant position - Answer>>> C.
Semi-Fowler's position with the arm on the operative side elevated
A client begins an antidepressant drug during the second day of hospitalization. Which
assessment is most important for the nurse to include in this client's plan of care while the client
is taking the antidepressant?
A. Appetite
B. Mood
C. Withdrawl
D. Energy level - Answer>>> B. Mood
Which criterion is best for the nurse to use when evaluating a client's response to an analgesic
that was administered for postoperative pain?
A. Amount of medication required to relieve pain
B. Activity without guarding or grimacing
, C. Objective parameters of blood pressure and respirations
D. Subjective score on a 1 to 10 pain scale - Answer>>> D. Subjective score on a 1 to 10 pain
scale
A client is diagnosed with Pericarditis after a Myocardial Infarction (MI) and asks the nurse,
"Why did this happen?" What explanation should the nurse offer?
A. The sac surrounding the heart has become inflamed from the cells damaged by the heart
attack
B. The space around your heart is filling with fluid and your healthcare provider will have to
explain the
treatment
C. The heart cells have been infiltrated by organisms and a secondary autoimmune reaction has
occurred
D. This is an infection of the lining of the heart caused by bacteria entering through your gums -
Answer>>> A. The sac surrounding the heart has become inflamed from the cells damaged by
the heart attack
In describing the "at risk" individual for developing Breast Cancer, the nurse should recognize
that which client is at the highest risk? The woman who is...
A. a 40-year-old African American with Hypertension (HTN)
B. a 35-year-old with trauma to the breast
C. a 32-year-old whose mother had breast cancer
D. a 50-year-old Caucasian who has never had a mammogram - Answer>>> C. a 32-year-old
whose mother had breast cancer
Based on the documentation in the medical record, which action should the nurse implement
next?