Download QUESTION AND ANSWER DOC and more Quizzes Nursing in PDF only on Docsity!
□ Questions
A client with asthma receives a prescription for high blood pressure during a clinic visit. Which prescription should the nurse anticipate the client to receive that is least likely to exacerbate asthma? Pindolol (Visken). Carteolol (Ocupress).
Metoprolol tartrate (Lopressor). Propranolol hydrochloride (Inderal).
□ □ 2. A male client who has been taking propranolol (Inderal) for 18 months tells the nurse that the healthcare provider discontinued the medication because his blood pressure has been normal for the past three months. Which instruction should the nurse provide? Report any uncomfortable symptoms after stopping the medication.
Stop the medication and keep an accurate record of blood pressure.
Ask the healthcare provider about tapering the drug dose over the next week.
Obtain another antihypertensive prescription to avoid withdrawal symptoms.
□ □ 3. A client who is taking clonidine (Catapres, Duraclon) reports drowsiness. Which additional assessment should the nurse make? How long has the client been taking the medication? Does the client use any tobacco products? Has the client experienced constipation recently? Did the client miss any doses of the medication? □ □ 4. The nurse is preparing to administer atropine, an
anticholinergic, to a client who is scheduled for a cholecystectomy. The client asks the nurse to explain the reason for the prescribed medication. What response is best for the nurse to provide? Provide a more rapid induction of anesthesia.
Decrease the risk of bradycardia during surgery. Induce relaxation before induction of anesthesia.
Minimize the amount of analgesia needed postoperatively.
□ □ 5. An 80 - year-old client is given morphine sulphate for postoperative pain. Which concomitant medication should the nurse question that poses a potential development of urinary retention in this geriatric client? In su lin .
An ta ci ds .
Tricyclic antidepressants.
Nonsteroidal antiinflammatory agents.
□ □ 6. A client with osteoarthritis is given a new prescription for a nonsteroidal antiinflammatory drug (NSAID). The client asks the nurse, "How is this medication different from the acetaminophen I have been taking?" Which information about the therapeutic action of NSAIDs should the nurse provide? Are less expensive.
Provide antiinflammatory response. Cause gastrointestinal bleeding.
of Type 2 diabetes mellitus and influenza. Which categories of illness should the nurse develop goals for the client's plan of care? Two acute illnesses. Two chronic illnesses.
One chronic and one acute illness. One acute and one infectious illness.
□
Following an emergency Cesarean delivery, the nurse encourages the new mother to breastfeed her newborn. The client asks why she should breastfeed now. Which information should the nurse provide? Initiate the lactation process. Prevent neonatal hypoglycemia. Stimulate contraction of the uterus. Facilitate maternal-infant bonding.
□
Which intervention should the nurse include in the plan of care for a female client with severe postpartum depression who is admitted to the inpatient psychiatric unit? Full rooming-in for the infant and mother.
Restrict visitors who irritate the client. Supervised and guided visits with infant. Daily visits with her significant other.
□
A 16-year-old male client is admitted to the hospital after falling off a bike and sustaining a fractured bone. The healthcare provider explains the surgery needed to immobilize the fracture. Which action should be implemented to obtain a valid informed consent?
Instruct the client sign the consent before giving medications.
Obtain the permission of the custodial parent for the surgery. Obtain the signature of the client’s stepfather for the surgery.
Notify the non-custodial parent to also sign a consent form.
□
During a client assessment, the client says, "I can't walk very well. " Which action should the nurse implement first? Identify the problem. Consider alternatives.
Predict the likelihood of the outcome. Choose the most successful approach.
□
The nurse identifies a client's needs and formulates the nursing problem of, "Imbalanced nutrition: less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30 pounds over the last 6 months. " Which short-term goal is best for this client? Eat 50 % of six small meals each day by the end of one week. Meals prepared during hospitalization will be fed by the nurse.
Verbalize understanding of plan and of intention to eat meals.
Demonstrate progressive weight gain toward the ideal weight.
A male client is angry and is leaving the hospital against medical advice (AMA). The client demands to take his chart with him and states the chart is "his" and he doesn' t want any
personalities. Require the UAPs to reach a compromise.
Weigh the consequences of each possible solution. Encourage the two to view the humor of the conflict.
□
The nurse is caring for a client who is unable to void. The plan of care establishes an objective for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 pm. Which client response should the nurse document that indicates a successful outcome? Demonstrates adequate fluid intake and output. Voids at least 1000 mL between 7 am and 3 pm. Verbalizes abdominal comfort without pressure. Drinks 240 mL of fluid five times during the shift.
□
The nurse plans a teaching session with a client but postpones the planned session based on which nursing problem? Activity intolerance related to postoperative pain.
Noncompliance with prescribed exercise plan. Ineffective management of treatment regimen. Knowledge deficit regarding impending surgery.
□
A client who has active tuberculosis (TB) is admitted to the medical unit. What action is most important for the nurse to implement? Place an isolation cart in the hallway. Fit the client with a respirator mask. Don a clean gown for client care.
Assign the client to a negative air-flow room.
□
A client is receiving atenolol (Tenormin) 25 mg PO after a myocardial infarction. The nurse determines the client's apical pulse is 65 beats per minute. What action should the nurse implement next? Notify the healthcare provider. Measure the blood pressure. Administer the medication. Reassess the apical pulse.
□
The nurse is assessing a client and identifies a bruit over the thyroid. This finding is consistent with which interpretation? Thyroid cyst. Thyroid cancer.
Hypothyro idism.
Hyperthyr oidism.
□
A 6-year-old child is alert but quiet when brought to the emergency center with periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess the child for additional manifestations of a basilar skull fracture. What assessment finding would be consistent with a basilar skull fracture? Asymmetry of the face and eye movements. Abnormal position and movement of the arm. Hematemesis and abdominal distention.
Rhinorrhoea or otorrhoea with Halo sign.
appearance.
□
A child is receiving maintainance intravenous (IV) fluids at the rate of 1000 mL for the first 10 kg of body weight, plus 50 mL/kg per day for each kilogram between 10 and 20. How many milliliters per hour should the nurse program the infusion pump for a child who weighs 19. 5 kg?
(Enter numeric value only. If rounding is required, round to the nearest whole number. ) 61 □
The nurse obtains the pulse rate of 89 beats/minute for an infant before administering digoxin (Lanoxin). Which action should the nurse take? Assess respiratory rate for one minute next. Give the medication dosage as scheduled.
Wait 30 minutes and give half of the dosage of medication. Withhold the medication and contact the healthcare provider.
□
The nurse is developing a teaching plan for an adolescent with a Milwaukee brace. Which instruction should the nurse include? Remove the brace just before going to bed. Dress with the brace over regular clothing. Shower with the brace directly against the skin. Wear the brace over a T-shirt 23 hours per day.
□
A 9-year-old is hospitalized for neutropenia and is placed in reverse isolation. The child asks the nurse, "Why do you have to wear
a gown and mask when you are in my room?" How should the nurse respond? “There are many forms of bacteria and germs in the hospital. ” “To protect you because you can get an infection very easily. ” “After taking medication for 24 hours a gown and mask won't be needed. ” "Your condition could be spread to staff and other clients in the hospital. ” □
The nurse is giving discharge instructions to the parents of a newborn with a prescription for home phototherapy. Which statement by a parent indicates understanding of the phototherapy? “I need to change the baby’s position every four hours. ”
“I should leave the baby under the light all of the time. ” “I will keep the baby’s eyes covered when the baby is under the light. ” “I should dress the baby in light clothing when the baby is under the light. ” □
A male client who had abdominal surgery has a nasogastric tube to suction, oxygen per nasal cannula, and complains of dry mouth. Which action should the nurse implement? Put petroleum jelly on the lips and around the nasogastric tube.
Allow the client to drink water and record on the I and O record.
Offer the client ice chips and instruct client to spit out the water.
Apply a water soluble lubricant to the lips, oral mucosa and nares.
□
The nurse is assessing the laboratory results for a
A nurse with Marfan's syndrome who is postmenopausal. A nurse with oncology experience who may be pregnant. The nurse who is caring for another client who has Clostridium difficile.
□
Which information should the nurse provide a client who has undergone cryosurgery for Stage 1A cervical cancer? Notify the healthcare provider if heavy vaginal discharge occurs.
Use condoms for sexual intercourse during the next week. Flat subclinical mucosal lesions are a common harmLess side effect.
Use a sanitary napkin instead of a tampon.
□
Which nurse follows a client from admission through discharge or resolution of illness and coordinates the client's care between healthcare providers? Case manager. Nurse- manager. Quality manager. Discharge manager.
The nurse is preparing a client for a scheduled surgical procedure. What client statement should the nurse report to the healthcare provider? Expresses fear about the surgical procedure. Recalls drinking a glass of juice after midnight.
Reports a history of hives after eating shellfish. States has a history of post-operative nausea.
The parents of a 14-year-old boy express concern about their son's behavior, which ranges from clean- cut and personable to "grungy" and sullen. They have tried talking with him and disciplining him, but he continues to demonstrate confusing behaviors. Which information is best for the nurse to provide? Adolescents who demonstrate labile behaviors are at risk for self-injury.
Rebelliousness requires consequences to prevent socially deviant behavior.
Early adolescence is a developmental stage of normal experimentation.
The parents should consider hospitalization to prevent self injury.
□
The nurse is interviewing a female client whose spouse is present. During the interview, the spouse answers most of the questions for the client. Which action is best for the nurse to implement? Direct the questions to the spouse whenever possible. Repeat each question and tell the client to speak up. Ask another nurse to complete the interview.
Ask the spouse to step out for a few minutes.
□
The nurse determines that a client's body weight is 105 % above the standardized height-weight scale. Which related factor should the nurse include in the nursing problem, "Imbalanced nutrition: more than body requirements?" Morbidly obese. Markedly obese.
Inadequate lifestyle changes in diet and exercise. Increased morbidity and mortality risks.
□
Unequal pupils.
Loss of central reflexes. Inability to open the eyes.
Change in level of consciousness.
□
When documenting assessment data, which statement should the nurse record in the narrative nursing notes? Hair is within normal limits.
Most all permanent teeth are present.
S1 murmur auscultated in supine position. Slight tenderness in the left upper quadrant.
□
A female client reports to the nurse that her sleep was interrupted by "thoughts of anger toward my husband. " What type of thoughts is the client having? Obs essi ve.
Pho bic.
Del usio nal.
Para noid .
□
The nurse attempts to notify the healthcare provider about a client who is exhibiting an extrapyramidal reaction to psychotropic medications. When the receptionist for the answering service offers to take a message, which nursing action is best for the nurse to take?
Ask when the healthcare provider plans to return to the office and the usual office hours.
Tell the receptionist to have the healthcare provider return the phone call.
Provide the receptionist with the client's name, age, and type of reaction.
Ask the receptionist to notify the client's family if the healthcare provider cannot be contacted.
□
A primipara with a breech presentation is in the transition phase of labor. The nurse visualizes the perineum and sees the umbilical cord extruding from the introitus. In which position should the nurse place the client? Left supine with thighs flexed on her abdomen. Right lateral side with both legs flexed.
Semi-Fowler's with head of bed elevated 30 degrees. Supine with the foot of the bed elevated.
□
The nurse is developing a series of childbirth preparation classes for primigravida women and their significant others. What is the priority expected outcome for these classes? Educate significant others about providing support for their
partner during labor.
Participants can identify at least three coping strategies to use during labor.
Teach and practice breathing techniques to help cope with contractions during labor.
Introduce comfort measures that are effective techniques to use during labor and delivery.
□
A female client makes routine visits to a neighborhood community health center. The nurse notes that this client often presents with
Which group is likely to be most effective in developing the new care map? Nurse-manager group.
Multidisciplinary group. Single- discipline group. Surgical staff group.
□
The scope of professional nursing practice is determined by rules promulgated by which organization? State's Board of Nursing.
State Nursing Associations. American Nurses Association (ANA).
National Labor Relations Board (NLRB).
□
An older client who has been bedridden for a month is admitted with a pressure ulcer on the left trochanter area. The nurse determines that the ulcer extends into the subcutaneous tissue. At which stage should the nurse document this finding? S t a g e 1. S t a g e 2. S t a g
e 3. S t a g e 4. □
After receiving report, the nurse prioritizes the client care assignment. Which client should the nurse assess first? The client who has a new onset of difficult breathing.
An anxious client who is 3 days post myocardial infarction. The client with type 2 diabetes mellitus who has a call light on.
A client whose blood transfusion is near completion.
□
When meeting with the client and the family, which nursing intervention demonstrates the nurse's role as collaborator of care?
Coordinating and educating about multidisciplinary services. Providing information on financial assistance programs. Referring and consulting with other healthcare specialities. Informing about the findings that determine clinical diagnosis.
□
Preoperatively, a client is to receive 75 mg of meperidine (Demerol) IM. The Demerol solution contains 50 mg/mL. How much solution should the nurse administer?
5 mL.
