A client arrives in the emergency center with a blood alcohol level of 500 mg/dl.
When transferred to the observation unit, the client becomes demanding, aggressive,
and shouts at the staff. Which assessments finding is most important for the nurse to
identify in the first 24 hours?
Give this one a try later!
Agitation and threats to harms staff
A 7-year-old boy is brought to the clinic because of facial edema. He reports that he
has been voiding small amounts of dark, cloudy, tea-colored urine. The parents state
that their son had a sore throat 2 weeks earlier, but it has resolved. After assessing the
child's vital signs and weight, what intervention should the nurse implement next?
a. Perform an otoscopic examination
b. Measure the child's abdominal girth
c. Collect a urine specimen for routine urinalysis
d. Obtain a blood specimen for serum electrolytes.
,Give this one a try later!
c. Collect a urine specimen for routine urinalysis
A female client reports that her hair is becoming coarse and breaking off, that the
outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which
follow-up question is best for the nurse to ask?
a. "Is there a history of female baldness in your family?"
b. "Are you under any unusual stress at home or work?"
c. "Do you work with hazardous chemicals?"
d. "Have you noticed any changes in your fingernails?"
Give this one a try later!
d. "Have you noticed any changes in your fingernails?"
Based on principles of asepsis, the nurse should consider which circumstance to be
sterile?
a. One inch- border around the edge of the sterile field set up in the operating room
b. A wrapped unopened, sterile 4x4 gauze placed on a damp table top.
c. An open sterile Foley catheter kit set up on a table at the nurse waist level
d. Sterile syringe is placed on sterile area as the nurse riches over the sterile field.
Give this one a try later!
c. An open sterile Foley catheter kit set up on a table at the nurse waist
level
,An adult client with schizophrenia begin treatment three days ago with the
Antipsychotic risperidone. The client also received prescription for trazodone as
needed for sleep and clonazepam as needed for severe anxiety. When the client
reports difficulty with swallowing, what action should the nurse take?
a. Obtain a prescription for an anticholinergic medication
b. Determine how many hours declined slept last night
c. Administer the PRN prescription for severe anxiety
d. Watch the thyroid cartilage move while the client swallows
Give this one a try later!
a. Obtain a prescription for an anticholinergic medication
After receiving the Braden scale findings of residents at a long-term facility, the
charge nurse should to tell the unlicensed assistive personnel (UAP) to prioritize the
skin care for which client?
a. An older adult who is unable to communicate elimination needs.
b. An older man whose sheets are damped each time he is turned.
c. A woman with osteoporosis who is unable to bear weight.
d. A poorly nourished client who requires liquid supplement.
An older man whose sheets are damped each time he is turned.
Give this one a try later!
b. An older man whose sheets are damped each time he is turned.
An adult female client with chronic kidney disease (CKD) asks the nurse if she can
continue...Medications. Which medication provides the greatest threat to this client?
a. Magnesium hydroxide (Maalox).
b. Birth control pills
, c. Cough syrup containing codeine
d. Cold medication containing alcohol
Give this one a try later!
a. Magnesium hydroxide (Maalox).
A middle-aged woman, diagnosed with Graves' disease, asks the nurse about this
condition. Which etiological pathology should the nurse include in the teaching plan
about hyperthyroidism? (Select all that apply.)
Graves' disease, an autoimmune condition, affects thyroid stimulating hormone
receptors.
T3 and T4 hormone levels are increased
Large protruding eyeballs are a sign of hyperthyroid function
Weight gain is a common complaint in hyperthyroidism
Early treatment includes levothyroxine (Synthroid).
Give this one a try later!
Graves' disease, an autoimmune condition, affects thyroid stimulating
hormone receptors.
T3 and T4 hormone levels are increased
Large protruding eyeballs are a sign of hyperthyroid function
Progressive kyphoscoliosis leading to respiratory distress is evident in a client with
muscul...Which finding warrants immediate intervention by the nurse?
a. Extremity muscle weakness
b. Bilateral eyelid drooping
c. Inability to swallow pills
d. Evidence of hypoventilation
Give this one a try later!
When transferred to the observation unit, the client becomes demanding, aggressive,
and shouts at the staff. Which assessments finding is most important for the nurse to
identify in the first 24 hours?
Give this one a try later!
Agitation and threats to harms staff
A 7-year-old boy is brought to the clinic because of facial edema. He reports that he
has been voiding small amounts of dark, cloudy, tea-colored urine. The parents state
that their son had a sore throat 2 weeks earlier, but it has resolved. After assessing the
child's vital signs and weight, what intervention should the nurse implement next?
a. Perform an otoscopic examination
b. Measure the child's abdominal girth
c. Collect a urine specimen for routine urinalysis
d. Obtain a blood specimen for serum electrolytes.
,Give this one a try later!
c. Collect a urine specimen for routine urinalysis
A female client reports that her hair is becoming coarse and breaking off, that the
outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which
follow-up question is best for the nurse to ask?
a. "Is there a history of female baldness in your family?"
b. "Are you under any unusual stress at home or work?"
c. "Do you work with hazardous chemicals?"
d. "Have you noticed any changes in your fingernails?"
Give this one a try later!
d. "Have you noticed any changes in your fingernails?"
Based on principles of asepsis, the nurse should consider which circumstance to be
sterile?
a. One inch- border around the edge of the sterile field set up in the operating room
b. A wrapped unopened, sterile 4x4 gauze placed on a damp table top.
c. An open sterile Foley catheter kit set up on a table at the nurse waist level
d. Sterile syringe is placed on sterile area as the nurse riches over the sterile field.
Give this one a try later!
c. An open sterile Foley catheter kit set up on a table at the nurse waist
level
,An adult client with schizophrenia begin treatment three days ago with the
Antipsychotic risperidone. The client also received prescription for trazodone as
needed for sleep and clonazepam as needed for severe anxiety. When the client
reports difficulty with swallowing, what action should the nurse take?
a. Obtain a prescription for an anticholinergic medication
b. Determine how many hours declined slept last night
c. Administer the PRN prescription for severe anxiety
d. Watch the thyroid cartilage move while the client swallows
Give this one a try later!
a. Obtain a prescription for an anticholinergic medication
After receiving the Braden scale findings of residents at a long-term facility, the
charge nurse should to tell the unlicensed assistive personnel (UAP) to prioritize the
skin care for which client?
a. An older adult who is unable to communicate elimination needs.
b. An older man whose sheets are damped each time he is turned.
c. A woman with osteoporosis who is unable to bear weight.
d. A poorly nourished client who requires liquid supplement.
An older man whose sheets are damped each time he is turned.
Give this one a try later!
b. An older man whose sheets are damped each time he is turned.
An adult female client with chronic kidney disease (CKD) asks the nurse if she can
continue...Medications. Which medication provides the greatest threat to this client?
a. Magnesium hydroxide (Maalox).
b. Birth control pills
, c. Cough syrup containing codeine
d. Cold medication containing alcohol
Give this one a try later!
a. Magnesium hydroxide (Maalox).
A middle-aged woman, diagnosed with Graves' disease, asks the nurse about this
condition. Which etiological pathology should the nurse include in the teaching plan
about hyperthyroidism? (Select all that apply.)
Graves' disease, an autoimmune condition, affects thyroid stimulating hormone
receptors.
T3 and T4 hormone levels are increased
Large protruding eyeballs are a sign of hyperthyroid function
Weight gain is a common complaint in hyperthyroidism
Early treatment includes levothyroxine (Synthroid).
Give this one a try later!
Graves' disease, an autoimmune condition, affects thyroid stimulating
hormone receptors.
T3 and T4 hormone levels are increased
Large protruding eyeballs are a sign of hyperthyroid function
Progressive kyphoscoliosis leading to respiratory distress is evident in a client with
muscul...Which finding warrants immediate intervention by the nurse?
a. Extremity muscle weakness
b. Bilateral eyelid drooping
c. Inability to swallow pills
d. Evidence of hypoventilation
Give this one a try later!
