2024 Predictor Exam A Test Bank with 150+ Questions from Actual Past Exam, Exams of Nursing

Download 2024 Predictor Exam A Test Bank with 150+ Questions from Actual Past Exam and more Exams Nursing in PDF only on Docsity! 2024 Kaplan Predictor Exam A Test Bank with 150+ Questions from Actual Past Exam and 100% Correct Answers The nurse cares for a toddler diagnosed with croup. The nurse notes the toddler's respiratory and heart rates have increased significantly. Sub sternal and intercostal retractions are pronounced, and the child is restless. Which action should the nurse take FIRST? a. Suction the child's airway. b. Contact the health care provider. c. Percuss the child on the back. d. Increase the oxygen flow rate. --------- Correct Answer --------- b. Contact the health care provider. The client reports dyspnea, sever chest pain, nausea, and increased anxiety. Which lab value would cause the nurse to contact the physician? a. Creatinine kinase (CK) 155 units/L. b. Troponin T 0.9 ng/mL. c. Low-density-lipoproteins (LDL) 175 mg/dL. d. Total serum lipids 850 mg/dL. --------- Correct Answer --------- b. Troponin T 0.9 ng/mL. The nurse cares for infants in the newborn nursery. Which observation requires the nurse to contact the physician? a. The Asian female, 12 hours old, has a large bluish area noted across the sacrum and left hip. b. An African-American make, 2 hours old, has fine bi-basilar crackles. c. Uneven skin folds are noted on a the upper legs of a Mexican-American female born 6 hours ago. d. The anterior fontanel of a Caucasian male born 28 hours ago is moderately firm and flat. --------- Correct Answer --------- c. Uneven skin folds are noted on a the upper legs of a Mexican-American female born 6 hours ago. The nurse cares for the client diagnosed with partial thickness burns to the entirety of both arms. Using the Rule-of-Nines, the nurse estimates the injury is which percentage? a. 18% b. 29% c. 36% d. 9% --------- Correct Answer --------- a. 18% The home care nurse visits the client diagnosed with late stage Parkinson's disease. The client sits in a wheelchair. Which statement, if made by the caretaker, indicates to the home care nurse teaching is effective? a. "My Client should push the hips up from the wheelchair for about 10 seconds every hour or so." b. "My client should elevate the knees with a pillow when lying in bed." c. "I will limit my client's time in the wheelchair to 30 minutes each day." d. "I will encourage my client to c --------- Correct Answer --------- a. "My Client should push the hips up from the wheelchair for about 10 seconds every hour or so." The home care nurse makes a visit to the client diagnosed with heart failure. The client reports having difficulty sleeping at times. The nurse should take which action FIRST? a. Recommend taking over-the-counter diphenhydramine (Benadryl) b. Encourage a half hour of moderate exercise prior to going to bed. c. Obtain a thorough sleep assessment history. d. Instruct the client to nap during the day. --------- Correct Answer --------- c. Obtain a thorough sleep assessment history. The nurse cares for the client admitted to the critical care unit. The nurse observes splinter hemorrhages in the nails, painful nodules on the fingertips and splenomegaly. It is MOST important for the nurse to take which action? a. Determine if client can comply with home IV therapy. b. Auscultate the precordium for murmurs. (ENDOCARDITIS) c. Instruct the client about the importance of balancing rest and activity. d. Encourage the client to perform oral hygiene twice a day. --------- Correct Answer ----- ---- b. Auscultate the precordium for murmurs. (ENDOCARDITIS) An adolescent undergoing hemodialysis tells the nurse, "My friends are all going on a big trip over spring break and I can't go. I don't think they'll miss me much anyway." Which is the BEST response by the nurse? a. I would not worry about that. You can communicate with them while they are gone. b. You must be disappointed. Describe what you are feeling right now. c. I've been left out of things before; you'll feel better when the break is over. --------- Correct Answer --------- b. You must be disappointed. Describe what you are feeling right now. The nurse cared for clients diagnosed with AIDS. The nurse recognizes which statement is true regarding therapy? 1. Pneumonia and influenza vaccines are contraindicated. 2. Protease inhibitors affect cell replication and have been successful. 3. Clients respond best when using single antiviral-type of medication. 4. Most of the medications used are administered by the IV route. --------- Correct Answer --------- 2. Protease inhibitors affect cell replication and have been successful. The nurse instructs the client about a lumbar puncture. In which position will the client be placed? 3. Pimento cheese with crackers, grapes, cookies, 4 oz diet soda. 4. Grilled cheese sandwich, dill pickle, apple, 4 oz tomato juice. --------- Correct Answer --------- 1. Turkey on wheat bread, carrot sticks, chocolate cake, 6 oz iced tea LOW SODIUM DIET, WATER FOLLOWS SALT The nurse obtains a health history for the school-age child diagnosed with asthma. It is most important for the nurse to follow up on which statement made by the child? 1. "I use a vaporizer in my room every night". 2. "I play football and basketball". 3. "I live in a rural area". 4. "I snack on fresh fruit and raw vegetables". --------- Correct Answer --------- 3. "I live in a rural area". The nurse cares for the client just admitted to the surgical unit from recovery after a total hip replacement. It is MOST important for the nurse to take which action? 1. Elevate the affected extremity on pillows. 2. Position the client in high Fowler's position. 3. Place the client in Buck's traction. 4. Position the client with the legs abducted. --------- Correct Answer --------- 4. Position the client with the legs abducted. ABDUCTION SPLINTER OR TWO PILLOWS BETWEEN LEGS The nurse cares for the school-age child receiving phenytoin. The nurse should observe for which known adverse effect? 1. Hyperactivity several hours after ingestion. 2. Gingival hyperplasia. 3. Flushed face within an hour of ingestion. 4. Pinpoint pupils. --------- Correct Answer --------- 2. Gingival hyperplasia. (phenytoin =Dilantin=anticonvulstant) The nurse cares for the child diagnosed with cystic fibrosis. The nurse should intervene if the child is eating which food? 1. Chili. 2. Roasted chicken tenders. 3. A vanilla milkshake. 4. Slice of watermelon. --------- Correct Answer --------- 3. A vanilla milkshake. LOW FAT, HIGH PROTEIN, HIGH CARB AND CALORIES The client diagnosed with type 1 diabetes reports to the nurse, "I feel really nervous and jittery all over". The nurse notes regular insulin was administered two hours ago. Which action should the nurse take FIRST? 1. Review all medications the client has received. 2. Determine the client's recent dietary intake. 3. Administer a simple carbohydrate. 4. Request laboratory draw serum blood glucose. --------- Correct Answer --------- 2. Determine the client's recent dietary intake. Question 93 is #1 --------- Correct Answer --------- Question 94 is #2 --------- Correct Answer --------- The nurse cares for the client diagnosed with bipolar disorder. The nurse determines which activity is appropriate for the client during a period of mania? Select all that apply. 1. Relaxation exercises. 2. Playing board games with other clients. 3. Watching the television. 4. Scheduled rest periods. 5. Aerobic exercises. 6. Listening to soft music. --------- Correct Answer --------- 1. Relaxation exercises. 4. Scheduled rest periods. 5. Aerobic exercises. 6. Listening to soft music The health department nurse cares for the client diagnosed with tuberculosis and positive HIV status, sharing concerns over financial and childcare issues and life expectancy. Which referral is MOST appropriate for this client? 1. A non-denominational chaplain. 2. Financial counselor at a non-profit agency. 3. Social worker from social services department. 4. The director of the local homeless shelter. --------- Correct Answer --------- 3. Social worker from social services department. The adolescent tells the school nurse she is planning to start sexual relations with her boyfriend. Which is the BEST response by the nurse? 1. "I can make a referral to a gynecologist for you". 2. "Have you discussed this decision with your parents?" 3. "Surely you understand I'll have to let your parents know". 4. "How do you plan on paying for contraceptives? --------- Correct Answer --------- 2. "Have you discussed this decision with your parents?" The nurse cares for the client after colostomy surgery. Eight hours after surgery, what observation would the nurse expect? 1. A dusky-red appearance of the stoma. 2. Absence of any output from the colostomy. 3. Bright bloody drainage from the nasogastric tube. 4. Presence of hyperactive bowel sounds. --------- Correct Answer --------- 2. Absence of any output from the colostomy. The nurse care for the clients in the Sleep Study Unit. The nurse recognizes which client is at GREATEST risk for developing obstructive sleep apnea? 1. 30 year old male, works nightshift as a security guard. 2. 50 year old female, smokes two packs/day. 3. 60 year old male, 55 pounds over ideal weight. 4. 40 year old female, active alcoholic. --------- Correct Answer --------- 3. 60 year old male, 55 pounds over ideal weight. The client after radical prostatectomy expresses concern related to ongoing urinary incontinence. Which response by the nurse is BEST? 1. Have you been doing Kegel exercises? 2. It is important to anticipate leakage and stay close to a bathroom at all times. 3. Drinking more fluids with your meals will decrease the need to void. 4. Avoiding caffeine and alcohol may reduce bladder irritation. --------- Correct Answer -- ------- 1. Have you been doing Kegel exercises? The client reports severe lower back pain radiating down the left leg. The client identifies the pain as 9 on a 0-10 scale and states, "It feels like I've been stuck with a hot poker". Which order should the nurse anticipate? 1. Opioid analgesic. 2. Nonsteroidal anti-inflammatory drugs. 3. Immunosupressant agent. 4. Topical nonopioid analgesic. --------- Correct Answer --------- 1. Opioid analgesic. The nurse on the pediatric unit receives report from the previous shift. Which client should be seen FIRST? 1. The 8 year old newly diagnosed with type 1 diabetes with a blood sugar of 285 mg/dl. 2. The 2 year old diagnosed with asthma whose pulse oximeter reading is 97%. 3. The 6 year old recovering from an appendectomy with a temperature of 100.3 degrees F (37.9 degrees C). 4. The 10 year old with cerebral palsy with a newly placed enteral nutrition --------- Correct Answer --------- 1. The 8 year old newly diagnosed with type 1 diabetes with a blood sugar of 285 mg/dl. The nurse instructs the client receiving enoxaparin (LOVENOX). Which client response indicates teaching is EFFECTIVE? 1. I will inject the medication into the far left or right side of my abdomen every day. 2. I can take ibuprofen if I am feeling pain. 3. The antidote to enoxaparin is Vitamin K. 4. I am taking enoxaparin to dissolve blood cloths. --------- Correct Answer --------- 1. I will inject the medication into the far left or right side of my abdomen every day. The nurse cares for a client diagnosed with dehydration. The plan of care indicates the client is to drink two ounces of fluid every hour. The nurse determines the goal is met if which is recorded on the intake and output (I&O) sheet for an eight-hour shift? a. 360 ml b. 160 ml c. 480 ml d. 240 ml --------- Correct Answer --------- c. 480 ml 1 oz=30 ml; 60 oz*8= 480 ml The nurse and LPN/LVN care for clients on a medical-surgical unit. The RN should delegate which activity to the LPN/LVN? a. Follow up on the client's report of chest and back itching two hours after starting a patient controlled analgesia pump. b. Provide instruction for the client receiving the first nicotine patch. c. Inform the health care provider of the client's history of peptic ulcer disease prior to administration of streptokinase. d. Take the blood pressure and heart rate before admin --------- Correct Answer --------- d. Take the blood pressure and heart rate before administration of enalapril. The nurses care for the client diagnosed with tuberculosis. Before discontinuing airborne precautions, the nurse must confirm which? a. The tuberculin skin test is negative b. No acid-fast bacteria are in the sputum. c. The client has received anti-tuberculin medication for three days. d. The client's temperature has returned to normal. --------- Correct Answer --------- b. No acid-fast bacteria are in the sputum. The nurse cares for the client at 28 weeks gestation diagnosed with a complete placenta previa. The nurse determines discharge teaching is effective if the client makes which statement to her husband? a. I can go back to work tomorrow on a part-time basis b. I'm sorry to tell you we can't have sexual relations c. I will still be able to have a vaginal birth d. I have to come back in 48 hours for a vaginal exam --------- Correct Answer --------- b. I'm sorry to tell you we can't have sexual relations The nurse prepares the client diagnosed with myxedema for discharge. Which action should the nurse teach related to body temperature? a. "Alternate acetaminophen with ibuprofen every four hours for fever" b. "Take your temperature and record the results three times a day." c. "Put on multiple layers of clothes until you fell comfortably warm." d. "Use a heating pad during the day and electric blanket at night." --------- Correct Answer --------- c. "Put on multiple layers of clothes until you fell comfortably warm. The nurse cares for clients in the labor and delivery unit. The nurse anticipates which client is a candidate for induction of labor? a. The client with the fetal face as the presenting part. b. The client diagnosed with preeclampsia. c. The client diagnosed with active herpes infection. d. The client experiencing late decelerations. --------- Correct Answer --------- b. The client diagnosed with preeclampsia The nurse cares for the client diagnosed with HIV. The nurse determines which goal is MOST important? a. Prevent Kaposi's sarcoma. b. Prevent depression c. Prevent infections. d.Prevent social isolation. --------- Correct Answer --------- c. Prevent infections. The nurse educator presents an in-service on acyanotic heart disease. Which is the most common symptom of this disorder that the nurse educator should include? a. Severe retarded growth. b. Clubbing of the fingers and toes. c. Presence of an audible heart murmur. d. Polycythemia. --------- Correct Answer --------- c. Presence of an audible heart murmur. The nurse provides care for the client diagnosed with pneumonia who has postural drainage twice a day. Which client response indicates to the nurse that treatment is effective? a. "My upset stomach is better." b. "I am coughing up more sputum." c. "My cough is better." d. "I don't feel feverish anymore." --------- Correct Answer --------- b. "I am coughing up more sputum." The risk management department plans a program to reduce errors. Which is the most common cause of errors in medication administration? a. Failure to follow routine policy and procedures. b. Caring for too many clients. c. Responsible for administering numerous medications. d. Unfamiliar with monk of the new pharmaceuticals ordered. --------- Correct Answer ---- ----- a. Failure to follow routine policy and procedures. The nurse cares for the school-aged child newly diagnosed with type 1 diabetes. The nurse instructs the family that the child's insulin needs will decrease during which situation? a. Active exercise b. Infection c. Emotional stress. d. Puberty. --------- Correct Answer --------- a. Active exercise The nurse cares for the client receiving lactulose. The nurse determines the medication is effective if which is observed? a. The client's weight increases by 5 pounds. b. The client denies shortness of breath. c. The client's urinary output is 2000 ml daily. d. The client is alert and oriented to person, place and time. --------- Correct Answer ----- ---- d. The client is alert and oriented to person, place and time. The nurse cares for the three-year-old prior to a surgical procedure. Which behavior indicates that the child is coping with preoperative preparation? a. The child hops around the room pretending to be a bunny while the nurse attempts to obtain a blood pressure reading. b. The child talks about the picture of a nurse and client while coloring the picture using a number of bright colored crayons. c. The child sits quietly reading a story about a boy who is going to have surgery while the nurse r --------- Correct Answer --------- b. The child talks about the picture of a nurse and client while coloring the picture using a number of bright colored crayons. The nurse instructs the client after a total hip arthroplasty. The client will utilize which assistive devices in the home? SATA a. Wheelchair b. A long-handled shoehorn. c. A reaching device. d. A raised toilet seat. e. A trochanter roll. f. A shower bench. --------- Correct Answer --------- b. A long-handled shoehorn. c. A reaching device. d. A raised toilet seat. f. A shower bench. The client reports vomiting and diarrhea for three days. Which assessment finding does the nurse anticipate? a. Bradycardia b. Decreased blood pressure. c. Peripheral edema. d. crackles. --------- Correct Answer --------- b. Decreased blood pressure. The nurse cares for the client in active labor. The health care provider orders an oxytocin infusion. Which action should the nurse take FIRST after initiating the infusion? a. Time and record the length and strength of the contractions. The nurse cares for a client diagnosed with pancreatic cancer. When talking to the client about the diagnosis, the nurse anticipates the client will make which statement? a. How can I have cancer when I don't hurt anywhere on my entire body? b. I've been feeling fine and didn't go to the doctor until my skin was kind of yellow. c. I should have known something was wrong when I gained 10 pounds in six weeks. d. My last couple of bowel movements have look almost black in color. --------- Correct Answer --------- b. I've been feeling fine and didn't go to the doctor until my skin was kind of yellow. The parent of an adolescent diagnosed with hemophilia calls the nurse to discuss the adolescent's desire to participate in sports. Which activity should the nurse recommend? a. Soccer b. Gymnastics c. Swimming d. Snowboarding --------- Correct Answer --------- c. Swimming 1. The nurse prepares to administer medications to the following clients. Which medication should the nurse pass FIRST? a. Cephalexin to the postoperative client with a white blood cell count (WBC of 9.5/mm3 b. Morphine to the postoperative client term-42 reporting pain at a 5 on a 0-10 scale. c. Ipratropium to the newly-admitted client diagnosed with chronic obstructive pulmonary disease. d. Warfarin tot eh client with a prothrombin (PT) time of 16 seconds and an international normalized ratio --------- Correct Answer --------- c. Ipratropium to the newly-admitted client diagnosed with chronic obstructive pulmonary disease. The nurse provides discharge instructions to the client with a tube after traditional cholecystectomy. The nurse determines teaching is effective if the client makes which statement? a. The tube can be used to administer stone dissolving medications. b. This tube will stay in for 1-2 weeks and drainage will decrease. c. If it is this with mucus or blood, I an irrigate the t-tube. d. I should milk the tube every 4 hours and record the drainage. --------- Correct Answer --------- b. This tube will stay in for 1-2 weeks and drainage will decrease. The nurse prepares to administer digoxin for the 5-year-old child. The nurse should withhold the drug and contact the physician for which finding? a. The one-time dose of furosemide is also due. b. Child has not eaten in several hours. c. The nurse notes pallor of the child's skin. d. A apical heart rate of 88 assessed. --------- Correct Answer --------- d. A apical heart rate of 88 assessed. (60 or less adult, 90 or less children) The nurse cares for the client with a chest tube. Immediately after the tube is removed, it is MOST important for the nurse to take which action? a. Cover the section site with a moist saline dressing. b. Secure the insertion site with several steri-strips. c. Assist the health care provider to close the insertion site with sutures. d. Request a STAT portable chest X-ray. --------- Correct Answer --------- d. Request a STAT portable chest X-ray. The home care nurse cares for the client diagnosed with benign prostatic hyperplasia. The client reports not voiding since the previous evening. Assessment reveals a distended bladder. Which action should the nurse take NEXT? a. Apply gentle pressure over the client's pubic area. b. Encourage the client to increase oral intake of fluids. c. Obtain an order for a straight catheter. d. Assist the client into a warm shower. --------- Correct Answer --------- c. Obtain an order for a straight catheter. The nurse assigns the nursing assistive personnel (NAP) to the mother who is first day postpartum following a vaginal birth. Which tasks are appropriate for the nurse to delegate to the NAP? (SATA) a. Check the location of the fundus twice a shift. b. Help the mother to ambulate shortly after delivery. c. Assist the mother with changing the perineal pad. d. Inform the mother about appropriate cord cake. e. Assist the mother with breast-feeding. f. Instruct the mother about cleansing the perineum --------- Correct Answer --------- b. Help the mother to ambulate shortly after delivery. c. Assist the mother with changing the perineal pad. Two days after a short leg cast was applied for a fractured tibia, the client reports new, severe pain over the calf area. Which action should the nurse take FIRST? a. Instruct the client to elevate the leg above the heart. b. Obtain a cast cutter and elastic compression bandages c. Contact the health care provider. d. Assess bilateral deep tendon reflexes. --------- Correct Answer --------- c. Contact the health care provider. The nurse counsels the client diagnosed with herpes simplex virus (HSV) infection. Which suggestion by the nurse BEST meet the client's needs to cope with this diagnosis? a. Pamphlets about the disease and treatment. b. Web sites containing sexual transmitted disease (STD) information. c. Contact information for a local support group. d. Information about promising drug research. --------- Correct Answer --------- c. Contact information for a local support group. The nurse prepares the 3 year old for discharge after a tonsillectomy. The nurse recommends the parents offer the child which food during the first 24 hours? a. Cherry popsicle b. Vanilla milkshake c. Lemon-lime soft drink d. Cream of tomato soup. --------- Correct Answer --------- c. Lemon-lime soft drink The client receives enteral nutrition at 50 ml/hour due to dysphagia. Which nursing action diagnosis would be the priority? a. Risk for fluid volume excess. b. Risk for electrolyte imbalance. c. Risk for imbalanced nutrition. Less than body requirements. d. Risk for aspiration. --------- Correct Answer --------- d. Risk for aspiration The charge nurse has received change-of-shift report on a medical-surgical unit. Which activity can be delegated to an LPN/LVN? (SATA) a. Transfuse platelets for a client. b. Change a dressing on a client with a stage IV pressure ulcer. c. Initiate discharge teaching for the client whose B/P was 88/64 an hour ago. d. Obtain vital signs on a client whose BP was 88/64 an hour ago. e. Irrigate an urinary catheter. f. Administer water through a gastrostomy tube. --------- Correct Answer --------- b. Change a dressing on a client with a stage IV pressure ulcer. d. Obtain vital signs on a client whose BP was 88/64 an hour ago. e. Irrigate an urinary catheter. f. Administer water through a gastrostomy tube. The nurse presents information about misuse of medications to the senior citizen group. Which client response indicates a safe medication practice? a. It is okay to use someone else's medication if it is similar to my prescription. b. If I miss a dose of medication, I should not double up on the next dose. c. Combining prescribed medicines with other the counter ones is cost-saving. d. Sometimes we have prescriptions from several doctors out of necessity. --------- Correct Answer --------- b. If I miss a dose of medication, I should not double up on the next dose. The nurse cares for the client in the emergency department. The client's friends state the client inhaled varnish remover and passed out. The nurse notices a rash around the client's nose and mouth, axillary temperature 97.8 degrees, pulse 66, respiration 12, blood pressure 168/88, pulse oximetry 98%. Which action should the nurse take FIRST? a. Provide oxygen 2L per nasal cannula. b. Evaluate pupillary response. c. Listen to heart sounds a. Apply super absorbent perineal pads. b. Establish intravenous access. c. Administer oxygen per nasal cannula. d. Place the client in Trendelenburg position. --------- Correct Answer --------- c. Administer oxygen per nasal cannula. When providing respiratory care for the client with a tracheostomy, it is MOST important for the nurse to take which action? a. Keep the trach cuff inflated during suctioning. b. Apply suction as the catheter is being inserted. c. Instill acetylcysteine just prior to suctioning. d. Preoxygenate the client prior to suctioning. --------- Correct Answer --------- d. Preoxygenate the client prior to suctioning. The nurse provides care to a client diagnosed with cirrhosis. Which is the BEST explanation for the development of edema? a. Decreased concentration of plasma albumin. b. Decreased production of aldosterone causing sodium and water retention. c. Shunting of the blood from the portal vessels into the lower pressure vessels. d. Inadequate formation, use and storage of vitamin K. --------- Correct Answer --------- a. Decreased concentration of plasma albumin. With cirrhosis there is malnutrition, with malnutrition there is decreased albumin, with decreased albumin there is edema. Nurses working in hospital environments should follow which guideline related to effective hand washing? a. Use a petroleum-based lotion for prevention of dryness. b. Have the water temperature as hot as tolerated. c. Clean under artificial nails prior to starting shift. d. Wash for at least fifteen seconds covering all surfaces. --------- Correct Answer -------- - d. Wash for at least fifteen seconds covering all surfaces The nurse cares for the primigravida during the transition phase of labor. Which is MOST important for the nurse to include in the client's plan of care? a. Provide feedback to reduce client's anxiety. b. Assess client's emotional reaction to impending parenthood. c. Catheterize client is unable to void for 2 hours. d. Provide comfort measures including position changes. --------- Correct Answer --------- d. Provide comfort measures including position changes. The nurse cares for the client diagnosed with a hearing impairment. Which is a PRIORITY action for the nurse to take? a. Talk with a raised voice. b. Utilize more hand gestures. c. Speak at a slightly slower pace. d. Use more facial expressions. --------- Correct Answer --------- c. Speak at a slightly slower pace. The nurse cares for the newborn with a port wine stain covering the face and half the body. The nurse notes that the mother refuses to look at the newborn. Which response by the nurse is MOST appropriate? a. Allow the mother to recover from the fatigue of delivery and then bring the newborn to her. b. Empathetically the mother not to blame herself for the newborn's appearance. c. Talk to the family about the situation and encourage the family to comfort the other. d. Reinforce the health care pr --------- Correct Answer --------- d. Reinforce the health care provider's explanation of the defect and allow time for the mother to discuss her fears. The nurse reviews a diet containing broiled catfish, baked green beans, a roll, a brownie, and tea. The nurse identifies this diet is most appropriate for which condition? a. Celiac disease. b. Type 1 diabetes. c. Acute pancreatitis. d. Crohn's disease. --------- Correct Answer --------- d. Crohn's disease. ASSESS FIRST ;IPPA (she inspected and now palpate) The nurse admits the 6-month old infant diagnosed with hypovolemia secondary to diarrhea. The physician orders KCL 1 mEq per kg/body weight in 250 ml 0.9% saline. Prior to administering the medication, which action should the nurse take FIRST? 1. Validate the baby has wet a diaper. 2. Determine the possible causes for the diarrhea. 3. Offer the electrolyte solution orally. 4. Arrange for a central line catheter placement. --------- Correct Answer --------- 1. Validate the baby has wet a diaper. No PEE no K!!!!!! The nurse cares for the client diagnosed with HIV. The client reports difficulty coping with the diagnosis. The nurse encourages the client to take which action? 1. Attend church services weekly. 2. Obtain a prescription or an anti-depressant medication. 3. Keep a journal recording feelings. 4. Identify successful coping mechanisms used in the past. --------- Correct Answer ------ --- 4. Identify successful coping mechanisms used in the past. The nurse cares for a client scheduled for a magnetic resonance imaging (MRI) of the back. Which client response required an intervention by the nurse? 1. I am allergic to shellfish and iodine. 2. I use nitroglycerin tablets for angina. 3. I had a total hip replacement three years ago. 4. I am on a blood thinner and bleed easily. --------- Correct Answer --------- 3. I had a total hip replacement three years ago. The nurse instructs the client diagnosed with vitamin B12 deficiency. The nurse recognizes teaching is effective if the client chooses which menu? 1. Broiled chicken breast, white rice, green beans, and lemonade. 2. Liver and onions, macaroni and cheese, tossed salad, and milk. 3. Medium-rare beef steak, baked sweet potato, boiled carrots, and soda. 4. Baked pork chop, mashed potatoes, creamed corn, and tea. --------- Correct Answer - -------- 2. Liver and onions, macaroni and cheese, tossed salad, and milk. The nurse cares for the client diagnosed with advanced cirrhosis. When the client raises both arms, the nurse observes flapping tremors of the hands and wrists. What is the medical term used to describe this? 1. Apraxia. 2. Caput medusa. 3. Fetor hepaticus. 4. Asterixis. --------- Correct Answer --------- 4. Asterixis. The nurse cares for the client who returned from overseas having recently lost both lower limbs to a car bomb. The nurse notes the client is increasingly irritable, is unable to sleep well due to recurring nightmares, and seems hyper vigilant. The nurse recognizes these symptoms are most likely indicative of which condition? 1. Obsessive compulsive disorder (OCD). 2. Bipolar disorder. 3. Regression. 4. Post-traumatic stress disorder (PTSD). --------- Correct Answer --------- 4. Post- traumatic stress disorder (PTSD). The nurse cares for the client following a vegan diet. The nurse recognizes which meal selection is BEST? 1. Scrambled eggs, wheat toast, coffee, and cantaloupe. 2. Bagel with peanut butter, strawberries and orange juice. 3. Bran flakes, soy milk, grapefruit and tofu. 4. Fresh fruit, yogurt, blueberry muffin, and tea. --------- Correct Answer --------- 3. Bran flakes, soy milk, grapefruit and tofu. ONLY EATS VEGETABLE PRODUCTS. The nurse assists the client to breastfeeding the baby for the first time. Which observation by the nurse indicates that the baby is nursing appropriately? 1. Hypernatremia. 2. Hypomagnesemia. 3. Hypocalcemia. 4. Hyperkalemia. --------- Correct Answer --------- 1. Hypernatremia. The newly admitted client tells the nurse, "I have not had a good bowel movement in 10 days". It is MOST important for the nurse to ask which question. 1. What types of food with fiber do you eat? 2. Have you had small amounts of liquid stool? 3. Do you notice a bad odor to your breath? 4. Are you having any nausea and vomiting? --------- Correct Answer --------- 2. Have you had small amounts of liquid stool? CAN BE OBSTRUCTION OR IMPACTION The nursing instructor reviews electrolytes and discusses common causes for hypercalcemia. The instructor determines teaching is effective when the student choose which as a common cause of hypercalcemia? 1. Malnutrition. 2. Bone malignancy. 3. Hyperthyroidism. 4. Long-term use of furosemide. --------- Correct Answer --------- 2. Bone malignancy. (the bone releases calcium into the bloodstream) The nurse cares for the client after percutaneous transluminal coronary angioplasty (PTCA) with stent placement. The nurse determines care is appropriate if which tasks are delegated to the nursing assistive personnel (NAP)? Select all that apply. 1. Remind the client to remain flat in bed. 2. Obtain vital signs every 15-30 minutes. 3. Assess the distal pulses every 15-30 minutes. 4. Provide the client with fluids to drink. 5. Reinforce the pressure dressing. 6. Immediately call for an electroca --------- Correct Answer --------- 1. Remind the client to remain flat in bed. 2. Obtain vital signs every 15-30 minutes. 4. Provide the client with fluids to drink. The nurse cares for the client two days after surgery. As the nurse hangs a new bag of IV fluids, the client reports sudden chest pain and says. "I can't breathe". What would be the nurse's FIRST action? 1. Insert an intravenous line and obtain an apical heart rate. 2. Place the client in high Fowler's position and auscultate the lungs. 3. Determine if the client has a history of cardiac problems. 4. Ask the nursing assistant personnel to stay with the client while the nurse calls Respiratory Th --------- Correct Answer --------- 2. Place the client in high Fowler's position and auscultate the lungs. The nurse receives a call from a client. The client reports having dark-colored bowel movement. Which action by the nurse is MOST appropriate? 1. Determine if the client is taking ferrous sulfate. 2. Instruct the client to see the health care provider as soon as possible. 3. Tell the client to continue monitoring the bowel movement. 4. Ask if the client as eaten new foods. --------- Correct Answer --------- 1. Determine if the client is taking ferrous sulfate. The nurse cares for the client diagnosed with type 2 diabetes and an infection in the left foot. Which observation MOST concerns the nurse? 1. The wound site shows evidence of granulation. 2. WBC 8,300/mm3. 3. Erythrocyte sedimentation rate (ESR) 28.2 mm/h 4. T 99.2 F (37.3 C), P 88, R 18, BP 120/76 --------- Correct Answer --------- 3. Erythrocyte sedimentation rate (ESR) 28.2 mm/h The nurse cares for the client diagnosed with advanced Parkinson's disease. Which activity is MOST appropriate to decrease fatigue? 1. Establish a regular bed time. 2. Provide for morning and afternoon naps. 3. Avoid high carbohydrate foods. 4. Schedule alternating periods of rest and activity. --------- Correct Answer --------- 4. Schedule alternating periods of rest and activity. The client has a 2.5 centimeter abdominal aortic aneurysm (AAA) discovered on X-ray. The nurse determines which goal is MOST appropriate for the client? 1. The client will report pain of no greater than "4" on a 0-10 scale. 2. The client will return for follow-up appointments every 6 months. 3. The client will verbalize understanding of perioperative nursing care. 4. The client will limit activities to bathing, eating, dressing, and toileting. --------- Correct Answer --------- 4. The client will limit activities to bathing, eating, dressing, and toileting. The nurse cares for the client diagnosed with diabetes insipidus. Which finding will the nurse expect to observe? 1. Daily fluid intake of 1-2 liters. 2. Urine specific gravity of 1.050. 3. Daily urine output of 10 liter. 4. Serum sodium level of 120 mEq/L. --------- Correct Answer --------- 3. Daily urine output of 10 liter. (Polyuria 2 to 24 L/day, low specific gravity 0.006,) The nursing supervisor observes the staff nurse's ease and excellence in communicating with new parents and family members. The supervisor recommends the staff nurse for the position teaching childbirth classes. What component of leadership has the supervisor demonstrated? 1. Empowerment. 2. Charismatic leadership. 3. Compassionate leadership. 4. Shared governance. --------- Correct Answer --------- 1. Empowerment. The nurse receives report for clients on a Woman's Health Unit. Which client should the nurse see FIRST? 1. The client post bladder repair reports pain is not fully relieved by medication administered through the PCA pump. 2. The client 6 hours after a right mastectomy reports the sheets under her torso feel wet. 3. The client 12 hours after abdominal hysterectomy with a pulse of 90 and B/P 130/88. 4. The client diagnosed with pelvic inflammatory disease with an oral temperature of 101.8 degrees --------- Correct Answer --------- 2. The client 6 hours after a right mastectomy reports the sheets under her torso feel wet. The nurse instructs the client after a cataract extraction with a lens implant. The nurse determines further teaching is necessary if the client makes which statement? 1. I need to make every effort to avoid sneezing, coughing, or vomiting. 2. I have to sleep with this eye shield on but can wear my glasses during the day. 3. I should call the doctor if I start seeing double or flashes of light. 4. It's okay to bend over and pick up my grandchild if I am wearing my eye shield. -------- - Correct Answer --------- 4. It's okay to bend over and pick up my grandchild if I am wearing my eye shield. The nurse cares for the client in active labor. The client reports contractions started about 3 hours ago. The contractions occur every 4-5 minutes lasting for about 1 minute. The client's water broke about an hour ago, and the pains are getting worse. Which action should the nurse take first? 1. Administer oxygen 2 L/min by nasal cannula. 2. Place external uterine and fetal monitors on the client's abdomen. 3. Assist the client into a high-Fowler's position. 4. Instruct the partner to model pur --------- Correct Answer --------- 2. Place external uterine and fetal monitors on the client's abdomen. The client is scheduled for a pelvic ultrasound. Prior to the procedure it is MOST important for the nurse to take which action? 1. Encourage the client to completely empty her bladder.