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A nurse is assessing an adolescent client for sickle cell anemia. Which of the
following is a priority finding by the nurse?
a. A pain score 7 on a scale of 0 to 10
b. Shortness of breath
c. New onset of a new enuresis
d. Priapism - ANSWER-b. Shortness of breath
A nurse is caring for a client who is 1 day postop following a Hypophysectomy
for the removal of the pituitary tumor. Which of the following findings requires
further assessment by nurse?
a. Glascow scale score a 15
b. Blood drainage on initial dressing measuring 3 cm
c. Report of dry mouth
d. Urinary output greater than fluid intake - ANSWER-d. Urinary output greater
than fluid intake
A client with a left leg cast is using crutches for ambulation. The nurse
recognizes the client needs further instruction when?
a. Flexes elbows at 30 degrees when using the handgrips
b. Maintains 3 to 4 finger width between the crutch pad and axilla
,c. Places the crutches 6 inches in front and side of each foot when standing.
d. Pushes up from a chair with crutches on the unaffected side. - ANSWER-b.
Maintains 3 to 4 finger width between the crutch pad and axilla
A nurse is planning care for a client to prevent complications of immobility.
Which of the following actions should the nurse include in the plan of care?
a. Massage lower extremities daily to prevent DVT
b. Limit intake of Food high in calcium to prevent renal calculi.
c. Encourage client to lie supine prevent constipation.
d. Remove anti embolism stockings for 3 hours each day to decreased skin
breakdown. - ANSWER-d. Remove anti embolism stockings for 3 hours each
day to decreased skin breakdown.
A nurse is review the prescription for doxazosin with a client. Which of the
following should be included in the teaching?
a. Decrease caloric intake to reduce weight gain.
b. Increased dietary fiber to prevent constipation.
c. Rise slowly when sitting up from bed.
d. Take this medication each morning. - ANSWER-c. Rise slowly when sitting
up from bed.
A nurse is planning to provide teaching to a young adult client who has
insomnia. Which of the following should the nurse include in the teaching?
a. Exercising an hour before bedtime
b. Take a short nap today
c. Keep bedroom cool at night
d. Consume a high carbohydrate snack at bedtime. - ANSWER-d. Consume a
high carbohydrate snack at bedtime.
,A provider has written a do not resuscitate order for a client who is comatose
and does not have advance directives. A member of the clients family says to
the nurse, "I wonder when the doctor will tell us what's going on" Which of the
following actions should the nurse take first?
a. Request that the provider provide more information to the family.
b. Refer the family to a support group for grief counseling.
c. Offer to answer questions that family members have.
d. Ask the family what the provider has discussed with them. - ANSWER-d.
Ask the family what the provider has discussed with them.
A nurse is interviewing an older adult client about the physiological changes he
has been experiencing. Which of the following changes should the nurse
recognize is normally associated with the aging process?
a. Decreased sense of taste
b. Decreased blood pressure
c. Increased gastric secretions
d. Increased accommodation to near vision - ANSWER-a. Decreased sense of
taste
A nurse in an intensive care unit is planning care for a client who has alcohol
withdrawal syndrome. Which of the following should the nurse include in the
plan of care?
a. Administer disulfiram.
b. Provide frequent orientation to time and place.
c. Engage the client in group therapy.
d. Perform gastric lavage. - ANSWER-b. Provide frequent orientation to time
and place.
A nurse manager is planning an audit to measure the quality of care on the unit.
Which of the following is the most appropriate source for the nurse to consult?
a. Nursing manager colleagues
, b. Evidence-based practice data
c. Hospital administrators
d. Protocols in other hospitals - ANSWER-b. Evidence-based practice data
A nurse is caring for a client who had gastric bypass surgery 1 week ago and
has signs of early dumping syndrome. Which of the following findings should
the nurse expect? (SATA)
a. Syncope
b. Diaphoresis
c. Vertigo
d. Bradycardia - ANSWER-A & C
A nurse has been caring for a female client who has bruises on her arms that are
a result of physical abuse by her partner. The client states, "I don't know how
much longer I can take this, but I'm afraid he'll really hurt me if I leave" Which
of the following is an appropriate nursing intervention?
a. Assist the client to identity personal behaviors that trigger abusive behavior
b. Insist that the client report the abusive behavior to the proper authority
c. Offer to speak to the client's partner regarding his abusive behavior
d. Help the client to recognize the signs of escalation of abusive behavior -
ANSWER-d. Help the client to recognize the signs of escalation of abusive
behavior
A nurse is using Naegeles rule to calculate the expected delivery date for a
newly pregnant primigravida. The first day of the clients last period was
October 4. What is the expected delivery date? - ANSWER-July 11
A nurse notices smoke coming from a client's room and discovers a fire in the
wastebasket. After moving the client to safety, which of the following is the
priority action?