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A client with a basilar skull fracture has clear fluid leaking from the ears. The nurse should take which action first? a. Asses the clear fluid for protein b. Check the clear fluid for glucose c. Place cotton calls or dry gauze loosely in the ears d. Use an otoscope to assess the tympanic membrane for rupture - CORRECT ANSWERS B CSF contains glucose not protein. A nurse is caring for a client who has just undergone cardioversion. Which intervention is the nurse's priority after this procedure. a. Administer oxygen b. Monitoring the BP c. Administering antidysrhythmic medications d. Monitoring the client's LOC - CORRECT ANSWERS A ABC's of nursing. All other choices are correct, but not priority. A client with diabetes mellitus who is scheduled to have blood drawn for determination of the glycosylated hemoglobin (HbA1c) level asks the nurse why the test is necessary if he is performing blood glucose monitoring at home. Which is the best response for the nurse to provide? a. Detect diabetic complications b. Assess long-term glycemic control c. Determine whether the client is at risk for hypoglycemia d Determine whether the prescribed insulin dosage is correct - CORRECT ANSWERS B
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A nurse caring for a client with acquired immunodeficiency syndrome is monitoring the client for signs of complications. Which of the following would cause the nurse to suspect infection with Pneumocystis jirovec? SATA a. Diarrhea b. Tachypnea c. Pedal edema d. Intermittent fever e. Dyspnea with ambulating f. Expectoration of frothy mucus - CORRECT ANSWERS B, D, E A opportunistic respiratory infection associated with AIDs that causes dyspnea, nonproductive cough, intermittent fever, fatigue, anorexia, tachypnea, wt. loss. Zidovudine is prescribed for a client with AIDS. The nurse tells the client that it is important to report back to the clinic as scheduled for which follow-up diagnostic? a. Blood glucose checks b. Blood pressure checks c. Complete blood counts (CBC) d. Electrocradiographic studies - CORRECT ANSWERS C Zidovudine is an antiviral medication that cause cause agranulocytosis and anemia. After a non-immunocompromised client undergoes a Mantoux test for TB infection, an area of induration 6 mm wide developed. The client asks the nurse what this result means. Which is the best response? a. We'll have to repeat the test because the result was inconclusive b. The swollen area is small, so that means your test result is negative
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A nurse provides instruction to a client with COPD about home oxygen therapy. Which statement made by the client indicates need for further instruction? a. I should limit activity as much as possible b. If I have trouble breathing, I need to call the doctor c. I need to drink lots of fluids to keep my mucus thin d. I can apply petroleum jelly to my nose if the oxygen dries it out e. I should wear a scarf over my nose and mouth in cold weather f. If I get a flu shot, I do not have to worry about being around people with colds - CORRECT ANSWERS A, D, F A nurse is monitoring the neurological status of a client who underwent craniotomy 3 days ago. Which signs or symptoms would prompt the nurse to notify the primary health care provider immediately? a. Disorientation to date b. Pupils equal and reactive at 4 mm c. Mild headache relieved by acetaminophen with codeine d. Pain with forward flexion of the neck onto the chest - CORRECT ANSWERS D A complication of cranial surgery is meningitis. A man calls the clinic and tells the nurse that he sustained a bee sting on his leg while working in his yard. The client states that he is not allergic to bees and wants to know how to treat the sting. The nurse tells the client to first take which action? a. Place a cool compress on the sting site b. Apply an antipruritic lotion to the sting site c. Apply a topical corticosteroid to the sting site
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d. Take an oral antihistamine such as diphenhydramine (Benadryl) - CORRECT ANSWERS A A nurse is assigned to conduct an admission assessment of a client who was treated in the emergency department after attempting suicide by cutting her wrists with a razor blade. When the client arrives at the nursing unit, the nurse should take which action first? a. Ask the client to sign a no-harm contract b. Ask the client to report any suicidal thoughts immediately c. Place the client under suicide precautions with 15-minute checks d. Check the dressings that were placed over the client's wrists in the emergency department - CORRECT ANSWERS D First assess the physical state of the patient for safety then implement precautions. A nurse is preparing to administer digoxin to a client with heart failure. When assessing the client, the nurse notes an apical pulse rate of 58 beats/min. Also, the client complains of anorexia and nausea. Which action should the nurse take first on the basis of these assessment findings? a. Contact the primary health care provider b. Administer an as-needed antiemetic c. Check the most recent digoxin level d. Administer the digoxin with an antacid - CORRECT ANSWERS C A nurse is assessing a client who has undergone radical neck dissection for the treatment of cancer. The nurse hears stridor when auscultating over the trachea. On the basis of this finding, which is the priority nursing action? a. Assess the client's pulse oximetry Incorrect
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a. Assessing the radial pulse in the right extremity b. Using the LA ti take BP readings c. Drawing pre-dialysis blood specimens from the LA d. Assessing the area over the AV fistula for a bruit and three each shift e. Placing a pressure dressing over the site after each dialysis treatment f. Administering IV fluids through the venous site of the AV fistula as needed - CORRECT ANSWERS A, B, C, D A nurse is evaluating outcomes for a client with Guillain-Barre syndrome. Which outcome does the nurse recognize as optimal respiratory outcomes for the client? a. Normal deep tendon reflexes b. Improved skeletal muscle tone c. Absences of paresthesias in the lower extremities d. Clear sound in the lower lung fields bilaterally e. pO2 of 85 mmHg and pCO2 of 40 mmHg - CORRECT ANSWERS D, E A nurse of the telemetry unit is caring for a client who has had a MI and is now attached to a cardiac monitor. The nurse is monitoring the client's cardiac rhythm and nots ventricular fibrillation. Which nursing intervention should the nurse take first? a. Calling the rapid response team b. Preparing the client for cardioversion c. Asking the client to bear down and cough d. Preparing to administer diltiazem - CORRECT ANSWERS A The pattern of ventricular fibrillation is identified and can be a result after a patient with an MI. VF makes the patient feel faint, then loses consciousness
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and becomes pulseless and apneic (BP and heart sounds absent). Treatment is to terminate VF and covert it into a rhythm via defibrillation-> call a rapid and initiate CPR. Cardioversion is used for ventricular or supraventricular tachydysrhythmias. A nurse developing a plan of care for a client with a spinal cord injury includes measures to prevent autonomic dysreflexia (hyperreflexia). Which intervention does the nurse incorporate into the plan to prevent this complication? a. Keeping the fan running in the client's room b. Keeping the linens wrinkle free under the client c. Limiting bladder catheterization to once every 12 hours d. Avoiding the administration of enemas and rectal suppositories - CORRECT ANSWERS B The most frequent cause of autonomic dysreflexias are a distended bladder and impacted feces. Other causes include stimulation of the skin by tactile, thermal, or painful stimuli. The nurse renders care in such a way as to minimize these risks. A nurse provides home care instructions to a client who has been fitted with a halo device to treat a cervical fracture. Which statement by the client indicates the need for further teaching? a. I need to get more fluids and fiber into my diet b. I should cut my food into small pieces before I eat c. I need to put powder under the vest twice a day to prevent sweating d. I have to check the pin sites everyday and watch for signs of infection - CORRECT ANSWERS C Cleanse the skin under the wool liner each day to prevent rashes and soars.
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should be reported and verified in the laboratory. Although feeding is an intervention, the result of a bedside glucose must be verified by the laboratory. Some infants need IV glucose to maintain glucose balance and prevent damage to the brain. A pregnant woman is being admitted to the maternity unit. The woman tells the nurse that she felt a large gush of fluid from her vagina on the way to the hospital. The nurse detects a fetal heart rate of 90 beats/min. On physical examination, the nurse finds that the umbilical cord is protruding from the vagina. Which actions should the nurse perform? Select all that apply. Placing the woman in knee-chest position Administering oxygen at 2 to 4 L/min by nasal cannula Administering terbutaline to stop contractions With two gloved fingers, exerting upward pressure, into the vagina, on the presenting part Wrapping the cord loosely in a sterile towel saturated with warm sterile normal saline solution - CORRECT ANSWERS A, C, D Oxygen should be administered at 8-10 L/min via face mask A nurse provides information to the mother of a child with diarrhea about signs and symptoms that indicate the need to call the primary health care provider. Which statement by the mother indicates the need for further instruction? "I'll call the doctor if she gets dizzy and acts sick." "I'll call the doctor if she has severe stomach cramps." "I'll call the doctor if her temperature is 102°F (38.9°C) or higher." "I'll call the physician if she goes longer than 6 hours without urinating." - CORRECT ANSWERS C
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Call doctor at temperature above 100. A nurse reviewing the medical history of an infant experiencing gastroesophageal reflux (GER) would expect to note documentation of which other issue? Refusal to suck Frequent diarrhea Recurrent otitis media Inability to pass stools - CORRECT ANSWERS C Vomiting or spitting up after a meal, hiccupping, and recurrent otitis media resulting from pooling of secretions in the nasopharynx during sleep are characteristics of all types of GER. A nurse reviewing the record of a child with suspected acute poststreptococcal glomerulonephritis notes that the child recently had a streptococcal throat infection that was treated with antibiotics. Which diagnostic test will confirm the presence of acute poststreptococcal glomerulonephritis does the nurse expect to find? Throat culture Blood urea nitrogen (BUN) Antistreptolysin (ASO) titer White blood cell (WBC) count - CORRECT ANSWERS C In caring for a child admitted to the hospital with Kawasaki disease, the nurse should monitor the child most closely for signs which complication?
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A primary health care provider prescribes morphine sulfate, 2.5 mg intravenously stat, for a client with terminal cancer. The medication ampule reads, "Morphine sulfate 10 mg/mL." How many milliliters of medication does the nurse prepare to administer the correct dose? Please enter the number only. - CORRECT ANSWERS 0. A nurse is caring for the client who is in bed and begins to exhibit seizure activity. Which actions does the nurse implement to care for the client? Select all that apply. Observing and timing the seizure Loosening any restrictive clothing Turning the client's head to the side Removing the pads on the side rails Inserting an airway into the client's mouth Removing objects that might injure the client from the vicinity - CORRECT ANSWERS A, B, C, F The nurse is participating in a facility's planning committee to deal with possible bioterrorism threats. The nurse should recommend implementing which infection control measures to be used for clients in whom smallpox is diagnosed? Select all that apply. Enteric Droplet Contact Standard Protective isolation - CORRECT ANSWERS B, C, D
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Smallpox is transmitted from person to person in infected aerosols and air droplets spread by way of face-to-face contact with an infected person after fever has begun, especially if the infected person is also coughing. The disease can also be transmitted in contaminated clothes and bedding, although the risk of infection from this source is much lower. Therefore droplet and contact precautions are necessary. Standard precautions are implemented for the care of all clients. Enteric precautions are implemented if the infectious agent is transmitted by way of contact with feces. Protective isolation is implemented when the client is neutropenic and needs to be protected from infection. A nurse is caring for a client in labor who is receiving an oxytocin infusion. The nurse notes that the client is experiencing uterine hypertonicity. The nurse should take which action immediately? Stop the oxytocin infusion Check the client's blood pressure Contact the primary health care provider Place the client in a side-lying position - CORRECT ANSWERS A An emergency department nurse is caring for an older client who may have been physically abused by her caregiver. In planning care for the client, the nurse takes which priority action? Notifying the police department Obtaining psychiatric help for the caregiver Contacting adult protective services to investigate the situation Telling the caregiver that he or she is not allowed to care for the client - CORRECT ANSWERS C
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The amount of suction being applied to the chest tube system - CORRECT ANSWERS A A nurse on the day shift is assigned to care for four clients. In which order will the nurse assess the clients after receiving report from the night shift. A client scheduled for an electrocardiogram (ECG) at 11 a.m. A client on nothing-by-mouth (NPO) status who is for bronchoscopy at 9 a.m. A client who has undergone above-the-knee amputation who is scheduled for discharge home A client who had a seizure at 2 a.m. and was treated with intravenous (IV) diazepam and phenytoin - CORRECT ANSWERS D As a nurse is providing care, the client suddenly experiences a tonic-clonic seizure. The nurse would immediately take which action first? Call the physician Turn the client to the side Restrain the client's limbs Insert an airway in the client's mouth - CORRECT ANSWERS B A nurse is providing care to a client with a closed chest tube drainage system. When the nurse assists the client in turning onto his side, the chest tube is accidentally dislodged from the insertion site. The nurse must immediately take which action? Reinsert the chest tube Turn the client onto his back Contact the primary health care provider Apply pressure over the chest tube insertion site - CORRECT ANSWERS D
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A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse notes an audible wheeze. The nurse tries to remove the suction catheter from the client's trachea but is unable to do so. After immediately disconnecting the suction source from the catheter, which intervention does the nurse implement next? Calling a code Administering an inhaled bronchodilator Connecting oxygen to the suction catheter Encouraging the client to take deep breaths - CORRECT ANSWERS C The inability to remove a suction catheter is a critical situation. This finding, along with the client's symptoms presented in the question, indicates bronchospasm and bronchoconstriction. The nurse must immediately disconnect the suction source from the catheter but leave the catheter in the trachea. The nurse then connects the oxygen source to the catheter, because the client is at risk for hypoxia. A client with skeletal traction applied to the right leg complains of severe pain in the leg. The nurse realigns the client's position, but this intervention does not relieve the pain. Which action would the nurse take next? Providing pin care Calling the primary health care provider Removing some of the traction weights Medicating the client with the prescribed analgesic - CORRECT ANSWERS B The nurse realigns the client and, if this is ineffective, calls the primary health care provider. The nurse never removes traction weights unless this is specifically prescribed by the primary health care provider. Severe leg pain, once traction has been established, indicates a problem. The client should be medicated after an attempt has been made to identify and treat the cause of the pain.
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A client with a nasogastric tube who underwent bowel resection 2 days ago A client on nothing-by-mouth (NPO) status who is scheduled for a barium enema at 10 a.m. - CORRECT ANSWERS A client who was admitted during the night because of congestive heart failure A client who has been fitted with a closed chest tube drainage system A client with a nasogastric tube who underwent bowel resection 2 days ago A client on nothing-by-mouth (NPO) status who is scheduled for a barium enema at 10 a.m. The nurse is observing a new nurse employee perform an otoscopic examination of an adult client. The nurse determines the new nurse employee understands the procedure if the new nurse employee takes which action? Uses a small speculum to decrease the discomfort Pulls the pinna up and back before inserting the speculum Tilts the client's head forward before inserting the speculum Pulls the earlobe down and back before inserting the speculum - CORRECT ANSWERS B Old= up Young= down A primigravida is admitted to the labor unit. During assessment, the client's membranes rupture spontaneously. What is the priority nursing action? Checking the amniotic fluid Checking the fetal heart rate Assessing the contraction pattern Preparing for immediate delivery - CORRECT ANSWERS B
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When the membranes rupture in the birth setting, the nurse immediately assesses the fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord. A postpartum nurse is caring for a client who had a placenta previa. Which nursing intervention does the nurse, reviewing the plan of care, identify as the priority for this client? Fundal assessment Monitoring of urine output Frequent assessment of lochia Inclusion of iron in every meal - CORRECT ANSWERS C A rubella titer is performed on a woman who has just been told that she is pregnant. The results of the titer indicate that the mother is not immune to rubella. The nurse realizes the patient understands patient teaching if the patient makes which statement? "I may need to get a therapeutic abortion." "I will need an immunization against rubella immediately." "Immunization against rubella is required after delivery." "Antibiotics will be prescribed to prevent the infection." - CORRECT ANSWERS C MMR vaccines are contraindicated in pregnancy A nurse performing a fundal assessment after a vaginal birth notes that the fundus is above the umbilicus and displaced from the midline. What should the nurse do first? Massage the fundus Help the client void
