Docsity
Docsity

Prepare for your exams
Prepare for your exams

Study with the several resources on Docsity


Earn points to download
Earn points to download

Earn points by helping other students or get them with a premium plan


Guidelines and tips
Guidelines and tips

Nursing Care Prioritization and Client Assessment, Exams of Nursing

A series of nursing scenarios and questions related to patient care, prioritization, and assessment. It covers various health conditions such as bone infection, car accident, sleep disorders, physical abuse, myasthenia gravis, leukemia, ulcerative colitis, acute kidney injury, angina pectoris, stroke, diabetes, diarrhea, fever, ischemic cerebrovascular event, pneumonia, copd, pregnancy, aphasia, nutritional therapy, post-anesthesia care, radiation implants, infection control, and more. Intended for nursing students or professionals to test their knowledge and understanding of nursing care.

Typology: Exams

2023/2024

Available from 04/27/2024

ultranurse
ultranurse 🇺🇸

65 documents

1 / 39

Toggle sidebar

Partial preview of the text

Download Nursing Care Prioritization and Client Assessment and more Exams Nursing in PDF only on Docsity! PEDIATRICS NUR0416 3 CAT 3 KAPLAN 3 QUESTIONS AND ANSWERS UPLOADED LATEST 2024 GRADED A+ 1. The nurse auscultates crackles throughout all lung fields and measures a heart rate of 132 bpm, a respiratory rate of 30, and blood pressure of 102/54 mm Hg in a client recovering from an esophagectomy. Which action will the nurse take first? 1. Place the client on continuous pulse oximetry. 2. Monitor the client for changes in blood pressure. 3. Notify the health care provider. 4. Assist the client to use the incentive spirometer. 2. The nurse assigns a client diagnosed with cancer who is receiving chemotherapy to a nursing assistive personnel (NAP). Which instruction is most important for the nurse to include? 1. Perform hand hygiene frequently. 2. Wear a mask when entering the room. 3. Monitor the roommate for signs of infection. 4. Monitor the amount of protein the client eats. 3. The nurse provides care for a client diagnosed with a bone infection. The client was given intravenous morphine 3 hours ago and cannot have another dose for an hour. The client reports pain that is rated as 6 out of 10. The nurse implements several nonpharmacological approaches. The client’s pain level is now a 3 out of 10. Which action should the nurse take next? 1. Notify the health care provider. 2. Administer the morphine early. 3. Instruct the client that the next dose cannot be given for an hour. 4. Ask the client what is an acceptable pain level. 4. The nurse provides care for a client who was in a car accident as the result of falling asleep at the wheel. The client reports only being able to sleep 3 to 4 hours a night over the past month, due to stress. The client reports waking up frequently during the night. Which outcome is most appropriate for the nurse to include in the client’s plan of care? week. 1. Client will verbalize a plan to implement a sleep promoting program within the next 2. Client will fall asleep with less difficulty over the next 2 weeks. 3. Client will achieve a more normal sleep pattern within 2 to 4 weeks. 4. Client will achieve an improved sense of adequate sleep over the next 4 weeks. 5. The nurse reviews medications prescribed for a client recovering from surgery. Which prescription causes the nurse the most concern? 1. Diphenhydramine 50 mg PO at bedtime, as needed. 2. Furosemide 40 mg IV q.d. 3. Morphine sulfate 2 mg IV every hour, as needed, for pain. 4. Oxygen at 2 L/min via nasal cannula. 6. The nurse reads the result of a tuberculosis (TB) skin test on a client with no known risk factors for TB. Which finding will the nurse interpret as a positive result? 1. Erythema of 5 or more millimeters. 2. Induration of 5 or more millimeters. 3. Induration of 10 or more PEDIATRICS NUR0416 3 CAT 3 KAPLAN 3 QUESTIONS AND ANSWERS UPLOADED LATEST 2024 GRADED A+ millimeters. 4. Induration of 15 or more millimeters. PEDIATRICS NUR0416 3 CAT 3 KAPLAN 3 QUESTIONS AND ANSWERS UPLOADED LATEST 2024 GRADED A+ 1. Hand hygiene using an alcohol-based hand rub is effective against pertussis. 2. Family members and others in close contact with the infant should be vaccinated. 3. Airborne isolation precautions are required for 5 days after the start of antibiotic therapy. 4. Pertussis is most severe for the elderly. 5. Even if a person’s immunization status for pertussis is unknown, it is safe to immunize again. 14. The nurse reviews the care needs for assigned clients. Which client will the nurse assess first? 1. Client with ulcerative colitis who reports rectal bleeding. 2. Client with an acute kidney injury with a urine output of 100 mL over the past 6 hours. 3. Client with angina pectoris who reports a headache after receiving a dose of prescribed nitroglycerin. 4. Client with a radioactive implant for cervical cancer who is in the bathroom. 15. The nurse teaches a client how to self-administer nasal drops. Which statement is part of these instructions? 1. “Occlude one nostril prior to instilling the drops.” 2. “Store the medication vial in the refrigerator between doses.” 3. “Shake the medication vial for several minutes before opening.” 4. “Sit with the neck flexed backward for 5 minutes after instilling the drops.” 16. The nurse assists the code team treating a client with asystole. Cardiopulmonary resuscitation (CPR) is in process. Which direction by the code team leader requires the nurse to intervene? 1. “Push hard and push fast during compressions.” 2. “Give atropine 1 mg followed by an NS flush.” 3. “Give epinephrine 1 mg every 3 to 5 minutes.” 4. “Continue CPR for 2 minutes and then check rhythm.” 17. The nurse provides care to a 10-month-old infant. For which statement made by the parent will the nurse intervene? (Select all that apply.) 1. “My child has a two-word vocabulary.” 2. “My child gained 1 ounce this week.” 3. “My child cannot walk unless I hold under the arms.” 4. “My child cries and spreads the arms in and out when I bump the crib.” 5. “My child’s soft spot on top of the head is still open.” 18. The charge nurse assigns several clients to a novice nurse who is fresh off unit orientation. Which client will the charge nurse assign the novice nurse to provide care during this shift? (Select all that apply.) 1. A client on airborne precautions for newly diagnosed tuberculosis (TB). 2. A client diagnosed with chronic obstructive pulmonary disease (COPD) discharging tomorrow. 3. A client diagnosed with acute pneumonia on a bilevel positive airway pressure PEDIATRICS NUR0416 3 CAT 3 KAPLAN 3 QUESTIONS AND ANSWERS UPLOADED LATEST 2024 GRADED A+ (BiPAP) machine. 4. A client status postoperative for a vaginal hysterectomy done earlier in the day. 5. A toddler diagnosed with respiratory syncytial virus (RSV) admitted an hour ago. PEDIATRICS NUR0416 3 CAT 3 KAPLAN 3 QUESTIONS AND ANSWERS UPLOADED LATEST 2024 GRADED A+ 19. The nurse teaches a group of nursing students about cultural competency. Which strategy will the nurse include to improve the students' cultural competency? (Select all that apply.) 1. Participate in continuing education classes about culturally congruent care. 2. Develop culturally competent approaches to care. 3. Talk with clients about their cultural views of health. 4. Assess own skill level and seek improvement. 5. Realize that personal preferences can influence the client’s preferences. 20. The nurse manager is concerned about increased instances of client confusion and disorientation in the intensive care unit (ICU). Which nursing intervention is most effective in resolving this issue? 1. Promote day time periods of sleep. 2. Monitor noise levels during the night. 3. Prioritize and cluster care activities. 4. Turn off TVs and unnecessary lights. 21. The nurse provides care to a client with asthma. Which co-morbid condition does the nurse identify as a trigger for an acute asthma episode? 1. Psoriasis. 2. Cellulitis. 3. Rheumatoid arthritis. 4. Hiatal hernia. 22. The nurse manager creates a discharge teaching form for clients with acquired immunodeficiency syndrome (AIDS). Which statement will the manager include on this form? (Select all that apply.) 1. Avoid children who have just gotten a live vaccine. 2. A condom is necessary during sexual activity. 3. Contact sports, such as football, must be avoided. 4. Drug paraphernalia must not be shared with others. 5. Sexual activity must be restricted to a single partner. 23. The nurse provides pain management teaching to an older adult client diagnosed with osteoarthritis (OA). Which medication does the nurse discuss as the initial treatment of choice for OA pain? 1. Morphine. 2. Acetaminophen. 3. Ibuprofen. 4. Cyclobenzaprine. 24. The nurse prepares teaching materials to review chest physiotherapy with the parents of a pediatric client diagnosed with cystic fibrosis (CF). Which observation indicates to the nurse that additional teaching is needed? (Select all that apply.) 1. Blood pressure 110/68 mm Hg. 2. Pulse oximetry 88% on room air. PEDIATRICS NUR0416 3 CAT 3 KAPLAN 3 QUESTIONS AND ANSWERS UPLOADED LATEST 2024 GRADED A+ are ruled out for this client? 1. Airborne precautions. PEDIATRICS NUR0416 3 CAT 3 KAPLAN 3 QUESTIONS AND ANSWERS UPLOADED LATEST 2024 GRADED A+ 2. Droplet precautions. 3. Reverse precautions. 4. Contact precautions. 31. The nurse develops a teaching plan for a client with hyperlipidemia. Which lifestyle change will the nurse include in the plan? (Select all that apply.) 1. Consume a diet low in saturated fat. 2. Engage in regular, high-intensity aerobic activity. 3. Stop tobacco use by any possible means. 4. Avoid exposure to second-hand smoke. 5. Consume a diet low in soluble fiber. 32. The nurse who is a practicing Muslim requests to wear a hijab while working. Which action will the nurse manager take next? 1. Decline the request. 2. Make the accommodation. 3. Advocate for modification of the organization’s dress code. 4. Review the organization’s dress code policy. 33. The nurse provides care for a client diagnosed with insomnia. Which intervention does the nurse include in the nursing care plan? 1. Encourage afternoon naps. 2. Provide dairy products 30 minutes before bedtime. 3. Advise the client to vary retire and awake times. 4. Limit naps to less than 60 minutes. 34. The nurse is proving care for several clients. Which client need will the nurse address first? 1. Client with a stroke needing a hand splint reapplied. 2. Client with diabetes and a fasting blood glucose of 78 mg/dL requesting a snack. 3. Client with diarrhea needing the bedside commode emptied. 4. Client with emphysema requesting assistance with ambulation. 35. The nurse provides care to a newly admitted client. At which time will the nurse conduct a medication reconciliation? (Select all that apply.) 1. At every clinic appointment. 2. At the pharmacy. 3. Upon discharge to home. 4. Upon entry into the unit. 5. Upon transfer to a skilled unit. 36. The nurse provides care for a client experiencing a fever who also reports bone pain, redness, and swelling. The client asks the nurse which treatment will likely be prescribed by the health care provider (HCP). Which response from the nurse is the most accurate? 1. “Usually a few days of bed rest and antibiotics are needed.” 2. “You will need surgery and then antibiotics for a few weeks.” 3. “Antibiotics will be prescribed for several weeks, which you can take at home.” PEDIATRICS NUR0416 3 CAT 3 KAPLAN 3 QUESTIONS AND ANSWERS UPLOADED LATEST 2024 GRADED A+ 4. “If the area improves with rest and warm compresses, you might just need pain medication.” PEDIATRICS NUR0416 3 CAT 3 KAPLAN 3 QUESTIONS AND ANSWERS UPLOADED LATEST 2024 GRADED A+ 1. Client who had a myocardial infarction 3 hours ago and is experiencing two to three premature ventricular contractions per minute. 2. Client who had a lumbar puncture 2 hours ago and is reporting a headache rated as an 8 on a pain rating scale of 0 to 10. 3. Client who had a permanent pacemaker inserted 12 hours ago and is reporting dizziness. 4. Client who had a total hip replacement 8 hours ago and is in a semi-Fowler position. 44. A nurse works to establish a nurse-client relationship with a client who is new to the mental health unit. Which task does the nurse perform during the introductory phase of the nurse-client relationship? (Select all that apply.) 1. Discuss confidentiality with the client. 2. Assist the client to explore feelings. 3. Clarify the client’s problem. 4. Summarize the client’s success. 5. Identify the tasks the client should accomplish. 45. The nurse provides care for a client who reports a lack of appetite, nausea, and passing a small amount of liquid stool throughout the day for several days. Which action does the nurse do next? 1. Administer prescribed medication for constipation. 2. Consult with the dietitian regarding client’s diet. 3. Perform a digital rectal exam. 4. Obtain a stool sample from the client. 46. While assessing an adolescent for a sore throat and fatigue, the nurse notes multiple wounds in different levels of healing on both of the client’s arms. Which action will the nurse take first? 1. Inquire as to how the wounds occurred. 2. Ask about a history of sexual abuse. 3. Assess the wounds for healing and signs of infection. 4. Report the findings to the nursing supervisor. 47. The nurse performs triage at a mass casualty incident. Which client will the nurse recommend receive treatment first? 1. Adolescent client with abdominal bleeding and confusion. 2. School-aged child with lacerations on the face and scalp. 3. Older adult client with a chest wound who is apneic. 4. Adult client with an open fracture of the humerus with present radial pulses. 48. A female client received 2 units of packed red blood cells (PRBCs) for gastrointestinal bleeding. Which finding indicates to the nurse that the client may need an additional transfusion? (Select all that apply.) 1. Pulse rate 115 beats/minute. 2. Blood pressure 82/40 mm Hg. 3. Hemoglobin 13 g/dL (130 g/dL). 4. Hematocrit 28%. 5. Red blood cell count 4 X 106 cells/µL (4.4 X 1012 cells/L). 49. The nurse notes the client’s electrocardiogram (ECG) rhythm is torsades de pointes. PEDIATRICS NUR0416 3 CAT 3 KAPLAN 3 QUESTIONS AND ANSWERS UPLOADED LATEST 2024 GRADED A+ Which assessment does the nurse complete after a normal sinus rhythm is restored? PEDIATRICS NUR0416 3 CAT 3 KAPLAN 3 QUESTIONS AND ANSWERS UPLOADED LATEST 2024 GRADED A+ 1. Monitor for ST segment depression. 2. Monitor for QT interval prolongation. 3. Monitor for PR interval prolongation. 4. Monitor for narrow QRS complexes. 50. The nurse manager reviews the importance of using best evidence when planning client care during a nursing staff meeting. Which nursing staff response indicates additional information is required regarding evidence-based practice? (Select all that apply.) 1. “I’m glad that standardized care plans are gone.” 2. “Care plans now will be customized and useful.” 3. “I always liked research and now we can do it with our clients.” 4. “A software program to help search for information will be helpful.” 5. “Now we know that interventions for care will work for our clients.” 51. A client receiving a blood transfusion develops a cough, rales in bilateral lower lung lobes, shortness of breath, and restlessness. Which action will the nurse take? (Select all that apply.) 1. Slow down the blood transfusion. 2. Place client on the left side. 3. Apply oxygen. 4. Administer prescribed furosemide. 5. Monitor vital signs every 2 to 4 hours. 52. The nurse creates a care plan for a client diagnosed with bilateral lower lobe pneumonia. Which intervention is appropriate for the nurse to delegate to the nursing assistive personnel (NAP)? (Select all that apply.) 1. Instructing the client on the importance of increasing fluid intake. 2. Assisting the client to a high-Fowler position when in bed. 3. Encouraging the client to not talk when receiving a nebulizer treatment. 4. Reminding the client to use the incentive spirometer every hour when awake. 5. Encouraging the client and family to wash their hands frequently. 53. The nurse provides cares for a client with a sodium level of 156 mEq/L (156 mmol/L). Which health care provider prescription does the nurse anticipate? 1. A 3% saline solution. 2. A 5% dextrose solution. 3. A 0.9% saline solution. 4. A lactated ringer solution. 54. The nurse provides care for a client who just returned from total hip arthroplasty with a gravity drain. Which type of drainage does the nurse expect to find in the gravity drain? 1. Sanguineous. 2. Serous. 3. Purulent. 4. Serosanguineous. 55. The nurse is discussing infection control guidelines with a group of student nurses. PEDIATRICS NUR0416 3 CAT 3 KAPLAN 3 QUESTIONS AND ANSWERS UPLOADED LATEST 2024 GRADED A+ 61. A client suddenly develops anxiety, dyspnea, and tachypnea immediately after central venous access device (CVAD) insertion. The nurse determines that which complication is the most likely cause of the client’s distress? (Select all that apply.) 2. Pneumothorax. 3. Pulmonary edema. 4. Heart failure. 5. Cardiac tamponade. 62. The nurse provides care for a client in the post-operative anesthesia care unit (PACU) who had an open reduction for a hip fracture. Which nursing diagnosis is the highest priority? 1. Anxiety. 2. Risk for Infection. 3. Acute pain. 4. Delayed surgical recovery. 63. The nurse provides care for a client with sealed radiation implants to treat uterine cancer. Which action is appropriate for the nurse to implement? (Select all that apply.) 1. Keep the client’s door open to prevent isolation. 2. Place a dosimeter film badge on the client’s gown. 3. Restrict visitors less than 16 years of age. 4. Keep long-handled forceps in the client’s room. 5. Limit each visitor to no more than 30 min per day. 64. The nurse prioritizes care for a group of clients after receiving hand-off communication. Which client does the nurse see first? 1. An older adult client with pneumonia requiring intravenous access for the next dose of antibiotics. 2. A middle-age adult client with urinary retention who has not voided for 8 hours. 3. A middle-age adult client receiving morphine by patient-controlled analgesia with a respiratory rate of 12 breaths/min. 4. An older adult client with confusion identified as being at risk for falling. 65. The nurse performs medication reconciliation for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which class of medication does the nurse question because of possible adverse effects in clients with COPD? 1. Anticoagulants. 2. Benzodiazepines. 3. Loop diuretics. 4. Angiotensin converting enzyme inhibitors. 66. The nurse assesses the respiratory status of a 12-hour-old newborn. Which finding does the nurse report to the health care provider? (Select all that apply.) 1. Nasal flaring. 2. Acrocyanosis. 3. Tachypnea. 4. Ten second periods of apnea. 5. Respiratory rate of 40 breaths per minute. 1.Air embolism. PEDIATRICS NUR0416 3 CAT 3 KAPLAN 3 QUESTIONS AND ANSWERS UPLOADED LATEST 2024 GRADED A+ 67. The nurse reviews a list of pregnant clients waiting to be seen in an antepartum clinic. Which client will the nurse recommend that the health care provider see first? 1. Client at 10 week's gestation reporting urinary frequency. 2. Client at 17 weeks' gestation reporting no fetal movement. 3. Client at 25 weeks' gestation reporting shortness of breath with walking. 4. Client at 37 weeks' gestation reporting nocturia. 68. The nurse delegates care of a client at risk for venous thromboembolism to the LPN/LVN. Which action by the LPN/LVN causes the nurse to intervene? (Select all that apply.) 1. Reinforce the need to flex and extend legs and feet every 2 hours with the client. 2. Apply sequential compression devices to the client. 3. Administer enoxaparin 80 mg subcutaneously to the client. 4. Teach the client the symptoms of pulmonary embolism. 5. Administer oral norgestimate-ethinyl estradiol to the client. 69. The nurse provides care for a client diagnosed with aphasia. Which action does the nurse implement when communicating with this client? (Select all that apply.) 1. Have family members translate for the client as needed. 2. Ask questions that can be answered by “yes” or “no.” 3. Decrease environmental stimuli that might be distracting. 4. Allow body contact such as clasp of hand or touching. 5. Provide the client with simple recorded instructions. 70. The nurse instructs a client about a low-fat, high-fiber diet. Which food does the client chose that best indicates an understanding of the low-fat, high-fiber diet? 1. Garden salad with hard-boiled eggs and Italian dressing. 2. Vegetable stock soup with vegetables served with oat bread. 3. Tuna salad sandwich with celery on whole wheat bread. 4. Broiled chicken stuffed with chopped apples and walnuts. 71. The nurse provides care for a 12-month-old infant. The infant’s parent states to the nurse, “My baby sleeps 18 hours a day; 14 hours at night and a 4 hour nap.” Which action does the nurse take next? 1. Let the parent know this is normal for the infant’s age. 2. Instruct the parent to cut back on the time the infant naps. 3. Notify the health care provider. 4. Instruct the parent to put the infant to bed earlier at night. 72. The nurse provides care for a client who begins nutritional therapy with parenteral nutrition. The client reports feeling anxious and restless. Which action does the nurse take to prevent the client from being injured? 1. Secure all connections in the system. 2. Monitor vital signs every two hours. 3. Calculate intake and output every four hours. 4. Check blood glucose levels every four hours. PEDIATRICS NUR0416 3 CAT 3 KAPLAN 3 QUESTIONS AND ANSWERS UPLOADED LATEST 2024 GRADED A+ 73. The nurse administers a regular insulin intravenous (IV) infusion for a client diagnosed with diabetic ketoacidosis (DKA). Which finding indicates to the nurse that the client is experiencing complications from the insulin infusion? (Select all that apply.) 1. Blood glucose of 66 mg/dL (3.6 mmol/L). 2. Increased urine output. 3. Sodium of 148 mEq/L. 4. Altered mental status. 5. Potassium of 3.0 mEq/L. 74. The nurse assesses the respiratory status of 6 newborns. Which finding does the nurse report to the health care provider? (Select all that apply.) 1. Respirations 38 breaths per minute at 30 minutes of age. 2. Six-second periods of apnea at 1 hour of age. 3. Grunting at 20 minutes of age. 4. Nasal flaring when the infant is supine. 5. Abdomen and chest rise together for each breath. 75. The nurse plans the discharge of a client recovering from an ischemic stroke. Which core measure needs to be met for this client? (Select all that apply.) 1. Provide a prescription for a statin medication at discharge. 2. Refer the client for psychotherapy at discharge. 3. Meet goals for nutrition within 1 week. 4. Provide and document stroke education prior to discharge. 5. Prevent venous thromboembolism. 76. Which activities can the nurse delegate to the nursing assistive personnel (NAP) for client in the post anesthesia unit (PACU)? (Select all that apply.) 1. Obtaining vital signs 2. Assisting with positioning 3. Suctioning the oropharynx 4. Accompanying client transfer 5. Measuring urine output 77. The nurse provides care for a client experienced major head trauma. The client is scheduled to receive a bolus enteral feeding. Which is the most important action the nurse takes? 1. Measure intake and output 2. Monitor blood glucose levels 3. Check albumin level 4. Monitor for diarrhea 78. The nurse provides care for a client diagnosed with itractable pain. The client is prescribed magnesium sulfate 2 mg intravenous push (IVP) now and every 4 to 6 hours, PRN for pain. Which action should the nurse take first? 1. Administer the medication 2. Insert an intravenous access device 3. Question the prescribed medication PEDIATRICS NUR0416 3 CAT 3 KAPLAN 3 QUESTIONS AND ANSWERS UPLOADED LATEST 2024 GRADED A+ 85. The nurse reviews care needs for group of clients. Which activity does the nurse delegate to the nursing assistive personnel (NAP)? (Select all that apply.) 1. Reinforce the dressing of a with a pressure injury 2. Monitor the vital signs of a client who had myocardial infarction 12 hours ago, and being transferred from the coronary care unit 3. Administer a presented tap water enema to a client scheduled for a colonoscopy in 2 hours 4. Assist a client who had an above the knee amputation 40 hours ago into a prone position 5. Help a client who had a colon resection 36 hours ago to ambulate 86. The nurse reviews a list of pregnant clients waiting to be seen in an antepartum clinic. Which client will the nurse recommend that the health care provider see first? 1. Client at 10 week’s gestation reporting urinary frequency. 2. Client at 17 weeks’ gestation reporting no fetal movement 3. Client at 25 weeks’ gestation reporting shortness of breath with walking 4. Client at weeks’ gestation reporting nocturia 87. The nurse asses the respiratory status of 6 newborns. Which finding does the nurse report to the health care provider? (SATA): 1. Respirations 38 breaths per minute at 30 minutes of age 2. Six- second periods of apnea at 1 hour of age 3. Grunting at 20 minutes of age 4. Nasal flaring when the infant is supine 5. Abdomen and chest rise together for each breath 88. The nurse provides care for a client who is severely withdrawn. Which medication will the nurse expect to be prescribed for this client: 1. Lorazepam 2. Chlordiazepoxide 3. Phenytoin 4. Citalopram 89. A client asks for an explanation about advances directives. Which entity should the nurse include in the response to this client? (SATA) 1. Living will 2. Health care proxy 3. Organ donor card 4. Hospice benefit guide 5. Do-not-resuscitate prescription 90. The charge nurse observes a client care provided by staff members. Which observation will the nurse immediately intervene? (SATA): 1. Speech-language pathologist offers a post-cerebral vascular accident (CVA) client thickened liquid from a spoon. 2. Health care provider uses a personal stethoscope to asses a client with pneumonia caused by Acinetobacter. 3. Nursing assistive personnel (NAP) changes bed linen while the client with Meniere disease ambulates to the bathroom PEDIATRICS NUR0416 3 CAT 3 KAPLAN 3 QUESTIONS AND ANSWERS UPLOADED LATEST 2024 GRADED A+ 4. LPN/LVN gathers normal saline, blood tubing, and premedication for a client going to receive a blood transfusion 5. Nurse leaves a client’s room and enters another before performing hand hygiene 91. The nurse provides care to a client receiving mechanical ventilation for 4 days. Which action will the nurse use to prevent ventilator-associated pneumonia (VAP)? Select all that apply: 1. Change the ventilator tubing once a shift 2. Elevate the head of the bed 30 to 45 degrees 3. Wear a surgical mask during suctioning 4. Perform daily spontaneous breathing trials 5. Drain condensation from the ventilator tubing 92. The nurse assesses a client diagnosed with heart failure. The nurse’s findings include a heart rate of 126 beats/min and an altered level of consciousness. Which action should the nurse take next? 1. Assess the clients for jugular distention 2. Evaluate the client’s peripheral pulses 3. Administer the prescribed diuretic medication Notify the health care provider of the status change 93. A client with benign prostatic hyperplasia has a postvoid residual volume of 200 mL. Which medication will the nurse expect the health care provider to prescribe for this client? 1. Alfuzosin 2. Tolterodine 3. Dutasteride 4. Amitriptyline 94. The nurse provides care for a client diagnosed with colon cancer. The clioent is scheduled to have an endoscopy, a PET scan and an MRI. The client questions the nurse as to why all these tests are necessary Which response by the nurse is best? 1. The tests serve to obtain a 3 dimensional view of the tumor. 2. The tests help the provider gather detailed tumor information 3. The provider can use the tests to determine the grade of the tumor cells. 4. The provider will use the tests to decide if chemotherapy will be helpful. 95. The nurse provides care for a client who requests testing for human immunodeficiency virus (HIV). Which intervention is most important for the nurse to perform before administering testing? 1. Discuss prevention practices to prevent the transmission of HIV to others. 2. Explain that all tests must be repeated twice to be valid. 3. Ask the client to identify all sexual partners. 4. Determine when the client thinks the exposure to HIV occurred. 96. The nurse provides care for a client with a platelet count 38,000. Which actions are appropriate for the nurse to take? (Select all the apply) PEDIATRICS NUR0416 3 CAT 3 KAPLAN 3 QUESTIONS AND ANSWERS UPLOADED LATEST 2024 GRADED A+ 1. Give prescribed Vitamin B12 IM. 2. Monitor neurologic changes every 4 hours 3. Perform chest physiotherapy twice daily. 97. The nurse assesses a newborn to determine gestational age. Which finding does the nurse document as a characteristic of a post-term neonate? 1. Slow recoil of the pinna. 2. Skin that is cracked and peeling. 3. Absent vernix. 4. Deep plantar creases. 5. Lanugo present on the extremities. 98. The nurse notes that a toddle- age client has burn marks in various stages of healing and is fearful of male health care professionals. Which action will the nurse take next? 1. Document the findings in the chart. 2. Talk to the nursing supervisor. 3. Ask the client what happened. 4. Discuss the findings with the health care provider. 99. The nurse teaches a client about how yoga can control pain. Which client statement indicates to the nurse that the client understands the teaching? 1. “ I will learn how to visualize images that can help me relax” 2. “I will learn how to perform exercises to improve my circulation” 3. “ I will learn to control my physiological responses to pain.” 4. “ I will use to sound to help relieve my distress.” 100. The nurse provides care for a client diagnosed with a seizure disorder. Which client care activity does the nurse delegate to a nursing assistive personnel (NAP)? (Select all that apply) 1. Place respiratory equipment at the bedside. 2. Remove harmful objects from the clients reach. 3. Apply foam padding around the bed rails. 4. Time the duration of seizure activity. 5. Teach the client about antiseizure meds. 101. The health care provider prescribes a unit of PRBCs for a client admitted with lower gi bleeding. Which step will the nurse take when administering the blood product? (Select all that apply.) 1. Ensure adequate infusion access is present before obtaining the blood from the blood bank. 4. Apply firm pressure to venipuncture sites.5. Keep pathways and bedside uncluttered. PEDIATRICS NUR0416 3 CAT 3 KAPLAN 3 QUESTIONS AND ANSWERS UPLOADED LATEST 2024 GRADED A+ 3. Inquire about an allergy to shellfish. PEDIATRICS NUR0416 3 CAT 3 KAPLAN 3 QUESTIONS AND ANSWERS UPLOADED LATEST 2024 GRADED A+ 4. Provide with a meal. 107. The nurse notes these findings in a newborn: skin smooth and transparent, abundant lanugo on back, slow recoil pinna, and absent plantar creases. When planning care, the nurse will assess the newborn for which condition? 1. Subinvolution 2. Hyperglycemia 3. Postmaturity syndrome 4. Respiratory distress syndrome 108. The charge nurse notes that a client is seen in the emergency department (ED) for the third time in 5 weeks. The client has a history of a chronic respiratory disorder and diabetes mellitus. The client’s record lists multiple home addresses and no family. The client indicates a lack of employment. Which referral is most appropriate for this client? 1. Hospital social worker. 2. Community housing. 3. Case manager 4. County welfare program 109. The nurse who is a practicing Muslim requests to wear a hijab while working. Which action will the nurse manager take next? 1. Decline the request 2. Make the accomodation 3. Advocate for modification of the organization’s dress code. 4. Review the organization’s dress code policy 110. The nurse provides care for a client preparing to go to sleep. The client states to the nurse “ I just can’t relax, and I don’t want to take any sleep medication. What else can I do?” Which action by the nurse can help promote relaxation for sleep? ( Select all that apply) 1. Provide a large snack with warm milk. 2. Remove the wrinkles from the bed linen. 3. Provide a backrub. 4. Reposition the client. 5. Provide extra pillow. 111. The nurse suspects that a client with a head injury is developing Cushin triad. Which finding causes the nurse to make this clinical determination? (Select all that apply) 1. Resp rate 20 breaths/min 2. Pulse oximeter 92% 3. Pulse 52 beats/min and irregular. 4. Temperature 98.4 F PEDIATRICS NUR0416 3 CAT 3 KAPLAN 3 QUESTIONS AND ANSWERS UPLOADED LATEST 2024 GRADED A+ 5. Blood pressure 180/58 mm Hg PEDIATRICS NUR0416 3 CAT 3 KAPLAN 3 QUESTIONS AND ANSWERS UPLOADED LATEST 2024 GRADED A+ 3. Calculate intake and output ever four hours 4. Check blood glucose levels every four hours 118. The nurse provides care for a client diagnosed with asthma. The client is prescribed albuterol and beclomethasone metered dose inhalers. Which client action indicates to the nurse that further teaching Is needed? 1. Using a spacer with both inhalers. 2. Rinsing the mouth after taking the beclamethasone metered dose inhaler. 3. Writing down how many doses have been taken from the metered dose inhaler. 119. The nurse is caring for a client admitted with a COPD exacerbation. Which finding would require immediate attention from the nurse? (Select all that apply) 1. Decreased expiratory peak flow meter readings. 2. Evidence of finger clubbing 3. Increased anterior posterior chest diameter 4. Change in sputum color and amount 5. Presence of fever and tachycardia. 120. The nurse assesses a 4 hour old newborn for acrocyanosis. Which finding does the nurse expect? (Select all that apply) 1. Blue extremities rated “1” for color on Apgar score. 2. Cyanosis of the trunk and thoracic region 3. Cyanosis of the hands and feet. 4. Color returns quickly after blue area is blanched. 5. Cyanosis of the lips and mucous membranes. 121. The nurse supervises the care of clients diagnosed with dehydration. Which client does the nurse delagate to the LPN/LVN? 1. Client with hemoglobin decreased from 18 to 14 2. Client with urine specific gravity decreased from 1.040 to 1.035 3. Client with serum sodium level increased from 149 meq to 155 4. Client with bUN level increased from 24 to 30 122. The nurse provides care to an older adult client in the hospital. Which factor increases this client’s risk of falling? (Select all that apply) 4. Using the beclomethasone inhaler, waiting 5 minutes, then taking the albuterol inhaler. PEDIATRICS NUR0416 3 CAT 3 KAPLAN 3 QUESTIONS AND ANSWERS UPLOADED LATEST 2024 GRADED A+ 1. Glare from bright lights 2. HTN 3. Obesity PEDIATRICS NUR0416 3 CAT 3 KAPLAN 3 QUESTIONS AND ANSWERS UPLOADED LATEST 2024 GRADED A+ 4. Medication interactions 5. Previous falls 123. The nurse provides care to a client with a neutrophil count of 1000 cells/mm^3 (1 x 109/L). Which intervention will the nurse include in the clients care plan? (Select all that apply) 1. Check gums for bleeding. 2. Omit uncooked foods from the diet 3. Check temp every 4 hours 4. Drink only bottled water 5. Microwave on high when reheating food 124. A client who is pregnant is prescribed a medication that is pregnancy category D. Which statement does the nurse make to the client when explaining this drug category? 1. Studies indicate adverse effects in animal fetuses but human fetuses are unknown 2. Studies indicate that a possible fetal risk in humans has been reported 3. Studies indicate fetal abnormalities have been reported 4. Studies indicate no risk to animal fetuses but human fetuses are unknown 125. The nurse provides care for a client diagnoses with an acute sickle cell crisis. Which clinical manifestation should the nurse expect to observe in the client during the shift assessment? (Select all that apply) 1. Weakness 2. Acute pain 3. Flushing of the skin 4. Erectile dysfuntion 5. Joint swelling 126. A nurse provides care for an adult client in the hospital. The caretaker from the client’s agency is at the bedside. The client voices concern about consenting to an elective surgery. The caretaker states, “Just sign the papers and stop acting like such a baby”. Which response by the nurse is the most appropriate? 1. Reassure the client about the surgery 2. Notify the surgeon of the clients feelings . 3. Ask the caretaker to not berate the client 4. Answer the clients questions about the surgery. 127. The nurse provides care to a client prescribed long-term prednisone for the treatment of COPD. Which side effect of prednisone does the nurse expect to observe? (Select all that apply) 1. Loss of appetite 2. K+ 3.1