Questions with Detailed Verified Answers
A nurse is caring for a client who has a prescription for famotidine 160 mg PO every 6
hr. Available is famotidine oral suspenision 40 mg/5 mL. How many mL should the
nurse administer per dose? Ans: 20 mL
A nurse is collecting data from a client who has an iron deficiency anemia. Which of
the following findings should the nurse expect? Ans: Difficulty concentrating
*In clients who have iron deficiency anemia, body cells do not receive the required
oxygen because there is less hemoglobin for binding. The nurse should recognize that
impaired oxygenation of brain tissue can lead to dizziness and difficulty concentrating.
A nurse manager is preparing to complete a performance analysis for a group of
assistive personnel (AP). The manager asks a staff nurse for feedback on each AP's
abilities. Which of the following actions should the staff nurse take? Ans: Discuss how
each AP's actions measure against the job description.
*To provide objective information, the staff nurse should compare the behavior of
each AP to the facility job description. The nurse can provide specific information
about how each AP either meets the standard or demonstrates a need for
improvement.
A nurse is reviewing a client's electronic medical record and kids that an assistive
personnel (AP) recorded the client's temperature as 35.5°C (95.5°F) 2 hr earlier.
Which of the following actions should the nurse take first? Ans: Check the client's
temperature
,*According to the nursing process, the first action the nurse should take is to collect
data from the client. Therefore, the nurse should retake the client's temperature.
A nurse on an acute care unit is collecting data from a school-age child who has cystic
fibrosis (CF). Which of the following findings is the priority for the nurse to report to
the provider? Ans: Reports lack of appetite
*The nurse should identify that the greatest risk to a child who has a decreased
appetite is pulmonary infection. Anorexia, along with other manifestations, such as loss
of weight and lethargy, are commonly seen in children who have CF which an infection
exacerbation. Typical manifestations of pulmonary infection, such as fever and
tachypnea, might now be seen in a child who has CF. Additionally, a child who is
anorexic is at increased risk for diminished lung function.
A nurse in a long-term care facility is observing a newly licensed nurse who is providing
tracheostomy care for a client. The nurse identifies proper performance of the
procedure when the newly licensed nurse selects which of the following solutions to
clean the inner cannula? Ans: Hydrogen peroxide
*The nurse should identify that sterile hydrogen peroxide solution is used to loosen
secretions from the inner cannula during cleaning. If the client skin becomes irritated,
the nurse should choose 9% sodium chloride solution.
A nurse is reinforcing discharge teaching with a client who is postoperative following
an open radical prostatectomy. Which of the following instruction should the nurse
include in the teaching? Ans: "Perform Kegel exercises daily."
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, *The nurse should instruct the client to perform Keagle exercises to promote the
control of urine flow and reduce incontinence.
A nurse is reinforcing teaching with a group of clients about the Heimlich maneuver
during a first aid class. The nurse should include the teaching that which of the
following manifestations indicates the need for the Heimlich maneuver to be
performed? Ans: Difficulty breathing
Coughing
Presence of stridor
*The Heimlich maneuver is performed when the airway is obstructed by foreign body.
A client who has an obstructed airway may exhibit manifestation such as coughing,
choking, gagging, difficulty breathing, cyanosis, and stridor.
A nurse is reinforcing discharge teaching with a client who has undergone been
litigation and stripping to treat varicose veins. Which of the following instruction
should the nurse include in the teaching? Ans: Walk for 1 to 2 hr each day.
* the nurse should instruct the client to walk at least 1 to 2 hours per day after
surgery to promote venous return.
A nurse is caring for a client following a bronchoscopy. Which of the following action
should the nurse take first? Ans: Check for a gag reflex
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