AND ANSWERS
A client is receiving a continuous half strength tube feeding at 50ml/hour. To prepare enough of the
solution for eight hours, how many ml of full strength feeding will the nurse need? (Enter numeric value
only.) - CORRECT ANSWER -200ml . 25 ml of full strength feeding mixed with 25ml of water provided
50ml of half strength. 25ml × 8 hours= 200ml
An elderly male client is experiencing urinary incontinence. What is the best initial nursing action? -
CORRECT ANSWER -Apply an external condom catheter
3. A male Muslim client with pneumonia is scheduled to receive a dose of an intravenous antibiotic but
refuses to allow the nurse to begin fthe fmedication, fstating fhe fcannot fallow ffluids fto fenter fhis fbody
fonce fhe fis fcleansed ffor fprayer. fWhat faction fshould fthe fnurse fimplement? f- fCORRECT fANSWER f-
Reschedule fadministration fof fthe fantibiotic funtil fafter fhe fcompletes fhis fprayers
UAP fusing fa fhand fsanitzers fthat fis falcohol ffor f2 fminutes f- fCORRECT fANSWER f-tell fthat fhand
fsanitizer fuse fis fless f> f2min
5.A fchild fis fto freceive fvancomycin f(Vancocin) f40 fmg/kg fIV fone fhour fbefore fa fscheduled fprocedure.
fThe fchild fweighs f44 fpounds. fHow fmany fmg fof fthe fmedication fshould fthe fnurse fadminister f-
fCORRECT fANSWER f-Answer: f800 fRationale: fFirst, fconvert fthe fchild's fweight fto fkg: f44 fpounds
fdivided fby
2.2pound/kg f= f20 fkg. fNext fcalculate fthe fmg/kg/dose, f40 fmg fx f20 fkg f= f800mg
6. fWhile fassisting fa fpostpartum fclient fwith fperineal fcare, fthe fnurse fnotes fthat fher fvaginal
fbleeding fspurts frather fthan ftrickles ffrom fthe fvagina. fThe futerine ffundus fis ffirm fand fthe fclient's
fvital fsigns fare fpulse f88 fbeats/minute; frespiratory frate, f21 fbreaths/minute; fand fblood fpressure,
f104/68 fmmHg. fWhat faction fshould fthe fnurse ftake fnext? f- fCORRECT fANSWER f-Compare fcurrent
fvital fsigns fwith fprevious fvital fsigns
,A f6-year fold fboy fwas fhit fwith fa fbat fwhile fplaying fat fschool. fHe fhas fa fsplinter fof fwood fimbedded
fin fhis feye. fWhich faction fshould fthe fschool fnurse ftake? f- fCORRECT fANSWER f-Have fthe fparent ftake
fthe fchild ffor femergency fhelp
Within ffour fweeks fof fchildbirth, fa fclient fis fadmitted fto fthe fhospital ffor fdisorganized fspeech fbizarre
fbehavior, fand fstrange fthoughts fabout fher finfant fbeing fpossessed fby fdemons. fThe fnurse fidentifies
fa fnursing fdiagnosis fof f"Altered fthought fprocesses, fsecondary fto" fwhat fcondition? f- fCORRECT
fANSWER f- fPostpartum fpsychosis
The fnurse fidentifies fa fpriority fdiagnosis fof, f"Altered fcomfort frelated fto fmenstrual fcramps" ffor fa f25-
year- fold ffemale fclient. fWhich fself-care factivity fshould fthe fnurse femphasize fin fthe fclient's fteaching
fplan? f- fCORRECT fANSWER f-Regular faerobic fexercise.
Psych/Alcohol/Tylenol foverdose fantidote f- fCORRECT fANSWER f-Give fMucomyst
Medical fSurgical/Laxative fabuses f- fCORRECT fANSWER f-Patient f-taking fMilk fof fMagnesium
Spiritual/Documentation f- fCORRECT fANSWER f-Native fAmerican f- fAllow fpt's ffamily fto fstay fin fthe froom
Leadership- fInterpreter finformed fconsent f- fCORRECT fANSWER f-Pt fshould fsign fthe fconsent
Geriatrics/Emergency fRib ffractures ffall f- fCORRECT fANSWER f-Pulmonary fembolism
A fclient fdiagnosed fwith fmajor fdepression fis fbeing fallowed fa fweekend fpass ffrom fthe fpsychiatric
funit. fWhich finstruction fshould fthe fnurse fprovide fto fthe fclient's ffamily? f- fCORRECT fANSWER f-Involve
fthe fclient fin fusual fat fhome factivities
Upon fassessment, fthe fnurse fdiscovers fthat fa fpostpartum fclient fhas fpersistent fred flochia.
, Which fof fthe ffollowing fdoes fthis fassessment ffinding fsuggest fto fthe fnurse? f- fCORRECT fANSWER f-
fCoagulation fdisorders
The fhealthcare fprovider fperforms fperitoneal fdialysis fon fa fclient, fafter fwhich f2 fliters fof ffluid fis
fdrained. fWhat faction fshould fthe fnurse fcomplete ffirst? f- fCORRECT fANSWER f-Assess fvital fsigns.
After fadministering fa fmedication fthrough fa fnasogastric ftube fconnected fto fsuction, fwhat faction
fshould fthe fnurse ftake ffirst? f- fCORRECT fANSWER f-Clamp fthe ftube
The fnurse fis fcaring ffor ffour fclients: fClient fA f94% fo2 fsaturation, fClient fB, fhemoglobin fof f8.;
Client fC, fpotassium flevel fof f3.8 fand fClient fD fappendectomy fwho fhas fa fwhite fblood fcell fcount fof
f15,000.
What
should fthe fnurse fimplement? f- fCORRECT fANSWER f-Determine fif fClient fB fhas ftwo funits fof fpacked
fcells favailable fin fthe fblood fbank.
Triage fquestion fwith fa ftrain fwreck fThe fpsychiatric fnurse fis fcalled fto fa ftrain fderailment fthat fwas
flikely fcaused fby fa fterrorist fbomb. fIn ftriaging fthose fin fneed fof fimmediate fcare, fwhat fis fthe fpriority
franking ffor fthese fcases?
(arrange fthese fcases fin forder for fpriority fwith fthe ftop fitem frequiring fthe fmost fimmediate fcare fand
fthe fbottom fitem frequiring fthe fleast fpriority fcare) f- fCORRECT fANSWER f-A fmother fand ffather fhave
fjust farrived fon fthe f.
A fcrying fchild fbeing fheld fby fanother fpassenger. fA fwoman fsitting fon fthe fground fwith fa fblanket.
A fmiddle-aged fman fwho fis fwandering faround
(arrange fin forder) f= fmiddle fage fwoman fbleeding- fwoman fw/ fblanket- fchild fcrying- fmother fand
ffather. f(Mine fdidn't fhave fa fmiddle fage fwoman fbleeding, finstead fit fhad fan fold fman fwandering fand
f- fCORRECT fANSWER f-correct forder fis: fwandering fold fman, fwoman fw/blanket, fman fholding fbaby,
fand fmother f& ffather)