Nursing Care Scenarios, Exams of Nursing

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1.A nurse on an inpatient unit is assisting with the discharge plan for a client who has schizophrenia. Which of the following resources should the nurse include in the plan? Contact information for enrollment in a 12-step program Contact information for a community mental health center A referral for respite care services A list of primary prevention activities: Contact information for a community men- tal health center 2.A nurse in a provider's office is reinforcing teaching with a client about performing testicular self-examination. Which of the following instructions should the nurse include? "Palpate both testicles firmly with your fingertips. Apply a cool compress to the scrotum prior to examination. Perform the self-examination every 3 months. Examine your testicles after a warm shower.": Examine your testicles after a warm shower." 3.A nurse is planning care for a client who is 1 day postoperative following abdominal surgery. Which of the following tasks should the nurse delegate to an assistive personnel? Showing the client how to use an incentive spirometer Transferring the client from the bed to a chair Checking the client's surgical dressing for bleeding Determining whether the client has Incisional pain: Transferring the client

2 / from the bed to a chair 4.A newly-licensed nurse tells another nurse that their password has expired and asks for assistance with inputting data into a client's electronic medical record. Which of the following statements should the nurse make? You won't be able to input any data until you reset your password." You can use my password on another terminal, but just this one time. If you'd like to give me the data, I can enter it for you." The charge nurse can log on for you and watch you input the data.: You won't be able to input any data until you reset your password." 5.A nurse on a postpartum unit is caring for a group of clients. Which of the following clients is the nurse's priority? A client who is 1 day postpartum and has not voided in 8 hr 'client who is 4 days postpartum and has lochia Serosa A client who is 3 days postpartum and has not had a bowel movement since prior to admission A client who is 2 days postpartum and whose fundus is 2 to 4 cm below the umbilicus: A client who is 3 days postpartum and has not had a bowel movement since prior to admission 6.A nurse is reinforcing home safety instructions with the guardian of an 18-month-old toddler. Which of the following responses by the guardian in- dicates an understanding of the teaching? I will place my child in a drop-side crib for napping. I will turn all pot handles toward the back of the stove." I will set the temperature of the water heater to 130 degrees." I will place my child's car seat forward-facing in the backseat.": I will turn all pot handles toward the back of the stove."

3 / 7.A nurse is caring for a client who is at 6 weeks of gestation. Which of the following laboratory findings should the nurse report to the provider? WBC 7.000/mm Hemoglobin 13 g/dL Blood glucose 130 mg/dL RBC 5.8 million/mm3: Hemoglobin 13 g/dL 8.A nurse is preparing to give change-of-shift report to the oncoming nurse. Which of the following information should the nurse include? Expected laboratory results Number of visitors Routine care Medical diagnosis: Expected laboratory results 9.A nurse is reinforcing teaching with a client who has gestational diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? "My baby is at risk for being underweight at birth." "My baby will be monitored for hypoglycemia after birth." "I should ensure that only S percent of my daily calories come from protein sources." I will check my blood glucose once every 8 hours.": "My baby will be monitored for hypoglycemia after birth." 10.A nurse is selecting foods for a client who is in the manic phase of bipolar disorder. Which of the following foods should the nurse offer the client? Mashed potatoes

4 / creamed corn Spaghetti with meat sauce Milkshake: Milkshake

5 / 11.A nurse is preparing to perform an irrigation to remove a buildup of cerumen from a client's ear. Which of the following actions should the nurse take? Use cool water to flush the cerumen from the ear canal. Aim the stream of water directly at the cerumen impaction. Remind the client to use a cotton swab periodically to remove cerumen. Instill cerumen-softening drops before the irrigation.: Instill cerumen- softening drops before the irrigation 12.A nurse is contributing to the plan of care for an adolescent client following surgery for a ruptured appendix. which of the following interventions should the nurse recommend to include in the plan? Offer the client a clear liquid diet when fully alert. Discontinue antibiotic therapy on the first postoperative day. Ensure that the client receives pain medication prior to ambulation. Encourage the client to change positions every 4 hr: Ensure that the client receives pain medication prior to ambulation. 13.A nurse is preparing a room for a client who has a tracheostomy tube. Which of following supplies should the nurse place in the room? irrigation set Hemostats Obturator Povidone-iodine: Obturator 14.A nurse is reinforcing teaching for a client who has a new prescription for low-dose aspirin. The nurse should inform the client that which of the following is known to interact with aspirin? Acetaminophen

6 / st. John's wort Ranitidine Ginkgo biloba: Ginkgo biloba 15.A nurse is reinforcing teaching with a newly licensed nurse about incident reports. The nurse should identify that which of the following situations re- quires the completion of an incident report? Insulin lispro was administered to a client immediately before bed. Nitroglycerin transdermal was applied to a client's chest. Cefotaxime was administered to a client after obtaining blood cultures. Digoxin was administered to a client who has a heart rate of 64/min.: Insulin lispro was administered to a client immediately before bed. 16.A nurse is collecting data from an older adult client and finds visible bruises on their lower legs. Which of the following client statements should the nurse identify as a risk factor for elder abuse? I take a blood thinner and I bump into things sometimes. "Please don't tell anyone you saw these: I do not want to go to a nursing home "My caregiver rearranged the furniture in the living room and I ran into the couch." "I don't like having to use my walker for short trips when I am in my home.: - "Please don't tell anyone you saw these: I do not want to go to a nursing home 17.A nurse is contributing to the plan of care for a newly admitted client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse recommend? Offer the dient flulds high in fiber and protein every hour.

7 / Monitor the client's vital signs twice per day.

8 / Weigh the client three times per week. Encourage the client to participate in group therapy activitles each day.: Offer the dient flulds high in fiber and protein every hour. 18.A nurse is collecting data from a client who is at 29 weeks of gestation. Which of the following findings should the nurse identify as a potential indication of a prenatal complication? Melasma Blurred vision Ptyalism Leg cramps: Blurred vision 19.A nurse is reviewing a client's laboratory results prior to administering the client's medications. The nurse notes that the client's lithium level is 2.0 mEq/L. Which of the following findings should the nurse expect? Muscle irritability Hypoglycemia increased BP constipation: constipation 20.A nurse is caring for a client who is pregnant and Rh-negative. The nurse should plan to monitor which of the following maternal laboratory test results to determine maternal-fetal blood incompatibility? Homocysteine aPTT Erythropoietin

9 / indirect Coombs: Erythropoietin

10 / 21.A nurse is reinforcing teaching with a newly licensed nurse about dis- charge planning. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? "A home hazard appraisal includes an assessment of the client's financial resources." The nurse should begin discharge planning upon the client's admission. *A medication reconciliation is required 24 hours prior to the client's dis- charge." The nurse is responsible for providing a written prescription for a client home care referral.": The nurse should begin discharge planning upon the client's admission. 22.A nurse is reinforcing teaching with a group of clients about deep breath- ing exercises to manage stress. Which of the following techniques should the nurse include in the teaching? "Repeat the exercise for 15 minutes." "Each breath should be exhaled using rapid, short breaths." "Take a deep breath through your mouth." "Hold inhaled breath for 3 seconds.": "Hold inhaled breath for 3 seconds." 23.A nurse is reinforcing dietary teaching with a client who has a new ileosto- my. Which of the following foods should the nurse recommend? Dried apricots Sunflower seeds Oranges yogurt: yogurt 24.A nurse is monitoring a client who has bipolar disorder and is exhibiting manifestations of mania. Which of the following findings should the nurse expect? (Select all that apply.)

11 / Overeating Anhedonia Grandiose thinking Flight of ideas Distractibility: Anhedonia Grandiose thinking Flight of ideas

25. A nurse is caring for a client who has heart failure and is taking furosemide. Which of the following statements by the client indicates a need for the nurse to intervene? I suck on hard candy for my dry mouth." I'm urinating in larger amounts." I've lost 3 pounds in the last week." I have to sleep sitting up.": I have to sleep sitting up." 26.A nurse is assisting with the admission of a client to an acute-care unit following a suicide attempt. Which of the following actions should the nurse take first? Assign the client to a semi-private room. Attend an interdisciplinary team meeting. Document the client's mood and affect. Search the client's personal belongings.: Search the client's personal

12 / belong- ings.

13 / 27.A nurse is reinforcing discharge teaching with the guardian of a child who had a cardiac catheterization 1 hr ago. Which of the following statements should the nurse include? Your child can take a tub bath tomorrow." You should keep your child home from school for 2 days." Your child can resume a regular diet when you return home." You can remove the pressure dressing from the site in 4 hours.": You should keep your child home from school for 2 days." 28.A nurse is administering the inactivated influenza vaccine to a group of clients at a health clinic. The nurse should recognize that which of the following conditions is a contraindication for this vaccine? Allergy to gelatin immunosuppression Moderate illness with fever Pregnancy: Moderate illness with fever 29.A nurse is assisting with the care of a client who is receiving 1 unit of packed RBs. The client is coughing and reports a headache and difficulty breathing. The client's vital signs indicate tachycardia and hypertension. The nurse should identify that the client is experiencing which of the following types of transfusion reactions? Mild allergic Febrile nonnemolytic Sepsis Circulatory overload: Sepsis 30.A nurse is collecting data from a 24-month-old toddler during an

14 / annual physical examination. Which of the following findings should the nurse report to the provider?

15 / Jumps with both feet Can draw a circle Weighs 12 kg (26.5 Ib) Has a vocabulary of four words: Weighs 12 kg (26.5 Ib) 31.A nurse is collecting data from an adult client. The nurse should identify that which of the following conditions increases the client's risk for falls? GERD Hyperthyroidism crohn's disease Multiple sclerosis: Multiple sclerosis 32.A charge nurse at a long-term care facility ensures that the workload is distributed equally among staff when making assignments. Wh following ethical principles is the nurse upholding? justice veracity Autonomy Fidelity: justice 33.A nurse is contributing to the plan of care for a client who has delirium. Which of the following interventions should the nurse recommend to include in the plan? Place a calendar in the client's room. Provide the client with four food choices at each meal.

16 / vary the client's activities daily.

17 / Assign a different caregiver to the client each day.: Place a calendar in the client's room. 34.A nurse is checking a newborn's Moro reflex. Which of the following actions should the nurse take to elicit this reflex? Place the newborn on a flat surface and clap hands loudly. Place the newborn on their abdomen and observe the movement of their extremities. Stroke upward on the lateral aspect of the newborn's foot. Stroke the newborn's cheek toward their mouth.: Stroke the newborn's cheek toward their mouth. 35.A nurse is contributing to the preparation of an in-service about child maltreatment for a group of staff members. Which of the following information should the nurse recommend? A child is at the highest risk for abuse from birth through 1 year of age. Sexual abuse is most often committed by a person who the child does not know. Physical neglect includes a failure to meet a child's needs for affection and attention. Emotional abuse is the most common form of child maltreatment.: A child is at the highest risk for abuse from birth through 1 year of age 36.A nurse at a long-term care facility is caring for a client who has AIDS. The client accidentally spills the contents of their urinal on the floor. After cleaning up the spill with soap and water, the nurse should apply a solution of water and which of the following disinfectants to the floor? Chlorhexidine Bleach Hydrogen peroxide

18 / Isopropyl alcohol: Bleach 37.A nurse is using an interpreter to communicate with a client who speaks a different language than the nurse. Which of the following actions should the nurse take? Maintain eye contact with the interpreter when asking questions. Observe the client's body language during the conversation. include medical terminology when discussing the client's condition. Avoid asking the client personal questions.: Avoid asking the client personal questions. 38.A nurse is reviewing the laboratory results of a client who takes aspirin daily. Which of the following laboratory blood values should the nurse identify as a contraindication for the administration of aspirin? Bleeding time 9.75 min WEC 8,000/mm HbA1C 4.8% Amylase 60 IU/L: Bleeding time 9.75 min 39.A charge nurse is observing a newly licensed nurse administer an enteral feeding to a client who has an established gastrostomy tube. Which of the following actions by the newly licensed nurse indicates that the charge nurse should intervene? The nurse administers 15 mL of water before administering the feeding. The nurse adds food coloring to the tube feeding. The nurse checks the volume of the aspirate . The nurse checks the pH of the aspirate.: The nurse adds food coloring to

19 / the tube feeding.

20 / 40.A nurse is monitoring an assistive personnel (AP) who is caring for several clients. For which of the following actions by the AP should the nurse inter- vene? Assists a family member with a client's postmortem care Ambulates a client who requires the use of a walker Obtains the bed weight of an immobile client Provides teaching to a client regarding ostomy care: Provides teaching to a client regarding ostomy care 41.A nurse is collecting data from a client who has bulimia nervosa. Which of the following findings should the nurse expect? Hypermagnesemia Amenorrhea Tooth erosion Hyperkalemia: Tooth erosion 42.A nurse is collecting data from an infant who has severe dehydration. Which of the following findings should the nurse expect? Slow respirations Sunken fontanels increased blood pressure Capillary refill 3 seconds: Sunken fontanels 43.A nurse is contributing to the plan of care for a client who is postoperative following a below-the-knee amputation. Which of the following strategies should the nurse include to help the client progress toward accep-

21 / tance of this body image alteration? Suggest that the client wear facility clothing until the prosthesis fitting

22 / Encourage the client to visit with someone who has had an amputation. Discourage the client from touching the residual limb for the first week. Reassure the client that the rehabilitation program is optional.: Encourage the client to visit with someone who has had an amputation. 44.A nurse is reviewing the laboratory values for an adolescent who is sched- uled for a surgical procedure. For which of the following laboratory values should the nurse notify the provider? Hgb 13 mg/dL HEt 42% WBC count 9,800/mm° Platelet count 120.000/mm: Platelet count 120.000/mm 45.A nurse is assisting with the care of a client who is in labor with ruptured membranes and has herpes simplex virus with active lesioi the following actions should the nurse take? Administer ampicillin IV to the client. initiate an oxytocin Infusion for the dient. Begin an amnioinfusion for the client. Prepare the client for a cesarean birth.: Prepare the client for a cesarean birth. 46.A nurse is collecting data from a client prior to administration of verapamil. Which of the following findings indicates a need to withhold the medication? Respiratory rate 18/min Potassium 4 mEg/L Blood pressure 170/82 mm Hg

23 / Pulse rate 48/min: Pulse rate 48/min

24 / 47.A nurse is collecting data for a client's health history and physical exam- ination. Which of the following information should the nurse identify as: risk factor for type 2 diabetes mellitus? History of mumps HIstory of exercise-induced asthma Age 35 years BMI 32.2: BMI 32.2 48.A nurse is reviewing the laboratory results of a client who has nephrotic syndrome. Which of the following results should the nurse expect? Proteinuria increased hemoglobin Hyperalbuminemia Hypolipidemia: Proteinuria 49.A nurse is reinforcing teaching with a client who has a new prescription for verapamil. Which of the following instructions should the nurse include in the teaching? Take the medication on an empty stomach. Change positions slowly. Increase calorie intake to minimize weight loss. Expect palpitations for 2 days.: Change positions slowly. 50.A nurse is caring for a client who is postoperative following a mastectomy. Which of the following actions should the nurse take to help the client cope with the body image change resulting from the surgery?

25 / Suggest that the client decide about reconstruction as soon as possible. Avold talking to the client about the surgery.