ATLS POST EXAM PRACTICE TEST CDR Questions with Correct Answer Latest Updates 2024.pdf, Exams of Nursing

Download ATLS POST EXAM PRACTICE TEST CDR Questions with Correct Answer Latest Updates 2024.pdf and more Exams Nursing in PDF only on Docsity! HESI PN PRACTICE EXAM TEST Final Exam Questions with Correct Answer Latest Updates 2024 The nurse is planning care for a client who has fourth degree midline laceration that occurred during vaginal delivery of an 8 pound 10 ounce infant. What intervention has the highest priority? A. Administer Prescribed stool softener B. Administer prescribed PRN sleep medications. C. Encourage breastfeeding to promote uterine involution D. Encourage use of prescribed analgesic perineal sprays. - A. Administer Prescribed stool softener The nurse is palpating the right upper hypochondriac region of the abdomen of a client. What organ lies underneath this area. A. Duodenum B. Gastric Pylorus C. Liver D. Spleen - C. Liver A client comes to the antepartum clinic and tells the nurse that she is 6 weeks pregnant. Which sign is she most likely to report? A. Decreased sexual libido B. Amenorrhea C. Quickening D. Nocturia - B Amenorrhea A client's daughter phones the charge nurse to report that the night nurse did not provide good care for her mother. What response should the nurse make? A. Ask for a description of what happened during the night B. Tell the daughter to talk to the unit's nurse manager C. Reassure the daughter that the mother will get better care. D. Explain that all the staff are doing the best they can. - A. Ask for a description of what happened during the night A hospitalized toddler who is recovering from a sickle cell crisis holds a toy and say's "mine". According to Erikson's theory of psychosocial development, this child's behavior is a demonstration of which developmental stage? A. Autonomy vs. Shame and doubt. B. Industry vs. Inferiority C. initiative vs. Guilt D. Trust vs. Mistrust - A. Autonomy vs. Shame and doubt. Which action should the nurse implement in caring for a client following an electroencephalogram (EEG)? A. Monitor the client's vital signs q4h B. Assess for sensation in the client's lower extremities C. Instruct the client to maintain bed rest for eight hours D. Wash any paste from the client's hair and scalp - D. Wash any paste from the client's hair and scalp The nurse is caring for a 75- year-old male client who is beginning to form a decubitus ulcer at the coccyx. Which intervention will be most helpful in preventing further development of the decubitus? A. Encourage the client to eat foods high in protein B. Assess the client with daily range of motion exercises C. Teach the family how to perform sterile wound care D. Ensure the IV fluids are administered as prescribed - A. Encourage the client to eat foods high in protein What is the homeostatic cellular transport mechanism that moves water from a hypotonic to a hypertonic fluid space? C. Observe a client rotate the subcutaneous site for an insulin pump D. Monitor a continuous narcotic epidural for a postoperative client - C. Observe a client rotate the subcutaneous site for an insulin pump After morning dressing changes are completed, a male client who has paraplegia contaminates his ischial decubiti dressing with a diarrheal stool. What activity is best for the nurse to assign to the unlicensed assistive personnel? A. Identify the need for additional supplies to provide an extra dressing change B. Provide perianal care and collect clean linens for the dressing change C. Document the diarrhea that necessitates an additional dressing change D. Position the client for access to the decubiti sties and remove dressings - B. Provide perianal care and collect clean linens for the dressing change The nurse is planning to evaluate the effectiveness of several drugs administered by different routes. ArtRage the routes of administration in the order from fastest to slowest rate of absorption. Subcutaneous Intravenous Intramuscular Sublingual Oral - Intravenous, sublingual, intramuscular, subcutaneous, oral. A 26-year-old gravida 4, para 0 had a spontaneous abortion at 9 weeks gestation. At one-house post dilation and curettage (D&C) the nurse assess the vital signs and vaginal bleeding. The client begins to cry softly. How should the nurse intervene? A. Offer to call the social worker to discuss the possibility of abortion B. Reassure the client that the infertility specialist can help C. Express sorrow for the client's grief and offer to sit with her D. Chart the vital signs and amount of vaginal bleeding - C. Express sorrow for the client's grief and offer to sit with her A terminally ill male client and his family are requesting hospice care after discharge from the hosptial and ask the nurse to explain what kind of care they should expect. The nurse should indicate that hospice philosophy focuses on what aspect of health care? A. Enhance symptom management to improve end of life quality B. facilitates assisted suicide with the client's consent C. Offers ways to postpone the death experience at home D. Provide training for family members to care for the client. - A. Enhance symptom management to improve end of life quality The nurse observes a wife shaving her husband's beard with a safety razor by holding the skin taut and shaving in the direction of the hair growth . What action should the nurse take? A. Advsie the wife to shave against the hair growth B. Teach the wife to keep the skin loose to avoid cuts C. Encourage the wife to continue shaving her husband D. Demonstrate the correct procedure to the wife - C. Encourage the wife to continue shaving her husband To assess pedal pulse what arterial sites should the nurse palpate? (select all that apply) A. Posterior tibialis artery B. Politeal artery C. External femoral artery D. Dorsalis pedis artery E Radial artery - A. Posterior tibialis artery, D. Dorsalis pedis artery The nurse is admitting a client who is diagnosed with Angina Pectoris. Which precipitating factor in this client's history is likely to be related to the anginal pain? A. Smokes one pack of cigarettes daily B. Drinks two beers daily C. Works in a job that requires exposure to the sun D. Eats while lying in bed - A. Smokes one pack of cigarettes daily The nurse is assessing an older resident of a long-term care facility who has a history of Benign Prostatic Hypertrophy and identifies that the client's bladder is distended. The healthcare provider prescribes post-voided residual catherterization over the next 24 hours and placement of an indwelling catheter if the residual volume exceeds 100 mL. The client's PO intake is 600 mL, and fifteen minutes ago, the client voided 90 mL. What action should the nurse take? A. Stand the client to void and run tap water within hearing distance before catheterizing the client. B. Straight catheterize and if the residual uring volume is greater than 100 mL, clamp catheter C. Catheterize q2H and place in an indwelling catheter at the end of the prescribed 24hr period. D. Catheterize with an indwelling catheter and if the residual volume is greater than 100 mL. Inflate the balloon. - D. Catheterize with an indwelling catheter and if the residual volume is greater than 100 mL. Inflate the balloon. A client is receiving dexamethasone (Hexadrol, Decadron). What symptoms should the nurse recognize as Cushionoid side effects? When inserting an indwelling urinary catheter (Foley) in a female client, the nurse observes uring flow into the tubing. What action is taken next? A. Document the color and clarity of the urine B. Insert the catheter an additional inch C. Ask the client to breathe deeply and slowly exhale D. Inflate the balloon with 5mL of sterile water - B. Insert the catheter an additional inch A client has a prescription for a Transcutaneous Electrical Nerve Stimulator (TENS) unit for pain management during the postoperative period following a lumber Laminectomy. What information should the nurse reinforce about the action of this adjuvant pain modality? A. Mild electrical stimulus on the skin surface closes the gates of nerve conduction for sever pain B. Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus C. An infusion of medication in the spinal canal will block pain perception D. The discharge of electricity will distract the client's focus on the pain - B. Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus Based on the Nursing diagnosis of "Potential for infection related to second and third degree burns," which intervention has the highest priority? A. Application of topical antibacterial cream B. Use of careful hand washing technique C. Administration of plasma expanders D. Limiting visitors to the burned client. - B. Use of careful hand washing technique The mother of an 8-year-old boy tells the nurse that he fell out of a tree and hurt his arm and shoulder, which assessment finding is the most significant indicator of possible child abuse? A. The child looks at the floore when answering the nurse's questions B. The mother's version of the injury is different from the child's version C. The child has several abrasions on the chest and legs D. The mother refuses to answer questions about family history - D. The mother refuses to answer questions about family history A client has a prescription for enteric-coated (EC) aspirin 325mg PO daily. The medication drawer contains one 325mg aspirin. What action should the nurse take? A. Contact the pharmacy and request the prescribed form of aspirin B. Instruct the client about the effects when given the medication C. Administer the aspirin with a full glass of water or a small snack D. Withhold the aspirin until consulting with the healthcare provider - C. Administer the aspirin with a full glass of water or a small snack The nurse explains the 2-week dosage prescription of prednison (Deltasone) to a client who has poison ivy over multiple skin surfaces. What should the nurse emphasize about the dosing schedule? A. Decrease dosage daily as prescribed B. Monitor oral temperature daily C. Take the prednison with meals D. Return for blood glucose monitoring in one week - C. Take the prednison with meals The nurse is preparing to administer a 1.2mL injection to a 4-year- old. Which are the best sites to administer an IM injection? Select all that apply. A. Vastus lateralis B. Ventrogluteal C. Dorsogluteal D. Rectus femoris E. Deltoid - A. Vastus lateralis B. Ventrogluteal C. Dorsogluteal Which nonfood item is the most common cause of respiratory arrest in young children? A. Broken rattles B. Buttons C. Pacifiers D. Latex balloons - D. Latex balloons A new mother is at the clinic with her 4-week old for a well baby check up. The nurse should tell the mother to anticipate that the infant will demonstrate which millstone by 2-months of age. A. Turns from side to back and returns B. Consistently returns smiles to mother C. Finds hands and plays with fingers D. Holds head up and supports weight with arms - B. Consistently returns smiles to mother The nurse is monitoring a client's intravenous infusion and observes that the venipuncture site is cool to the touch, swollen and teh infusion rate is slower than the prescribed rate. What is the most likely cause of this finding? D. A blood pressure of 180/110 - C. A respiratory rate of 10 breaths per minute Following an open reduction of the tibian, the nurse notes fresh bleeding on the client's cast. Which intervention should the nurse implement? A. Assess the client's hemoglobin to determine if the client is in shock B. Call the surgeon and prepare to take the client back to the operating room C. Outline the area with ink and check it q15 minutes to see if the area has increased D. No action is required since postoperative bleeding can be expected - C. Outline the area with ink and check it q15 minutes to see if the area has increased The nurse is with a client when the healthcare provider explains that the biopsy classifies the results as a T1N0M0 tumor. Later in the morning, the client asks the nurse, "what do these letters T1N0M0, stand for?" which response should the nurse provide first? A. "The letters are used to predict the prognosis of the cancer or tumor." B. "The letters stand for tumor size, node involvement and metastasis." C. "Let me refer you to the charge nurse." D. "Are you confused? Would you like to talk?" - B. "The letters stand for tumor size, node involvement and metastasis." The nurse plans to administer the rubella vaccine to a postpartum client whose titer is < 1:8 and who is breastfeeding? what information should the nurse provide this client? A. The client should bottle feed and pump her breast for 3 days following immunization B. The vaccine is given to produce maternal antibodies before lactation occurs C. The infant will receive immunization through the mother's breast milk D. The client should not get pregnant for 3 months after immunization - B. The vaccine is given to produce maternal antibodies before lactation occurs In counting a client's radial pulse, the nurse notes the pulse is weak and irregular. To record the most accurate heart rate, what should the nurse take? A. Recheck the radial pulse in thirty minutes B. Palpate the radial pulse for thiry seconds and double the rate C. Count the apical pulse rate for sixty seconds D. Compare the radial pulse rate bilaterally and record the higher rate. - C. Count the apical pulse rate for sixty seconds Which structures are located in the subcutaneous layer of the skin? A. Sebaceous and sweat glands B. Melanin and Keratin C. Sensory receptors and hair follicles D. Adipose cells and blood vessels - D. Adipose cells and blood vessels The nurse in charge of a Nursing unit in a long term care facility. Which task is best for the nurse to assign to an unlicensed assistive personnel (UAP) who i shelping with the care of several clients? A. Measure the amount of a client's residual urine after voiding B. Cleanse the perineal area of a client with urinary incontinence C. Insert a straight catheter to obtain a urine specimen for culture D. Provide catheter care for a client with a suprapubic catheter - B. Cleanse the perineal area of a client with urinary incontinence A client requires application of an eye shield to the right eye. What should the nurse do in order to apply tape in which direction to anchor the shield most effectively? A. Across the eye from the bridge of the nose to the right temple B. Longitudinally from the right forehead to the right cheek C. From the mid-forehead over to the right zygomatic process D. From the right lateral forehead surface to the medial nasal crease - B. Longitudinally from the right forehead to the right cheek 36 hours after delivery, the nurse determines a client's fundus is just above the umbilicus and displaced to the right of midline. What action should the nurse take first? A. Palpate the bladder for distention B. Ask the client when her last bowel movement occurred C. Catheterize the client and record the amount D. Assess the amount of lochia - A. Palpate the bladder for distention A client presents in the clinic because of generalized swelling after a bee sting. What intervention should the nurse implement first? A. Assess site of sting and remove stinger if present B. Perform mini-mental status exam to assess level of consciousness C. Determine respiratory status and apply a pulse oximeter D. Attach electrodes to monitor cardiac rhythm - C. Determine respiratory status and apply a pulse oximeter The nurse is administering multiple medications to a 78-year-old client because of problems related to polypharmacy. At this client's age, which assessment is most important for the nurse to make? A male client with Hypercholesterolemia is being discharged with a new prescription for simvastatin (Zocor). The client tells the nurse that he understands it is important to have liver tests performed periodically. How should the nurse respond? A. Instruct the client that the only regular testing needed is to monitor his cholesterol level B. Teach the client that liver test are usually only done if the client reports symptoms C. Review with the client that renal function tests are needed, rather than liver tests D. Confirm that the client correctly understands the need to monitor liver function regularly - D. Confirm that the client correctly understands the need to monitor liver function regularly An obese female client with a high serum cholesterol level comes to the clinic for a follow-up evaluation. She tells the nurse that she is now walking 30 minutes three times per week and is eating a carbohydrate free, high protein diet in order to lose weight. What response is best for the nurse to provide? A. Explain to the lcient that her diet choice is not helpful in lowering cholesterol levels B. Discuss the importance of maintaining a target heart rate during each excercise period C. Teach the client additional ways to lower cholesterol, including stress management D. Praise the client for her excercise and dieting efforts and encourage her to continue with this program - A. Explain to the lcient that her diet choice is not helpful in lowering cholesterol levels A child with Chronic Asthma is scheduled for Chest Physiotherapy. When should the nurse administer the meter-dosed inhalar (MDI) puff of bronchodilator relative to postural drainage treatments? A. Before postural drainage B. During postural drainage C. After postural drainage D. Between treatements - C. After postural drainage A client has a prescription for lorazepam (ativan) 1 mg for anxiety. The medication is supplied as 0.5mg tablets. How many tablets should the client take? (enter numeric value only. - 2 The nurse is caring for a middle-aged client who had a Myocardial infarction (MI) 3 days ago. Which finding is most important for the nurse to report? A. Frothy red-tinged sputum B. Irregular heart rate C. Two pound weight gain D. Dependent edema - B. Irregular heart rate A client is diagnosed with Clostridium Difficile (CDIFF). What action should the nurse implement to prevent the spread of the organism? A. Place a surgical mask on the client during transport B. Don non-sterile gloves when performing direct care C. Wear a particular respirator mask when in the room D. Keep the door closed to the client's room at all times - B. Don non-sterile gloves when performing direct care A 67-year-old woman who lives alone tripped on a rug in her home and fractured her right hip. The nurse knows that which predisposing factor contributes to the occurrence of hip fractures among elderly women. A. Urinary retention resulting in renal calculi formation B. Failing eyesight resulting in an unsafe environment C. Osteoporosis resulting from hormonal changes D. Transient ischemic attacks (TIAs) which impair mental activity - C. Osteoporosis resulting from hormonal changes An elderly client is admitted for evaluation of Alzheimer's disease. At 2AM, the nurse finds the client tyring to open the emergency door. What is the most appropriate response for the nurse to make in this situation? A. "This is the emergency door. Are you looking for the bathroom?" B. "You look confused. Would you like to talk about your feelings?" C. "Let's go back to your room. Your doctor does not want you to be walking alone." D. "You want to go outside at this time of night? It's dangerous out there." - A. "This is the emergency door. Are you looking for the bathroom?" Which nurse's behavior is a breach of client confidentiality according to the Health Insurance Portable Accountability Act (HIPPA) regulations? A. A daily report sheet with the information of the team's clients is taken home. B. Privileged health information (PH) is mailed through the US postal service C. A client is called by both the first and last name in a public waiting room. D. The ambulance health care provider is given information about the client's history - A. A daily report sheet with the information of the team's clients is taken home. A client is returning to the surgical unit after a total right knee replacement. Which assessment findings are most important for the nurse to include in this client's record? law mandates all newborns receive prophylactic treatment to prevent gonorrheal or chlamydial ophthalmic infection The scope of practice for the practical nurse includes which client assessments? A. An agitated client with bilateral wrist restraints B. New admission of a client with deep vein thrombosis C. Return of a postaneshesia client following a colon resection D. Transfer of a client with sepsis from a long-term care facility - D. Transfer of a client with sepsis from a long-term care facility What skin care measure should the nurse implement for a client who underwent an external radiation treatment the previous day? A. Cleanse the radiated area with water and pat the skin dry B. Lightly massage the radiated skin with a lanolin-based lotion C. Rinse the site with normal saline and cover with a sterile towel D. Use of soft washcloth to gently remove the skin markings - A. Cleanse the radiated area with water and pat the skin dry Which organ lays retroperitoeally? A. Kidneys B. Testicles C. Urinary bladder D. Pancreas - A. Kidneys The nurse is caring for a client with Myasthenia Gravis. What time of day is best for the nurse to schedule physical excercises with the physical therapy department? A. Before bedtime, at 2000 B. After breakfast C. Before the evening meal D. After lunch - B. After breakfast The nurse is planning to ambulate client who has been on bed rest for 24 hours following a Colon Resection. To ambulate this client safely, which intervention should the nurse implement first? A. Place non-skid shoes on the client B. Show the client how to use the call light C. Use a gait belt to support the client D. Assist the client to a bedside sitting position - D. Assist the client to a bedside sitting position A Client is admitted to the hospital with second and third degree burns to the face and neck. How should the nurse best position the client to maximize function of the neck and face and prevent contracture? A. The neck extended backward using a rolled towel behind the neck B. Prone position using pillows to support both arms outward from the torso C. Side-lying position using pillows to support the abdomen and back D. The neck forward using pillows under the head and sandbags on both sides - A. The neck extended backward using a rolled towel behind the neck A client receives a new prescription for the angiotensin II receptor antagonist losartan (Cozaar). Which client instruction should the nurse encourage this client to follow? A. Move slowly when getting up to prevent sudden dizziness B. Take this medication with or after meals C. Do not stop this medication until all of the tablets are gone D. Keep the dietary log during initial therapy - A. Move slowly when getting up to prevent sudden dizziness The healthcare provider prescribes erythromycin (ilosone) 300 mg PO QID. The medication label reads, "ilosone 100mg/5mL" How many mL should the nurse administer at each does? (Enter the numeric value only) - 15 The nurse is monitoring a client with an IV infusion in the left antecubital fossae. The infusion pump is functioning without alarms at the prescribed rate of 100mL/hour. The site is warm, red and without swelling. What conclusion should these findings indicate to the nurse? A. The IV fluids are infusing into the subcutaneous tissues and the pump should be stopped B. The infusion pump is functioning properly and the IV site is healthy C. The insertion date should be verified and the IV discontinued D. The site is inflamed and should be reported to the RN for placement in another site. - D. The site is inflamed and should be reported to the RN for placement in another site. The nurse reviewes the laboratory results of a client whose serum pH is 7.38 on the pH scale what does this value imply about the clients homeostasis A. Alkalosis B. Acidosis C. Normal serum PH D. Incompatible with life - C. Normal serum PH The nurse plans to assess a newborn and to check the infant's Moro reflex. In assessing this reflex, the nurse is evaluating which parameter? D. Use an acetaminophen suppository for the fever since the child is vomiting - A. Make the child NPO and hold all medications untill the vomiting has stopped A client is having Radical Masectormy. What is the position of choice during the immediate postoperative period? A. Side-lying on the operative side with the bed flat B. Supine with the arm on the operative side in a dependant position C. Semi-Fowler's position with the arm on the operative side elevated D. Sim's position with the arm on the operative side in a dependant position - C. Semi-Fowler's position with the arm on the operative side elevated The nurse assesses the perineum of a client 12 hours after a normal vaginal delivery and finds that she has Perineal Hematomas. The nurse should prepear for which treatment? A. Heat lamp three times per day B. Insertion of vaginal packing C. Cold packs to the perineum D. Operative excission of the hematomas - C. Cold packs to the perineum A client at 28 weeks gestation is admitted to the antepartum unit and is being treated for preterm labor. She has a prescription for brethine (Terbutaline) 250 micrograms subcutaneously q4h. The medication is available for injection in 1 mg per ML vials. How many mL should the nurse administer? A. 0.025 B. 0.0025 C. 0.25 D. 25.0 - C. 0.25 A school-aged child with AIDS is exposed to an active case of Varicella. The nurse should recommend that the family take which action? A. Obtain penicillin G 1000U weekly B. Obtain the varicella vaccine C. Enroll in a home school program D. Obtain the varicella zoster immune globulin - D. Obtain the varicella zoster immune globulin The principle of client advocacy is best demonstrated when the nurse exhibits which behaviors on behalf of the client? A. Nurse who contracts child protective services to report a mother's decision to refuse vaccination for her firstborn infant B. Nurse refusing to care for a convicted rapist stating that personal discomfort would inhibit provision of quality of care C. Nurse who translates complaints for a Spanish-speaking client to the healthcare provider during rounds D. Nurse sharing information about life after death with a grievin family who just lost a loved one - C. Nurse who translates complaints for a Spanish-speaking client to the healthcare provider during rounds The nurse is preparing a client for an Intravenous Pyelogram (IVP) scheduled for the following morning. What action is most important for the nurse to implement? A. Determine if the client has any allergies to shellfish B. Inform client that an IV dye will be administered before the IVP C. Explain that dizziness may occur when the dye is given D. Administer a bowel prep the evening before the procedure - A. Determine if the client has any allergies to shellfish A nurse refuses to perform a procedure because itis beyond the scope of practice for practical nurses. Which resource best defines the nurse's legal responsibility in regard to scope of practice? A. Nursing practice standards for Licensed Practical/Vocational Nurses B. State Nurse Practice Act C. Code of Ethics for Licensed Practical/Vocational Nurses D. Patients Bill of Rights - B. State nurse Practice Act While making the bed of a female client who is sitting in the bedside chair, the nurse observes the client seem anxious. To encourage verbalization by the client, what action should the nurse take? A. Continue to make the bed while conversing with the client B. Sit next to the client at a slight angle to continue the conversation C. Remain standing close enough to the client to hold her hand D. Bring a chair face-to-face with the client for further discussion - B. Sit next to the client at a slight angle to continue the conversation A client is admitted for observation after experiencing a Transient Ischemic Attack (TIA). The nurse anticipates implementing care for which client problem? A. High risk for injury B. Altered breathing patters C. Ineffective airway clearance D. High risk infection - B. Altered breathing patters An elderly postoperative client has the Nursing diagnosis, "Impaired mobility related to fear of falling." Which desired outcome best directs Nursing actions for this client? A. The physical therapis will instruct the client in the use of a walker The nurse is administering the shingles vaccine to an older male- client who asks why he should receive the immunization. Which information should the nurse provide? A. A history of chickenpox indicates that the harbors the dormant virus B. The client's last dose of adult immunizations was 10 years ago C. A recent outbreak of fever blisters indicates reactivation of the virus D. Multiple stressful personal experiences increase his risk of shingles - A. A history of chickenpox indicates that the harbors the dormant virus In preparing a client for a lumbar puncture, what action should the nurse implement? A. Assist the client to the bathroom to void B. Apply a pulse oximeter to the client's finger C. Teach the client to cough and deep breathing exercises D. Ensure that the client has been NPO for six hours. - C. Teach the client to cough and deep breathing exercises A client who had a lobectomy two days ago has 2 chest tubes, each attached to a water-sealed drainage system, Pleur-Evac. The nurse observes that in the last 8 hours the serosanguineous fluid has diminished to output in the drainage chamber. What is the most likely outcome of this observation? A. Removal of the lower chest tube, if a chest x-ray reveals no pleural accumulations B. Change the Pleur-Evac system and re-assess output in the empty chamber C. An increase in the prescribed suction force to facilitate-drainage of serosanguineous fluids D. Advance the chest tube to ensure proper placement of the tip to enhance drainage - B. Change the Pleur-Evac system and re-assess output in the empty chamber While caring for a client who has been vomiting, the nurse notes that the client's breath has developed a fuity odor. What assessment should the nurse perform first? A. Auscultate the client's bowel sounds B. Determine the client's capillary glucose C. Observe the color of the client's urine D. Measure the client's oxygen saturation - B. Determine the client's capillary glucose The nurse is preparing to assist an elderly client to the bathroom. The nurse knows that an elderly adult's center of gravity changes from the hips to another area of the body. Which area of the body is the center of gravity for the elderly client? A. Upper torso B. Head C. Feet D. Upper extremities - A. Upper torso A 60 year-old client with cancer of the liver is in Hepatic Coma and unresponsive. What should the nurse say to family members who are inquiring about the condition of their loved one? A. "Your loved one's condition is very critical, and there has been no response in the last 24 hours" B. "The nurses have not been able to arouse the client and the healthcare provider knows the outcome." C. "You need to discuss the condition with the charge nurse in a family conference." D. "The client's condition is extremely critical. Has your family made funeral arrangements?" - A. "Your loved one's condition is very critical, and there has been no response in the last 24 hours" A client complains of kidney pain. The nurse understands that the kidneys are located where? A. On the retroperitoneal posterior abdominal wall at the costovertebral angle B. Within the curve of the duodenum, posterior to the spleen C. Lateral to the stomach in the hypochondriac region D. Superior aspect of the bladder in right and left iliac region - A. On the retroperitoneal posterior abdominal wall at the costovertebral angle The nurse receives report on an adult client who has a central intravenous (IV) infusion. Where should the nurse observe when assessing the integrity of the access site? A. Umbilical area of the abdomen B. Antecubital fossae of the arm C. Chest wall below the clavicle D. Dorsal surface of the hand - C. Chest wall below the clavicle The healthcare provider prescribes an IV solution of clindamycin (Cleocin) 850mg in 75 mL of D2W to infuse over 30 minutes. The drop factor is 15 gtt/mL. The nurse should regulate the IV to deliver how many gtt/minute? (Enter numeric value only. if rounding is required round to the nearest whole number) 75mL X 15gtt/mL = 38 - 38 The nurse is administering a subcutaneous injection of epoetin (Epogen) to a client with Chronic Kidney Disease (CKD). This B. Suction the client's oral cavity C. Provide the client an emesis basin D. Place the client in a side-laying position - D. Place the client in a side-laying position The nurse is caring for a 10-year-old child with hemophilia who has recently been diagnosed as HIV positive. What precautions should the nurst take when interacting with the child and mother? A. No special precautions are needed B. Wear gloves only C. Wear gloves and a mask D. Wear a mask, gloves and gown. - A. No special precautions are needed A 26 year-old primigravida who delivered a 7-pound male infant 26 hours ago tells the nurse that she is confused about when she and her husband can return to having sexual intercourse. What info should the nurse reinforce with this client? A. They can have intercourse when the episiotomy is healed and the lochial flow has stopped B. They should wait to resume sexual activities until the fatigue assorted with a new baby has passed C. They can resume sexual activity at 6 weeks postpartum D. It is best to wait until both parties feel up to having sexual intercourse - A. They can have intercourse when the episiotomy is healed and the lochial flow has stopped The healthcare provider tells the family of a 6-year old child with a malignant brain tumor that the tumor is metastasizing and the child's condition is terminal. How can the nurse best help the family cope with this news? A. Refer the family to a support group to find answers to their questions B. Reinforce the stages of the grieving process C. Listen to the family's reactions and reflect and their fears and concerns D. Transfer the child to a private room - C. Listen to the family's reactions and reflect and their fears and concerns The nurse is implementing the plan of care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts? A. Describes being very depressed B. Has little appetite and neglects personal hygiene C. Is not interested in the activities of family and friends D. Begins to show signs of improvement - D. Begins to show signs of improvement On a short-staffed unit a long-term care facility, it is important that the nurse assign the unlicensed assistive personnel (UAP) to complete morning care for the resident with which problem first? A. Dyspnea who uses oxygen continously B. Straight catheterization to be performed q6h C. Frequent episidoes of fecal incontinence D. Bolus feeding via PEG tube to be performed q4h - C. Frequent episidoes of fecal incontinence The nurse assess a client receiving a hypertonic full strength tube feeding that is infusing continous at 50 mL/hr. Which finding is most important for the nurse to reprot to the charge nurse? A. Dry mucous membranes B. Gastric residual of 50 mL C. Report of increased hunger D. Hyperactive bowel sounds - C. Report of increased hunger A male client who was admitted with Gangrene of the right lower extremity (RLE) is confused and his wife refuses to sign the operative permit for an above the knee amputation. What action should the nurse take next? A. Explain the consequences of Sepsis if the amputation is delayed B. Notify the RN that the client's wife needs further explanation about the procedure C. Document on the client's record the refusal for surgical treatment D. Enourage the client's wife to express concerns about making the decision - D. Enourage the client's wife to express concerns about making the decision A male client attends a community support program for mentally impaired and chemically abusive clients. The client tells the nurse that his drug of choise are cocaine and heroin. What is the greatest health risk for this client? A. Hepatitis B. Hypertention C. Diabetes D. Glaucoma - D. Glaucoma A male client who was admitted with Gangrene of the right lower extremity (RLE) is confused and his wife refuses to sign the operative permit for an above the knee amputation. What action should the nurse take next? A. Explain the consequences of Sepsis if the amputation is delayed B. Notify the RN that the client's wife needs further explanation about the procedure C. Document on the client record the refusal for surgical treatement A. Keep the catheter intact while assisting the client with a shower B. Remove the catheter while the client takes a shower C. Provide the client with a sponge bath in a chair or the bed D. Assist the client with a tub with the catheter clamped - A. Keep the catheter intact while assisting the client with a shower Based on the Nursing diagnosis of, "Risk for Infection," which intervention should the nurse implement when providing care for an elderly client with Urinary incontinence? A. Maintain standard precautions B. Utilize an antibacterial perineal wash C. Insert an indwelling urinary catheter D. Initiate contact isolation precautions - A. Maintain standard precautions The charge nurse brings a #18fr urinary catheter (Foley) with a 30 mL balloon to the nurse who is preparing to insert a catheter in a female client who weighs 50 kg. What action should the nurse take first? A. Ask the client if she has previously been catheterized B. Position the client and observe the urinary meatus C. Obtain a 30 ml syringe and a vial of sterile water D. Consult with the chage nurse about the catheter - D. Consult with the chage nurse about the catheter An 82-year old client is admitted to the hospital with a fractured right hip. Following surgical repair, a footboard is placed at the client's feet. What is the reason the nurse will offer concerning the footboard? The footboard is used to... A. Prevent foot drop B. Prevent hip dislocation C. Promote moving in bed D. Promote early ambulation - A. Prevent foot drop Following a left leg above the knee amputation (AKA), a client voices several complaints. Which statement should be reported to the charge nurse immediately? A. My left foot is so painful B. My incision is so dry C. I've been feeling so light headed D. I'm tired of turning so much - C. I've been feeling so light headed In caring for a client following a below the knee amputation (BKA) which task is best for the nurse to delegate to the unlicensed assistive personnel (UAP) who is assisting with the care of this client? A. Empty and measure the drainage in the suction drainage device B. Reassure the client that phantom limb pain is genuine pain C. Review the client's vital signs for indications of infection D. Observe and mark the amount of drainage on the dressing - A. Empty and measure the drainage in the suction drainage device 2 days after an abdominal hysterectomy, an elderly client with diabetes Mellitus Type II has a syncopal episode. Her vital signs are within normal limites and her sugar is 325 mg/dL. what intervention should the nurse implement first? A. Give the client 4 ounces of orange juice B. Administer next scheduled dose of metformin (Glucophage) C. Cancel the clients dinner tray D. Administer regular insulin per sliding scale - D. Administer regular insulin per sliding scale A client returns to the postoperative unit following an open reduction and internal fixation of a hip fracture. The practical nurse applies the prescribed sequential compression devise (SCD) to both lower extremities. (BLE). What action is important when turning the client to a lateral position? A. Decrease the amount of pressure exerted on both legs while turning the client B. Replace the SCD's with an antiembolic stockings while using an abduction pillow C. Remove both of the SCDs while the cient is turned to the lateral position D. Observe the SCDs continue to inflate and deflate when the client is turned - D. Observe the SCDs continue to inflate and deflate when the client is turned When the nurse asks a male client with Bipolar Disorder if he is going to group session, he responds, "there is no use in me going to that group because all they talk about is Schizophrenia, which doesn't apply to me." Which response is best for the nurse to provide this client? A. "Tell me what medications you are taking right now" B. "You are probably right. The group really does not apply to your condition." C. "It sounds to me like it may be better for you that you stay here" D. "Let's talk about what you may have in common with the other group members." - D. "Let's talk about what you may have in common with the other group members." A client is admitted with a newly diagnosed case of active tuberculosis (TB). Which intervention should the nurse teach the client about controlling transmission of tuberculosis (TB)? A. Proper disposal of tissues when coughing B. Importance of an adequate diet C. Complication sof the disease The nurse is emptying the bedpan of a client with a bleeding gastric ulcer. What type of stool can the nurse expect this client to have. A. Black tarry stool B. Coffee-ground stool C. Bright red bloody stool D. Clay-colored stool - A. Black tarry stool Which structure of the tracheobronchial tree is the most likely to compromise air passage when the smooth muscle layer is affected? A. Secondary bronchi B. Bronchioles C. Segmental bronchi D. Alveolar ducsts - B. Bronchioles The nurse is administering routine medications to an assigned group of elderly clients at an extended care facility. Which physiological change commonly associated with aging, increases the elderly client's risk of having an adverse response to the medication? A. Decreased gastrointestinal motility B. Poor cognitive function C. Poor peripheral circulation D. Decreased mobility - A. Decreased gastrointestinal motility A client with diabetes is admitted with a 1cm size ulcer on the left great toe. The nurse observes that the left foot has a dusky color. In planning the client's care, which intervention should the nurse implement first? A. Bathe the wound daily with soap and water B. Record the color and temperature of the leg C. Perform dorsal flexion and extension exercises D. Check the client's dorsalis pedis and posterior tibialis pulse point - D. Check the client's dorsalis pedis and posterior tibialis pulse point An ambulatory client with an indwelling urinary catheter (Foley) is requesting to take a shower for the first time. What is the best intervention for the nurse to implement? A. Clamp the catheter and assist the client with a tub bath B. Keep the catheter intact and assist the client with a shower C. Encourage the client to do self-care and provide personal care products D. Assist the client with a sponge bath in a chair or the bed - B. Keep the catheter intact and assist the client with a shower The nurse overhears a conversation between an unlicensed assistive personnel (UAP) and another staff member in the hospital cafeteria line concerning a client's reaction to being given a diagnosis of terminal cancer. What is the best Nursing action? A. Approach the individuals involved and ask them to stop B. Write an incident report and submit it to the unit manager C. Tell the client of the UAPs concern for him D. Try not to listen to the conversation since it is confidential - B. Write an incident report and submit it to the unit manager During the past 30 days an elderly client has exhibited a progressively decreasing appetite, is spending increasing amounts of the daytime hours in bed, and refuses to participate in planned daytime activities. Which action should the nurse take? A. Withhold any medications that may cause these side effects B. Motivate the client by offering favorite foods as a prize C. Ask the family members to visit more often to stimulate the client D. Record the findings and report the symptoms to the charge nurse - D. Record the findings and report the symptoms to the charge nurse A client is receiving nitroglycerin sublingual tablets for angina. What response should the nurse expect the client to manifest in response to the administration of this drug during an acute anginal episode? A. Pulse oximetry within normal limits B. Cessation of acute chest pain C. Hypertension and headache D. Premature ventricular contractions (PVC) - B. Cessation of acute chest pain After a client returns from Hemodialysis, the nurse measures the client's weight and notes a 3-pound weight loss from the pre-dialysis weight. The client reports feeling weak and fatigued. What action should the nurse take next? A. Measure the client's blood pressure B. Auscultate the client's breath sounds C. Observe the client's legs for edema D. Determine the client's blood glucose - A. Measure the client's blood pressure When providing oral care to an unconscious client who is a mouth breather and does not swallow, which action is most important for the nurse to implement? A. Use an oral suction catheter in the buccal cavity B. Inspect the oral cavity using gloves fingers C. Perform oral cleansing with a sponge toothette A man who was brought to the psychiatric hospital by the sheriff because he was hallucinating and stumbling on a downtown street, refuses to wait for a psychiatric evaluation. Which action should the nurse take? A. Tell the man when the elevator will see him B. Alert the staff to monitor exits to prevent escape C. Warn the client that he is likely to have a seizure D. Offer a hot meal a clean bed and a sleeping pill - D. Offer a hot meal a clean bed and a sleeping pill The nurse is assessing care for residents on a 12-bed unit in an extended care facility. The staff consists of 1 unlicensed assistive personnel (UAP) and 1 certified medication aide. Which task should the nurse perform? A. Ambulate the client who has left hemiplegia and uses a cane B. Administer medications and formula to a client with a gastronomy tube C. Change a hydrocolloid dressing for a client with a stage II pressure ulcer D. Provide self-catheterization equipment for a client with paraplegia - B. Administer medications and formula to a client with a gastronomy tube The nurse is reviewing the discharge medication instructions with a client for disulfiram 10mg (Antabuse). Which instruction should the PN reinforce with the client? A. Avoid all sources of alcohol while taking this drug including cough syrups B. The medication should be taken at the same time each day C. Stop the drug if nausea, vomiting and/or prostration occur D. Have weekly blood tests to determine therapeutic drug levels and serum sodium - A. Avoid all sources of alcohol while taking this drug including cough syrups The nurse is preparing a client for a bone marrow aspiration. Which erythropoietic site is most likely to be used to obtain the specimen? A. Vertebrae B. Ribs C. Cranial bones D. Iliac crest - D. Iliac crest A male client admitted the morning of his scheduled surgery tells the nurse that he drank a glass of water during the night. What intervention will the nurse implement first? A. Auscultate the client for bowel sounds and ability to urinate B. Determine the amount of water and exact time it was taken C. Notify the healthcare provider of the client's fluid intake D. Reassure the client that a small amount of water is not harmful - B. Determine the amount of water and exact time it was taken The nurse is providing care for a client receiving an intravenous antibiotic to treat an infection. Which assessment findings require the most immediate action by the RN? A. Warm skin with elastic turgor B. Dry mouth with thirst C. Low grade fever with diaphoresis D. Hives with pruritus - D. Hives with pruritus The nurse should perform oral suctioning for a client with what problem? A. Atelactasis B. Dysphasia C. Gastric reflux D. Dysphagia - D. Dysphagia An elderly client at an adult daycare center with Type2 Diabetes Mellitus becomes unresponsive verbally and then tells the nurse, "I just don't feel right" Which initial action should the nurse take? A. Assess temperature B. Evaluate deep tendon reflexes C. Give 4 ounces of apple juice D. Administer glucagon 0.5mg IM - C. Give 4 ounces of apple juice A 75-year-old male client with Alzheimer's Disease (AD) is admitted to an extended care facility. What intervention should the nurse include into his client's Nursing care plan? A. Describe the activities available to the residents and encourage him to choose the ones he prefers B. Introduce the client to the Nursing staff and the residents as soon as possible C. Plan to have the same Nursing staff provide care for the client whenever possible D. Encourage the client to remain on the unit for 3 weeks until he is oriented to his new surroundings - C. Plan to have the same Nursing staff provide care for the client whenever possible A newborn infant with a tracheoesophageal repair is receiving Gastrostomy (GT) feedings postoperatively. What intervention should the nurse implement during the GT feedings? B. Bowel movements decrease to 1 every third day C. Urinary output decreases of 250mL in the last 24 hours D. D. Systolic blood pressure decrease of 10mmHg - B. Bowel movements decrease to 1 every third day A nurse sees a colleague taking drugs from the hospital unit. What action should the nurse take? A. Report the incident to the person in charge of the unit or Nursing supervisor B. Notify the hospital security staff to retrieve the drugs from the colleague C. Report the colleague to the peer review committee of the hospital D. Confront the colleague and tell him/her to take the drugs back to the unit - A. Report the incident to the person in charge of the unit or Nursing supervisor Which term describes 2 or more tissues that compose a structure and perform a specific function? A. Elastic tissue B. Organ C. System D. Serous membrane - B. Organ How many mL should the nurse document when calculating a client's 8-hour fluid intake? (Enter the numeric value only.) 0730 - 4 ounces of orange juice, hardboiled egg, and toast 1130 - 1/2 cup of soup, one half sandwich, and 1/2 cup of apple juice 1300 - vomitus of 100 mL 1400 - voided 250 ml and consumed one 12-ounce can of soft drink (type your answer in the box below) 1oz = 30mL; so 4oz of orange juice X 30mL = 120mL of orange juice Then 1 cup = 240; so ½ cup is 120mL of soup and ½ cup of apple juice is 120mL of apple juice = 240mL total vomitus is output, not intake, so ignore voided is output, not intake, so ignore 1 oz = 30mL; so 12oz is 12oz X 30mL = 360mL add them all; 120mL + 240mL + 360mL = 720mL - 720 A male client is receiving ferrous sulfate (iron), docusate sodium (Colace) and codeine. He reports that his last bowel movement was 3 days ago. During medication administration, which action should the nurse implement? A. Offer the client a full glass of water B. Give medications 2 hours apart C. Provide a snack with the medications D. Administer only the docusate sodium - A. Offer the client a full glass of water The nurse is caring for a primagravida 5 hours after a vaginal delivery. Which finding should the nurse report immediately to the charge nurse? A. Pulse rate of 90 beats/minute B. Rubor lochia saturating 3 perineal pads per hour C. Complaints of perineal pain D. Firm fundus between umbilicus and the symphysis pubis - B. Rubor lochia saturating 3 perineal pads per hour A client with recurrent urinary tract infections (UTI) is being discharged. What instruction is appropriate for the nurse to include in the discharge teaching plan? A. Drink 3 quarts of water daily B. Avoid swimming in public pools C. Avoid intercourse until all antibiotics have been taken D. Drink 3, 6-ounce cans of cranberry juice daily - A. Drink 3 quarts of water daily Which criterion is best for the nurse to use when evaluating a client's response to an analgesic that was administered for postoperative pain? A. Amount of medication required to relieve pain B. Activity without guarding or grimacing C. Objective parameters of blood pressure and respirations D. Subjective score on a 1 to 10 pain scale - D. Subjective score on a 1 to 10 pain scale A client is diagnosed with Pericarditis after a Myocardial Infarction (MI) and asks the nurse, "Why did this happen?" What explanation should the nurse offer? A. The sac surrounding the heart has become inflamed from the cells damaged by the heart attack B. The space around your heart is filling with fluid and your healthcare provider will have to explain the treatment C. The heart cells have been infiltrated by organisms and a secondary autoimmune reaction has occurred D. This is an infection of the lining of the heart caused by bacteria entering through your gums - A. The sac surrounding the heart has become inflamed from the cells damaged by the heart attack In describing the "at risk" individual for developing Breast Cancer, the nurse should recognize that which client is at the highest risk? The woman who is... A. a 40-year-old African American with Hypertension (HTN) B. a 35-year-old with trauma to the breast should the nurse administer? (enter the numeric value only) (Click on each chart tab for additional information. Please be sure to scroll to the bottom-right corner of each tab to view all information contained in the client's medical record.) - 8 A client is receiving 0.5 grams of a prescription medication that is dispensed as 500 mg/5mL. How many ml should the PN administer? (enter the numeric value only. If rounding is required, round to the nearest tenth.) - 5 The nurse is receiving a client following an emergency Cesarean Section (C-Section). Which information is most important for the nurse to obtain? A. Blood pressure and pulse rate B. Gravida and parity C. Medications received during labor D. Temperature and respiratory rate - A. Blood pressure and pulse rate The nurse is preparing to insert an indwelling catheter for an 89- year-old client who has severe contractures of both lower extremities. The client cries in pain when positioned supine while the nurse attempts to abduct the hips to visualize the perineum. What action should the nurse take? A. Report to the charge nurse that the client cannot cooperate for the insertion B. Recruit two UAPs to hold the legs apart while the catheter is inserted C. Position laterally for posterior access in visualizing the meatus for insertion D. Pre-medicate the client with a narcotic analgesic to relax the skeletal muscles - C. Position laterally for posterior access in visualizing the meatus for insertion An elderly client in the early postoperative period requires close monitoring due to aging and multisystem changes. The nurse monitors respirations and auscultates breath sounds frequently. What other intervention should the nurse implement related to the client's decreased vital capacity? A. Evaluate pulse oxygen saturation B. Allow extra education time C. Encourage high protein supplements D. Monitor intake and output - A. Evaluate pulse oxygen saturation The nurse can also refer to the external ear as what other known name... A. Pinna B. Malleus C. Incus D. Cochlea - A. Pinna During immediate postoperative period, which condition has the highest priority when planning Nursing care? A. Infection B. Respiratory obstruction C. Dehydration D. Cardiac arrest - B. Respiratory obstruction The nurse is providing instructions to the unlicensed assistive personnel (UAP) preparing to instruction is most important for the nurse to emphasize? A. Keep the head of the bed raised while the tube feeding is infusing B. Report any drainage observed around the GT insertion site C. Raise the entire bed while bathing the client to reduce back strain D. Use plenty of pillows to position the client on the side after bathing - B. Report any drainage observed around the GT insertion site A client is admitted to the rehabilitation unit after a Thrombotic Cerebrovascular Accident (CVA) with Right Hemiplegia and expressive aphasia. What intervention should the nurse implement to communicate with the client? A. Picture communication board B. Request a family member to interpret C. Electronic larynx device D. Dysphagia precautions - D. Dysphagia precautions The nurse is reviewing instructions for the use of pilocarpine eye drops with a client who has Glaucoma. The client states, "I should have these drops to anesthetize my eye if I experience pain" What action should the nurse implement? A. Explain to the client the eye drops do provide pain relief, but do not anesthetize the eyes B. Reassure the client that the drops will not be needed often since eye pain in glaucoma is not common C. Re-teach the client about the action of the eye drops to decrease pressure in the eye D. Document in the chart that the client understands the action and use the eye drops - C. Re-teach the client about the action of the eye drops to decrease pressure in the eye