Exam (elaborations) NURSING CRITICAL C QUESTIONS AND ANSWERS

NURSING CRITICAL C QUESTIONS AND ANSWERS Question 1 See full question 20s Which client is at highest risk for developing a urinary tract infection? You Selected:  a man with an indwelling urinary catheter Correct response:  a man with an indwelling urinary catheter Explanation: Remediation: Add a Note Question 2 See full question 6m 8s A client is recovering from a bacterial infection with intravenous antibiotics. The healthcare team is planning for the client to be discharged tomorrow. However, the client wants to leave today because the client’s animals do not have someone to feed them tomorrow. What is the nurse’s best response to this client? You Selected:  “You have a right to leave early, but let us make sure you are aware of all the complications that can occur.” Correct response:  “You have a right to leave early, but let us make sure you are aware of all the complications that can occur.” Explanation: Remediation: Add a Note Question 3 See full question 2m 3s A neonate born at 40 weeks' gestation admitted to the nursery is found to be hypoglycemic. At 4 hours of age, the neonate appears pale and his pulse oximeter is reading 75% on room air. What should the nurse do? You Selected:  Provide supplemental oxygen. Correct response:  Provide supplemental oxygen. Explanation: Remediation: Add a Note Question 4 See full question 2m 22s A client fears chemotherapy because of the side effects. What is the nurse's best response to the client's concerns? You Selected:  “We’ll give you medications to prevent the side effects, so you shouldn’t be too concerned.” Correct response:  “Each person responds differently to chemotherapy treatments. We’ll monitor your responses closely.” Explanation: Remediation: Add a Note Question 5 See full question 38s The nurse teaches the client with chronic cancer pain about optimal pain control. Which recommendation is most effective for pain control? You Selected:  Take prescribed analgesics on an around-the-clock schedule to prevent recurrent pain. Correct response:  Take prescribed analgesics on an around-the-clock schedule to prevent recurrent pain. Explanation: Remediation: Add a Note Question 6 See full question 30s A client received chemotherapy 24 hours ago. Which precautions are necessary when caring for the client? You Selected:  Wear personal protective equipment when handling blood, body fluids, and feces. Correct response:  Wear personal protective equipment when handling blood, body fluids, and feces. Explanation: Remediation: Add a Note Question 7 See full question 31s A client with dysphagia is being prepared for discharge. Which outcome indicates that the client is ready for discharge? You Selected:  The client is free from esophagitis and achalasia. Correct response:  The client is free from esophagitis and achalasia. Explanation: Remediation: Add a Note Question 8 See full question 9s A physician orders a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance? You Selected:  hypokalemia Correct response:  hypokalemia Explanation: Remediation: Add a Note Question 9 See full question 39s A hospitalized client with end-stage heart failure does not want to be resuscitated. The health care provider (HCP) has written the do-not-resuscitate (DNR) prescription on the client’s record. The client has a cardiac arrest, and the wife tells the nurse she wants the client to be resuscitated and asks the nurse to “do something.” What should the nurse do? You Selected:  Discuss the DNR prescription with the wife. Correct response:  Discuss the DNR prescription with the wife. Explanation: Remediation: Add a Note Question 10 See full question 1m 43s During the discharge planning teaching process, a client who has been prescribed tranylocypromine states that he enjoys a beer or two in the evenings. Which of the following is the nurse's most appropriate response? You Selected:  “Beer contains tyramine, which must be avoided when on this medication.” Correct response:  “Beer contains tyramine, which must be avoided when on this medication.” Explanation: Remediation: Add a Note Question 11 See full question 46s The staff of an outpatient clinic has formed a task force to develop new procedures for swift, safe evacuation of the unit. The new procedures haven't been reviewed, approved, or shared with all personnel. When a nurse-manager receives word of a bomb threat, the task force members push for evacuating the unit using the new procedures. Which action should the nurse-manager take? You Selected:  Determine that the procedures currently in place must be followed and direct staff to follow them without question. Correct response:  Determine that the procedures currently in place must be followed and direct staff to follow them without question. Explanation: Add a Note Question 12 See full question 1m 17s A client with cancer-related pain has been prescribed a narcotic analgesic to be given around the clock. The client is competent and has been actively involved in decisions regarding care. What should the nurse do if the client refuses the next dose of analgesia? You Selected:  Document the client’s choice and re-assess pain in 1 hour. Correct response:  Document the client’s choice and re-assess pain in 1 hour. Explanation: Add a Note Question 13 See full question 1m 30s A client was admitted for a 3-day stay on the psychiatric inpatient unit. At the time of discharge, the client says to the nurse, "It would nice to go out some time; tell me how I can reach you outside of the hospital." Which response by the nurse is most appropriate? You Selected:  "My relationship with you is professional and not social." Correct response:  "My relationship with you is professional and not social." Explanation: Remediation: Add a Note Question 14 See full question 34s The nurse is caring for an adolescent who has been admitted several times with uncontrolled type 1 diabetes. The child is now stabilized and is preparing for discharge. Which of the following should be the priority focus for the nurse when conducting discharge teaching? You Selected:  management of the therapeutic regimen Correct response:  management of the therapeutic regimen Explanation: Remediation: Add a Note Question 15 See full question 17s The nurse understands that client position is important when treating dyspnea. What position would be contraindicated for a client who has dyspnea? You Selected:  supine Correct response:  supine Explanation: Remediation: Add a Note Question 16 See full question 35s A 25-year-old primiparous client who gave birth 2 hours ago has decided to breastfeed her neonate. Which instruction should the nurse address as the highest priority in the teaching plan about preventing nipple soreness? You Selected:  placing as much of the areola as possible into the baby’s mouth Correct response:  placing as much of the areola as possible into the baby’s mouth Explanation: Remediation: Add a Note Question 17 See full question 35s Accompanied by her partner, a client seeks admission to the labor and delivery area. She states that she's in labor and says she attended the facility clinic for prenatal care. Which question should the nurse ask her first? You Selected:  "What is your expected due date?" Correct response:  "What is your expected due date?" Explanation: Remediation: Add a Note Question 18 See full question 1m 17s A first-time mother is concerned that her 6-month-old infant is not gaining enough weight. What should the nurse tell the mother? You Selected:  "Birth weight doubles by 6 months of age." Correct response:  "Birth weight doubles by 6 months of age." Explanation: Remediation: Add a Note Question 19 See full question 41s A nurse is admitting a client to the palliative unit and discussing advanced directives. Which of the following statements made by the client leads the nurse to believe the client requires clarification around advanced directives? You Selected:  “This will stop my daughter-in-law from putting me in a home.” Correct response:  “This will stop my daughter-in-law from putting me in a home.” Explanation: Remediation: Add a Note Question 20 See full question 37s The nurse preceptor overhears a student nurse talking to a grieving mother, whose child was stillborn, about her own pregnancy and fears about experiencing a loss. The student nurse and mother make arrangements for the student to pick up the client’s maternity clothes and baby furniture on the weekend. What is the preceptor’s most appropriate action? You Selected:  Discuss the situation with the nursing student after the visit has ended. Correct response:  Discuss the situation with the nursing student after the visit has ended. Explanation: Add a Note Question 21 See full question 29s The nurse is evaluating a parent’s understanding of measuring one tablespoon of medication in a medicine cup. At which level on the medicine cup would the nurse confirm an appropriate dose? You Selected:  Your selection and the correct area, market by the green box. Explanation: Add a Note Question 22 See full question 53s A client has just been admitted with acute delirium of unknown etiology. The client's daughter states that she is worried about her mom because she has never been this sick before. Which would be the most helpful statement to make to the daughter? You Selected:  “The health care provider will prescribe tests to find out what’s causing her condition.” Correct response:  “The health care provider will prescribe tests to find out what’s causing her condition.” Explanation: Remediation: Add a Note Question 23 See full question 31s When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first? You Selected:  Check the equipment. Correct response:  Check the equipment. Explanation: Remediation: Add a Note Question 24 See full question 2m The nurse is assessing a client, who has lung cancer with spinal metastasis, for pain. The client tells the nurse that the ordered opioid medication helps, but there is still a shooting pain down the client’s left leg. Identify the best pharmacologic measure to address this pain. You Selected:  an adjuvant, such as gabapentin Correct response:  an adjuvant, such as gabapentin Explanation: Add a Note Question 25 See full question 2m 38s A nurse counsels a mother with young children after leaving her abusive husband 6 months ago. The mother says, “My 6-year-old is starting to act just like his father. I just don’t know how to handle this.” Which response by the nurse is most appropriate? You Selected:  "Counseling for your son would be helpful." Correct response:  "Counseling for your son would be helpful." Explanation: Add a Note Question 26 See full question 32s A client with Addison's disease comes to the clinic for a follow-up visit. When assessing this client, the nurse should stay alert for signs and symptoms of: You Selected:  sodium and potassium abnormalities. Correct response:  sodium and potassium abnormalities. Explanation: Remediation: Add a Note Question 27 See full question 52s The health care provider (HCP) is calling in a prescription for ampicillin for a neonate. What should the nurse do? Select all that apply. You Selected:  Write down the prescription.  Repeat the prescription to the HCP over the telephone.  Ask the HCP to confirm that the prescription is correct. Correct response:  Write down the prescription.  Repeat the prescription to the HCP over the telephone.  Ask the HCP to confirm that the prescription is correct. Explanation: Remediation: Add a Note Question 28 See full question 1m 41s The nurse is notifying the health care provider via telephone of a change in condition of a client diagnosed with an exacerbation of asthma. Arrange the nursing statements in order as they would be communicated using the SBAR method. All options must be used. You Selected:  Hello. My name is Nurse Jones from Unit D.  I am notifying you because Bob Smith has become increasingly short of breath with audible wheezing this afternoon.  Mr. Smith was admitted yesterday with an exacerbation of asthma. He typically controls his asthma with oral medication and inhalers at home. He is ordered albuterol treatments twice daily. Oxygen is prescribed at 2 liters.  Respirations are now 32 breaths/minute. The pulse oximeter is 89%. Lungs reveal wheezing in all lung fields. Slight nasal flaring is noted.  I recommend that we increase his oxygen dose and prescribe an extra albuterol treatment. Correct response:  Hello. My name is Nurse Jones from Unit D.  I am notifying you because Bob Smith has become increasingly short of breath with audible wheezing this afternoon.  Mr. Smith was admitted yesterday with an exacerbation of asthma. He typically controls his asthma with oral medication and inhalers at home. He is ordered albuterol treatments twice daily. Oxygen is prescribed at 2 liters.  Respirations are now 32 breaths/minute. The pulse oximeter is 89%. Lungs reveal wheezing in all lung fields. Slight nasal flaring is noted.  I recommend that we increase his oxygen dose and prescribe an extra albuterol treatment. Explanation: Add a Note Question 29 See full question 52s Which type of solution, when administered I.V., would cause fluid to shift from body tissues to the bloodstream? You Selected:  hypertonic Correct response:  hypertonic Explanation: Add a Note Question 30 See full question 1m 12s A hospital employee asks the nurse if another hospital employee is a client on the medical unit. What statements made by the nurse protect client privacy? Select all that apply. You Selected:  "Client privacy is part of the hospital code of conduct."  "I am not able to provide that information." Correct response:  "I am not able to provide that information."  "Client privacy is part of the hospital code of conduct." Explanation: Add a Note Question 31 See full question 1m 25s A client who has skeletal traction to stabilize a fractured femur has not had a bowel movement for 2 days. The nurse should: You Selected:  increase the client’s fluid intake to 3,000 mL/day. Correct response:  increase the client’s fluid intake to 3,000 mL/day. Explanation: Remediation: Add a Note Question 32 See full question 2m 58s A client is using an over-the-counter nasal spray containing pseudoephedrine to treat allergic rhinitis. Which instruction about this medication would be most appropriate for the nurse to provide for the client? You Selected:  Overuse of pseudoephedrine can lead to increased nasal congestion. Correct response:  Overuse of pseudoephedrine can lead to increased nasal congestion. Explanation: Remediation: Add a Note Question 33 See full question 44s The client with a depressive disorder has been consistent with taking 12.5 mg of paroxetine extended release daily. The nurse judges the client to be benefiting from this drug therapy when the client demonstrates which behaviors? Select all that apply. You Selected:  completes homework assignments  decreases pacing  verbalizes feelings Correct response:  completes homework assignments  decreases pacing  verbalizes feelings Explanation: Remediation: Add a Note Question 34 See full question 26s The nurse is reviewing laboratory values of a client receiving clozapine. Which laboratory value should the nurse report to the health care provider (HCP)? You Selected:  WBC of 3,500/μL (3.5 X 109/L) Correct response:  WBC of 3,500/μL (3.5 X 109/L) Explanation: Remediation: Add a Note Question 35 See full question 2m 11s The nurse conducts a wellness screening on a 9-year-old client Which finding most suggests that that the client has typical social development? You Selected:  enjoys active play Correct response:  has a best friend Explanation: Add a Note Question 36 See full question 41s After being examined by a forensic nurse in the emergency department, a rape victim is prepared for discharge. Because of the nature of the attack, this client is at risk for posttraumatic stress disorder (PTSD). Which symptoms are associated with PTSD? Select all that apply. You Selected:  Sleep disturbances  Recurrent, intrusive recollections or nightmares  Difficulty concentrating Correct response:  Recurrent, intrusive