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Docs[11]nursing
paper 2
- The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? A) If I exercise at least two times weekly for one hour, I will lower my cholesterol. B) I need to avoid eating proteins, including red meat. C) I will limit my intake of beef to 4 ounces per week. D) My blood level of low density lipoproteins needs to increase. Correct answer(s): C 2. A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement? A) Obtain the pre-transfusion hemoglobin level. B) Prime the tubing and prepare a blood pump set-up.
C) Monitor vital signs q15 minutes for the first hour. D) Ensure the accuracy of the blood type match. Correct answer(s): D 3. The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement? A) Tell the UAP to use a larger cuff at the next scheduled assessment. B) Reassess the client's blood pressure using a larger cuff. C) Have the unit educator review this procedure with the UAPs. D) Teach the UAP the correct technique for assessing blood pressure. Correct answer(s): B 4. The nurse prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute? A) 80 B) 8
B) Conventional medications are likely to interact with folk remedies and cause adverse effects. C) Many complimentary healing practices can be used in conjunction with conventional practices. D) Conventional medical practices will ultimately replace the use of complimentary healing practices. Correct answer(s): C 7.
A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how many ml/hr should the infusion pump be set to deliver the secondary infusion? Correct answer(s): 150 8. The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? A) Encourage the client to cough to help loosen secretions. B) Advise the client to increase the intake of oral fluids. C) Rotate the suction catheter to obtain any remaining secretions. D) Re-oxygenate the client before attempting to suction again. Correct answer(s): D 9.
C) Leisure activities. D) Financial stressors. Correct answer(s): B 11. The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the nurse plan to administer? A) ½ tablet. B) 1 tablet. C) 1½ tablets. D) 2 tablets. Correct answer(s): C 12. During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure? A) Adequate venous blood flow to the lower extremities. B) Estimated amount of body fat by an underarm skinfold. C) Degree of flexion and extension of the client's knee joint.
D) Change in the circumference of the joint in centimeters. Correct answer(s): C 13. A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take?
Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent? A) Height in inches or centimeters. B) Weight in kilograms or pounds. C) Triceps skin fold thickness. D) Upper arm circumference. Correct answer(s): D 16. The nurse notices that the mother a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take? A) Talk directly to the child instead of the mother. B) Continue asking the mother questions about the child.
C) Ask another nurse to interview the mother now. D) Tell the mother politely to look at you when answering. Correct answer(s): B 17. What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A) It is more difficult to find a superficial vein in the feet and ankles. B) A decreased flow rate could result in the formation of a thrombosis. C) A cannulated extremity is more difficult to move when the leg or foot is used. D) Veins are located deep in the feet and ankles, resulting in a more painful procedure. Correct answer(s): B 18.
C) Obtain your healthcare provider's permission before starting meditation. D) Complementary therapy and western medicine can be effective for you. Correct answer(s): A 20. Seconal 0.1 gram PRN at bedtime is prescribed to a client for rest. The scored tablets are labeled grain 1.5 per tablet. How many tablets should the nurse plan to administer? A) 0.5 tablet. B) 1 tablet. C) 1.5 tablets. D) 2 tablets. Correct answer(s): B
An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct? A) Inquire about the source and type of pain. B) Examine the nose for congestion and discharge. C) Take vital signs for temperature elevation. D) Explore the abdominal area for distension. Correct answer(s): A 22. While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? A) Acknowledge that she is supporting the arm correctly. B) Encourage her to keep the joint covered to maintain warmth.
D) supine. Correct answer(s): B 25. A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client A) asks relevant questions regarding the dressing change. B) states he will be able to complete the wound care regimen.
C) demonstrates the wound care procedure correctly. D) has all the necessary supplies for wound care. Correct answer(s): C 26. A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? A) Contact the healthcare provider and complete a medication variance form. B) Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. C) Notify the charge nurse and complete an incident report to explain the missed dose. D) Give the missed dose at 1300 and change the schedule to administer daily at 1300. Correct answer(s): D 27. A client who is a Jehovah’s Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client’s beliefs?
The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior? A) The belief is held that the "evil eye" enters the child if anything cold is ingested. B) After surgery the child probably has refused all foods except broth. C) Eating broth strengthens the child's innate energy called "chi." D) Hot remedies restore balance after surgery, which is considered a "cold" condition. Correct answer(s): D 30. During a physical assessment, a female client begins to cry. Which action is best for the nurse to take? A) Request another nurse to complete the physical assessment.
B) Ask the client to stop crying and tell the nurse what is wrong. C) Acknowledge the client's distress and tell her it is all right to cry. D) Leave the room so that the client can be alone to cry in private. Correct answer(s): C 31. The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? A) Place the chair at a right angle to the bed on the client's left side before moving. B) Assist the client to a standing position, then place the right hand on the armrest. C) Have the client place the left foot next to the chair and pivot to the left before sitting. D) Move the chair parallel to the right side of the bed, and stand the client on the right foot. Correct answer(s): D 32.
