,Which of these instructions should a nurse include in the teaching plan for a client
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
who had removal of a cataract in the left eye?
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a. "Forcefully cough and take deep breaths every two hours to keep your airway clear."
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b. "Perform the prescribed eye exercises each day to strengthen your eye muscles."
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
c. "Rinse your eyes with saline each morning to prevent postoperative infection."
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
d. "Take the prescribed stool softener to avoid increasing intraocular pressure."
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Answer… d. "Take the prescribed stool softener to avoid increasing intraocular pressure."
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
Which of these measures should a nurse include when planning care for a school-
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aged child during a sickle cell crisis episode?
p4 p4 p4 p4 p4 p4 p4 p4
a. Monitoring for signs of bleeding. p4 p4 p4 p4
b. Providing pain relief. p4 p4
c. Administering cool sponge baths to reduce fevers. p4 p4 p4 p4 p4 p4
d. Offering a high calorie diet. p4 p4 p4 p4
Answer… b. Providing pain relief.
p4 p4 p4 p4
An adolescent has a nursing diagnosis of fatigue related to inadequate intake of
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
iron-rich foods. Selection of which of these lunches by the client indicates a
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
correct understanding of foods high in iron content?
p4 p4 p4 p4 p4 p4 p4 p4
a. Peanut butter and jam sandwich.
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b. Chicken nuggets with rice. p4 p4 p4
c. Tuna salad sandwich.
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d. Beefburger with cheese. p4 p4
, Answer …d. Beefburger with cheese.
p4 p4 p4 p4
A client has been admitted with acute pancreatitis. Which of these laboratory test
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results supports this diagnosis?
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a. Elevated serum potassium level. p4 p4 p4
b. Elevated serum amylase level. p4 p4 p4
c. Elevated serum sodium level. p4 p4 p4
d. Elevated serum creatinine level. p4 p4 p4
Answer …b. Elevated serum amylase level.
p4 p4 p4 p4 p4
When discussing weigh gain during pregnancy, a nurse should recommend that the
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total weight gain for a pregnant client who is at ideal body weight for her height is:
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a. at least 15 pounds.
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b. 15 to 20 pounds.
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c. 25 to 35 pounds.
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d. at least 45 pounds.
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Answer …c. 25 to 35 pounds.
p4 p4 p4 p4 p4
Which of these manifestations, if reported by a client who is 10-weeks-pregnant,
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
supports the diagnosis of ruptured tubal pregnancy.
p4 p4 p4 p4 p4 p4 p4
a. Sharp unilateral abdominal pain.
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b. Uncontrollable vomiting. p4
c. Marked abdominal distention. p4 p4
d. Profuse vaginal bleeding. p4 p4
Answer …a. Sharp unilateral abdominal pain.
p4 p4 p4 p4 p4
A client diagnosed with type 1 diabetes mellitus has a glycosylated hemoglobin
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
A1c of 4.2%. A nurse should interpret this to mean that the client has:
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a. had a period of sustained hyperglycemia.
p4 p4 p4 p4 p4
b. been non-compliant with home management.
p4 p4 p4 p4
c. been in relatively good diabetic control.
p4 p4 p4 p4 p4
d. eaten a high carbohydrate snack just prior to testing.
p4 p4 p4 p4 p4 p4 p4 p4
, Answer ..c. been in relatively good diabetic control.
p4 p4 p4 p4 p4 p4 p4
A nurse is caring for a client with burns and in reverse isolation. Which measures
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
should the nurse include?
p4 p4 p4 p4
a. Wearing disposable gloves when chaging the dressings.
p4 p4 p4 p4 p4 p4
b. Having the client wear goggles when staff is in the room.
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c. Wearing a gown, mask, and gloves when providing care to the client.
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d. Disposing of the client's soiled laundry in a red bag.
p4 p4 p4 p4 p4 p4 p4 p4 p4
Answer…c. Wearing a gown, mask, and gloves when providing care to the client.
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Which of these symptoms should a nurse expect to assess in a client who develops
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hypoglycemia?
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a. Fruity breath odor.
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b. Polyuria.
c. Diaphoresis.
d. Flushed skin. p4
Answer …c. Diaphoresis.
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A nurse should assess a child who has diabetes mellitus (type 1) for symptoms of
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hyperglycemia, which include:
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a. flushed skin and thirst.
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b. irritability and hunger. p4 p4
c. sweating and jitteriness.p4 p4
d. lethargy and tremors. p4 p4
Answer …a. flushed skin and thirst.
p4 p4 p4 p4 p4
A client has shortness of breath when lying down and usually assumes an
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
upright or sitting position in order to breathe more comfortably. A nurse should
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document this observation as:
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a. dyspnea.
b. bradypnea.
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who had removal of a cataract in the left eye?
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
a. "Forcefully cough and take deep breaths every two hours to keep your airway clear."
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
b. "Perform the prescribed eye exercises each day to strengthen your eye muscles."
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
c. "Rinse your eyes with saline each morning to prevent postoperative infection."
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
d. "Take the prescribed stool softener to avoid increasing intraocular pressure."
p4 p4 p4 p4 p4 p4 p4 p4 p4
Answer… d. "Take the prescribed stool softener to avoid increasing intraocular pressure."
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
Which of these measures should a nurse include when planning care for a school-
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
aged child during a sickle cell crisis episode?
p4 p4 p4 p4 p4 p4 p4 p4
a. Monitoring for signs of bleeding. p4 p4 p4 p4
b. Providing pain relief. p4 p4
c. Administering cool sponge baths to reduce fevers. p4 p4 p4 p4 p4 p4
d. Offering a high calorie diet. p4 p4 p4 p4
Answer… b. Providing pain relief.
p4 p4 p4 p4
An adolescent has a nursing diagnosis of fatigue related to inadequate intake of
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
iron-rich foods. Selection of which of these lunches by the client indicates a
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
correct understanding of foods high in iron content?
p4 p4 p4 p4 p4 p4 p4 p4
a. Peanut butter and jam sandwich.
p4 p4 p4 p4
b. Chicken nuggets with rice. p4 p4 p4
c. Tuna salad sandwich.
p4 p4
d. Beefburger with cheese. p4 p4
, Answer …d. Beefburger with cheese.
p4 p4 p4 p4
A client has been admitted with acute pancreatitis. Which of these laboratory test
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
results supports this diagnosis?
p4 p4 p4 p4
a. Elevated serum potassium level. p4 p4 p4
b. Elevated serum amylase level. p4 p4 p4
c. Elevated serum sodium level. p4 p4 p4
d. Elevated serum creatinine level. p4 p4 p4
Answer …b. Elevated serum amylase level.
p4 p4 p4 p4 p4
When discussing weigh gain during pregnancy, a nurse should recommend that the
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
total weight gain for a pregnant client who is at ideal body weight for her height is:
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
a. at least 15 pounds.
p4 p4 p4
b. 15 to 20 pounds.
p4 p4 p4
c. 25 to 35 pounds.
p4 p4 p4
d. at least 45 pounds.
p4 p4 p4
Answer …c. 25 to 35 pounds.
p4 p4 p4 p4 p4
Which of these manifestations, if reported by a client who is 10-weeks-pregnant,
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
supports the diagnosis of ruptured tubal pregnancy.
p4 p4 p4 p4 p4 p4 p4
a. Sharp unilateral abdominal pain.
p4 p4 p4
b. Uncontrollable vomiting. p4
c. Marked abdominal distention. p4 p4
d. Profuse vaginal bleeding. p4 p4
Answer …a. Sharp unilateral abdominal pain.
p4 p4 p4 p4 p4
A client diagnosed with type 1 diabetes mellitus has a glycosylated hemoglobin
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
A1c of 4.2%. A nurse should interpret this to mean that the client has:
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
a. had a period of sustained hyperglycemia.
p4 p4 p4 p4 p4
b. been non-compliant with home management.
p4 p4 p4 p4
c. been in relatively good diabetic control.
p4 p4 p4 p4 p4
d. eaten a high carbohydrate snack just prior to testing.
p4 p4 p4 p4 p4 p4 p4 p4
, Answer ..c. been in relatively good diabetic control.
p4 p4 p4 p4 p4 p4 p4
A nurse is caring for a client with burns and in reverse isolation. Which measures
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
should the nurse include?
p4 p4 p4 p4
a. Wearing disposable gloves when chaging the dressings.
p4 p4 p4 p4 p4 p4
b. Having the client wear goggles when staff is in the room.
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
c. Wearing a gown, mask, and gloves when providing care to the client.
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
d. Disposing of the client's soiled laundry in a red bag.
p4 p4 p4 p4 p4 p4 p4 p4 p4
Answer…c. Wearing a gown, mask, and gloves when providing care to the client.
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
Which of these symptoms should a nurse expect to assess in a client who develops
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
hypoglycemia?
p4
a. Fruity breath odor.
p4 p4
b. Polyuria.
c. Diaphoresis.
d. Flushed skin. p4
Answer …c. Diaphoresis.
p4 p4
A nurse should assess a child who has diabetes mellitus (type 1) for symptoms of
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
hyperglycemia, which include:
p4 p4 p4
a. flushed skin and thirst.
p4 p4 p4
b. irritability and hunger. p4 p4
c. sweating and jitteriness.p4 p4
d. lethargy and tremors. p4 p4
Answer …a. flushed skin and thirst.
p4 p4 p4 p4 p4
A client has shortness of breath when lying down and usually assumes an
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
upright or sitting position in order to breathe more comfortably. A nurse should
p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4 p4
document this observation as:
p4 p4 p4 p4
a. dyspnea.
b. bradypnea.
