Solu ons 2025.
Nurse reinforces teaching with a client scheduled for electroconvulsive therapy. Which of the
following statements by the client would require follow up?
a) I should not drive while I am receiving ECT.
b) I can take my valproic acid the morning of the procedure.
c) I will avoid food and drink for 8 hours prior to the procedure.
d) I may experience temporary confusion immediately a$er ECT. - Answer b)
The home health nurse is talking with the spouse of a client who has late-stage hun'ngton
disease. When the nurse recommends a hospital bed, the spouse becomes visibly upset and
states, "No hospital bed. I am not ready for it yet" Which of the following statements would be
appropraite for the nurse to make?
a) "We do not need to talk about this right now because you seem upset.
b) What upsets you about your spouse having a hospital bed?
c) A hospital bed will make it easier to care for your spouse
d) Are you not ready for this change in your life? - Answer b)
The nurse is caring for a client who has a prescrip'on for furosemide 1 mg/kg PO every 8 hours.
The client weighs 88 lb (40 kg). The nurse has furosemide 10 mg/mL oral suspension available.
How many mL should the nurse administer to the client with each dose? Record your answer
using a whole number. - Answer 4 mL
The nurse is administering ondansetron to a client. Which of the following statements by the
client would indicate that ondansetron has been effec've?
a) "The frequency of my diarrhea has decreased." (5%)
b) My pain level has gone down." (2%)
,c) ."The itching I was experiencing has resolved." (5%)
d) "My nausea is a lot be9er." (86%) - Answer d)
The nurse is caring for assigned clients. The nurse should first see the client who
a) is receiving 0.9% sodium chloride with 20 mEq/L (20 mmol/L) potassium chloride and has a
potassium level of 5.0 mEq/L (5.0 mmol/L) (normal: 3.5-5 mEq/L [3.5-5 mmol/L]) (15%)
b) is receiving a con'nuous infusion of 0.9% sodium chloride at 250 mL/hr and reports swollen
legs and a cough (75%)
c) was scheduled to be discharged 2 hours ago and reports increasing frustra'on regarding the
delay (1%)
d) had a hip replacement 2 days ago and is repor'ng intense itching at the incision site - Answer
b) Fluid overload (ie, dyspnea, lung crackles, peripheral edema, jugular venous distension) can
occur with increased infusion rates and should be addressed promptly to prevent respiratory or
cardiovascular compromise.
The nurse in the emergency department is assis'ng with the care of a 16-year-old client with
suspected sepsis. The client's parents are out of town and cannot be contacted to provide
consent for care. The nurse should recognize that the client should
a) receive treatment un'l the parents can be contacted (78%)
b) receive instruc'ons for follow-up care without receiving any treatment (2%)
c) be admi9ed but have treatment withheld un'l the parents can be contacted (13%)
d) receive a pregnancy test to determine if the client qualifies as an emancipated minor -
Answer a)
, The nurse is talking with a client who has been receiving escitalopram for the past 2 months and
reports no improvement in depressive feelings. Which of the following statements by the nurse
would be most appropriate?
a) "Con'nue taking the medica'on because it is too early to no'ce an improvement in
symptoms." (8%)
b) "We will talk with your health care provider about changing the prescrip'on." (5%)
c) "Have you had any recent changes or added stresses in your life?" (9%)
d) "Tell me more about how you have been taking this medica'on. - Answer d)
The nurse in the emergency department is caring for assigned clients. The nurse should suspect
child abuse if a
a) 1-year-old client has dyspnea and a swollen tongue a$er ea'ng part of a houseplant (3%)
b) 2-year-old client has a large hematoma on the forehead a$er falling out of a chair (5%)
c) .3-year-old client has second-degree burns on the face a$er pulling a cup of hot tea off the
table (5%)
d) .5-year-old client has 1 new and 2 healed humerus fractures a$er falling from a tree - Answer
d)
The nurse is speaking with a client who has schizophrenia. The client begins to look toward the
door and grimace. Which of the following responses would be most appropriate for the nurse to
make?
a) "When you don't look at me, I feel like you don't trust me." (1%)