2) EACH VERSION CONTAINS 120 QUESTIONS AND CORRECT
ANSWERS | GRADE A+
a nurse is administering a tap water enema to a pt who is constipated, during the
administration of the enema, the client states he is having abdominal cramps, what
action should the nurse take to relieve the client'scomfort Correct Answer - lower
the height of the solution container
a pt is diagnosed with left homonymous hemianopsia following a stroke, what
action should the nurse take? Correct Answer - place the clients bedside table on
the right side of the bed
a nurse is caring for a pt who is at risk for shock, what finding is the earliest indicator
that this complication is developing? Correct Answer -
narrowing pulse pressure
a nurse is assessing a client who has hypokalemia as a result of n/v, and diarrhea,
what finding should the nurse expect Correct Answer
- weak, irregular
pulse
a nurse is providing teaching for a client who has experienced an acuteepisode
of gastritis, what instruction should the nurse include in the teaching?
Correct Answer
- avoid drinking alcohol
a nurse at an outpt surgery center is providing discharge teaching to a pt anhis spouse
following surgical removal of a cataract, what should the nurse include? Correct
Answer -
the client should wear dark glasses while outdoors
a nurse is reviewing the ABG results of a client who the provider suspects has
metabolic acidosis. what would the nurse expect to see Correct
Answer
- pH below 7.35
a pt is experiencing SOB, fatigue, JVD, the nurse auscultates a third heart sound
(S3), what should the nurse anticipate as the cause of these s/s Correct
,Answer - HF
a nurse is administering potassium chloride elixer 40mEq divided into 2 equal doses
every 12 hours, available is 6.7 mEq/5mL. how many mL shouldthe nurse administer
per dose?
Correct Answer - 30mL
a nurse is caring for a pt in the ED who was just admitted with chest pain,possible acute
coronary syndrome. what should the nurse do first?
Correct Answer - administer sublingual
nitroglycerin (treat chest pain to reduce cardiac tissue
damage)
a nurse is caring for pt who is experiencing ventricular tachycardia with a pulse, the RRT
is at the bedside. what electrical intervention should be usedto correct this dysrhythmia?
Correct Answer - synchronized cardioversion
(tx for afib, SVT, and v tach with a pulse)
a nurse is caring for an adult pt who is experiencing delayed wound healing,which of
the following interventions should the nurse take? Correct
Answer
- monitor serum albumin levels and notify provider if below 3.5g/dL
(lack of protein increases the risk for a delay in wound healing and infection)
a nurse is teaching a client who has pre-dialysis ESKD about diet, what should be
included? Correct Answer - reduce intake of foods high in potassium
(potassium clearance is impaired in ESKD)
a nurse is caring for a client who has T1DM, the nurse misread the client's morning BG
level as 210mg/dL, instead of 120mg/dL and administered theinsulin dose appropriate
for a reading over 200mg/dL before the client's breakfast, what action is the nurse's
priority?
Correct Answer - monitorthe
,client for hypoglycemia
, a nurse is planning care for a pt who has a new diagnosis of DI, which of thefollowing
interventions should the nurse include in the plan of care?
Correct Answer - check urine specific gravity
a nurse is caring for a pt admitted with wheezing and coughing due to an allergic
reaction to a newly prescribed medication, what medication shouldbe
administered first? Correct Answer -
albuterol 3mL via nebulizer
a nurse is caring for a female client in the ED who reports SOB and pain in the lung
area, she states that she started taking BC pills 3 weeks ago and that she smokes, her
heart rate is 110/min, RR 40/min, and BP 140/80, herABGs are pH 7.50, PaCO2 29,
PaO2 60, HCO3 20, SaO2 86%, what is the priority of nursing interventions
Correct Answer -
administer oxygen viaface mask
a nurse is caring for a pt following repair of a fracture, what finding shouldalert the nurse that
the pt