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Questions
1. 1.ID: 383709206
A nurse in a physician's office is reviewing the medical record of a child with a diagnosis of lactose intolerance. Which of the following findings does the nurse expect to see documented in the child's record? A. Fatty stools B. Episodes of foul-smelling ribbonlike stools C. Episodes of profuse watery diarrhea and vomiting D. Episodes of cramping abdominal pain and excessive flatus Correct Awarded 1.0 points out of 1.0 possible points.
- 2.ID: 383706682 Warfarin sodium (Coumadin) is prescribed for a hospitalized client. While transcribing the physician's prescription, the nurse notes that the client is taking levothyroxine (Synthroid) to treat hypothyroidism. The nurse calls the physician to confirm the prescription for warfarin sodium because: A. Warfarin sodium amplifies the effect of levothyroxine B. Levothyroxine amplifies the effect of warfarin sodium Correct C. Warfarin sodium is contraindicated with the use of levothyroxine D. A severe allergic reaction may occur if warfarin sodium is administered concurrently with levothyroxine Awarded 1.0 points out of 1.0 possible points.
- 3.ID: 383707951 A nurse is caring for a client who is immobilized in skeletal traction after sustaining a leg fracture in a motor vehicle crash. The nurse notes that the client is restless, and the client complains of being bored. Which problem does the nurse identify on the basis of this information?
A. Lack of control B. Lack of physical mobility C. Lack of adequate diversional activity Correct D. Lack of energy to bathe and feed self Awarded 1.0 points out of 1.0 possible points.
- 4.ID: 383712001 A nurse in a physician's office is conducting a 2-week postpartum assessment of a client. During abdominal assessment, the nurse is unable to palpate the uterine fundus. This finding would prompt the nurse to: A. Document the findings Correct B. Ask the physician to see the client immediately C. Ask another nurse to check for the uterine fundus D. Place the client in the supine position for 5 minutes, then recheck the abdomen Awarded 1.0 points out of 1.0 possible points.
- 5.ID: 383710084 A nurse is providing instruction about insulin therapy and its administration to an adolescent client who has just been found to have diabetes mellitus. Which statement by the client indicates a need for further instruction? A. "It’s important to rotate injection sites." B. "I need to store the insulin in a cool, dry place." C. "I need to keep any unopened bottles of insulin in the freezer." Correct D. "I need to check the expiration date on the insulin before I use it." Awarded 1.0 points out of 1.0 possible points.
- 6.ID: 383703617 A client with myasthenia gravis is taking neostigmine bromide
10. 10.ID: 383704556
Cascara sagrada has been prescribed for a client with diminished colonic motor response as a means of promoting defecation. The nurse provides information to the client about the medication and tells the client to: A. Increase fluid intake Correct B. Consume low-fiber foods C. Consume foods that are low in potassium D. Contact the physician if the urine turns yellow-brown Awarded 1.0 points out of 1.0 possible points.
- 11.ID: 383710059 A male client arrives at the emergency department and reports to the nurse, "I woke up this morning and couldn't move my arms." He also tells the nurse that he works in a factory and witnessed an accident 3 weeks ago in which a fellow employee's hands were severed by a machine. What is the priority response by the nurse? A. Assessing the client for organic causes of loss of arm movement Correct B. Calling the crisis intervention team and asking them to assess the client C. Performing active and passive range-of-motion (ROM) exercises of the client's arms D. Asking the client to move his arms and documenting the loss of movement he has experienced Awarded 1.0 points out of 1.0 possible points.
- 12.ID: 383712409 A nurse is monitoring a hospitalized client who is being treated for preeclampsia. Which items of the following information elicited during the assessment indicate that the condition has not yet resolved? Type the option number that is the correct answer. Answer:
Nursing Progress Notes
- Hyperreflexia is present.
- Urinary protein is not detectable.
- Urine output is 45 mL/hr.
- Blood pressure is 128/78 mm Hg. Correct Awarded 1.0 out of 1.0 possible points.
- 13.ID: 383702979 A nurse provides home care instructions to a client with mild preeclampsia. The nurse tells the client that: A. Sodium intake is restricted B. Fluid intake must be limited to 1 quart each day C. Urine output must be measured and that the physician should be notified if output is less than 500 mL in a 24-hour period Correct D. Urinary protein must be measured and that the physician should be notified if the results indicate a trace amount of protein Awarded 1.0 points out of 1.0 possible points. B. 14.ID: 383710518 A client is found to have iron-deficiency anemia, and ferrous sulfate (Feosol) is prescribed. The nurse tells the client that it is best to take the medication with: A. Milk B. Apple juice C. Orange juice Correct D. Scrambled eggs Awarded 1.0 points out of 1.0 possible points.
Awarded 1.0 points out of 1.0 possible points. F. 18.ID: 383711493 A nurse is reviewing the medical record of an infant in whom hypertrophic pyloric stenosis (HPS) is suspected. Which characteristics associated with the disorder does the nurse expects see documented in the infant’s medical record? Select all that apply.
- Weight loss Correct B. Facial edema C. Metabolic acidosis - Projectile vomiting Correct - Distended upper abdomen Correct Awarded 1.0 points out of 1.0 possible points. G. 19.ID: 383706605 A (^) client is brought to the emergency department after sustaining smoke inhalation. Humidified oxygen is administered to the client by way of face mask, and arterial blood gases (ABGs) are measured. ABG analysis indicates arterial oxygenation^ (Pao^2 )^ of less than 60 mm Hg. On the basis of the ABG result, the nurse prepares to: A. Continue monitoring the client B. Increase the amount of humidified oxygen C. Continue administering humidified oxygen D. Assist in intubating the client and beginning mechanical ventilation Correct Awarded 1.0 points out of 1.0 possible points. H. 20.ID: 383711481 A client with tuberculosis will be taking pyrazinamide (Pyrazinamide), and the nurse provides instructions about the adverse effects of the medication. For which of the following occurrences does the nurse tell the client to contact the
physician? A. Headache B. Yellow skin Correct C. Difficulty sleeping D. Nasal congestion Awarded 1.0 points out of 1.0 possible points. I. 21.ID: 383703685 A nurse in the postpartum unit is caring for a client who delivered a healthy newborn 12 hours ago. The nurse checks the client's temperature and notes that it is 100.4° F (38° C). On the basis of this finding, the nurse would: A. Notify the physician B. Recheck the temperature in 4 hours Correct C. Encourage the client to breastfeed the newborn D. Institute strict bedrest for the client and notify the physician Awarded 1.0 points out of 1.0 possible points. J. 22.ID: 383708563 Alendronate (Fosamax) is prescribed for a client with postmenopausal osteoporosis. The nurse provides information on the medication to the client. When does the nurse tell the client to take the alendronate? A. At bedtime B. With orange juice, to enhance absorption at night C. Every morning before breakfast, with a full glass of water Correct D. Every morning after breakfast, after which the client should lie down for 30 minutes
contact the on-call physician Correct C. Withhold the medication until the physician can be reached in the morning D. Administer the medication but consult the physician when he becomes available Awarded 1.0 points out of 1.0 possible points. N. 26.ID: 383703653 An adult client with an ileostomy is admitted to the hospital with a diagnosis of isotonic dehydration. What findings does the nurse expect to note during the admission assessment? Select all that apply.
- Skin tenting Correct - Flat neck veins Correct - Weak peripheral pulses Correct D. Moist oral mucous membranes E. A heart rate of 88 beats/min F. A respiratory rate of 18 breaths/min Awarded 1.0 points out of 1.0 possible points. O. 27.ID: 383705047 A nurse provides instructions to a client who is preparing for discharge after a radical vulvectomy for the treatment of cancer. Which statement by the client indicates a need for further instruction? A. "I can resume sexual activity in 4 to 6 weeks." B. "I need to avoid straining when I have a bowel movement." C. "I should wear support hose for 6 months and elevate my legs frequently." D. "I need to contact my surgeon immediately if I feel any numbness in my genital area." Correct Awarded 1.0 points out of 1.0 possible points.
P. 28.ID: 383705088
A client with depression is being encouraged to attend art therapy as part of the treatment plan. The client refuses, stating, "I can't draw or paint." Which of the following responses by the nurse is therapeutic? A. "Why don't you really want to attend?" B. "This is what your physician has prescribed for you as part of the treatment plan." C. "OK, let's have you attend music therapy. You can sing there. How does that sound?" D. "Perhaps you could attend and talk to the other clients and see what they’re drawing and painting." Correct Awarded 1.0 points out of 1.0 possible points. Q. 29.ID: 383708590 A client is found to have posttraumatic stress disorder (PTSD) after witnessing a terrorist attack that caused the deaths of hundreds of people. The nurse, developing a plan of care for the client, identifies posttrauma syndrome as a concern and identifies a client outcome that states, "The client will cope effectively with thoughts and feelings of the event." Which nursing interventions will assist the client in achieving this outcome? Select all that apply.
- Being honest, nonjudgmental, and empathetic Correct - Assessing the immediate posttraumatic reaction Correct C. Encouraging the client to keep a journal focused on the trauma Correct D. Asking the client about the use of alcohol and drugs before and since the event Correct E. Promoting discussion of the reasons the client was responsible for the traumatic event F. Discouraging the use of support groups until the client is able to use effective coping techniques
C. Assess the client for the presence of bowel sounds D. Ask the client to gargle with a warm saline solution Awarded 1.0 points out of 1.0 possible points. U. 33.ID: 383702952 An emergency department nurse has a physician's prescription to irrigate a client's ears. List in order of priority the steps that the nurse should take in performing this procedure. Correct
- Use an otoscope to ensure that the tympanic membrane is intact.
- Warm tap water to body temperature.
- Fill an irrigating syringe with warm water.
- Insert the irrigating solution by directing the solution toward the wall of the ear canal.
- Document the completion of the procedure and how the client tolerated it. Awarded 1.0 points out of 1.0 possible points.
- 34.ID: 383711485 A nurse provides home care instructions to a client with coronary artery disease (CAD) who is being discharged from the hospital. Which statement by the client indicates a need for further instruction? A. "I need to carry my nitroglycerin with me at all times." B. "I need to check my pulse before, during, and after exercise." C. "I need to avoid foods with saturated fats and foods high in cholesterol." D. "I need to participate in aerobic and weightlifting exercise three times a week." Correct
A nurse provides instruction to a pregnant woman about foods containing folic acid. Which of these foods does the nurse tell the client to consume as sources of folic acid? Select all that apply. E. Bananas F. Potatoes
- Spinach Correct - Legumes Correct - Whole grains Correct J. Milk products Awarded 1.0 points out of 1.0 possible points. B. 36.ID: 383703683 The nurse notes the presence of drainage on the mustache dressing of a client who has undergone transsphenoidal hypophysectomy. The initial nursing action is to:
- Contact the surgeon B. Change the dressing C. Document the findings D. Check the drainage for glucose Correct Awarded 1.0 points out of 1.0 possible points. C. 37.ID: 383703643 A nurse is preparing to care for a preschool-age child with sickle cell anemia who is experiencing vasoocclusive pain. Which method of assessing the degree of pain the child is experiencing is most appropriate? A. Asking the child to describe the intensity of the pain B. Asking the child to use a numeric rating scale of 0 to 100 C. Asking the child whether the patient-controlled analgesia (PCA) pump is relieving the pain D. Asking the child to point to the face, on a spectrum ranging from smiling to very sad, that best describes the pain Correct
C. Checking the client's blood pressure Correct D. Ensuring that the uterus is contracted Awarded 1.0 points out of 1.0 possible points. G. 41.ID: 383704525 A nurse is performing an assessment of a client with suspected pheochromocytoma. Which clinical manifestation does the nurse expect to note? A. Weight gain B. Flushed face C. Client complaint of diarrhea D. A blood pressure higher than the normal range Correct Awarded 1.0 points out of 1.0 possible points. H. 42.ID: 383706090 A nurse, conducting an assessment of a client being seen in the clinic for symptoms of a sinus infection, asks the client about medications that he is taking. The client tells the nurse that he is taking nefazodone hydrochloride (Serzone). On the basis of this information, the nurse determines that the client most likely has a history of: A. Depression Correct B. Diabetes mellitus C. Hyperthyroidism D. Coronary artery disease Awarded 1.0 points out of 1.0 possible points. I. 43.ID: 383711491 A home care nurse prefills syringes containing NPH (Humulin N) and regular (Humulin R) insulin for a client with diabetes mellitus who will be administering his own insulin but has difficulty seeing and accurately preparing doses. The nurse places the medication in the client's refrigerator with the syringes: A. Lying flat B. In a horizontal position C. In a vertical position with the needles pointing up Correct D. In a vertical position with the needles pointing down Awarded 1.0 points out of 1.0 possible points. J. 44.ID: 383708594 A client is found to have hypoxemic respiratory failure. Which
finding does the nurse expect to note on review of the results of the client's arterial blood gas analysis?
- Pao^2 of^73 mm^ Hg,^ Paco^2 of^62 mm^ Hg B. Pao 2 of 58 mm Hg, Paco 2 of 35 mm Hg C. Pao 2 of 60 mm Hg, Paco 2 of 45 mm Hg D. Pao 2 of 49 mm Hg, Paco 2 of 32 mm Hg Correct Awarded 1.0 points out of 1.0 possible points. K. 45.ID: 383713112 A client receiving parenteral nutrition (PN) suddenly experiences chest pain and dyspnea, and the nurse suspects an air embolism. The nurse immediately places the client in a lateral Trendelenburg position, on the left side. What action does the nurse take next? A. Auscultating heart sounds B. Clamping the intravenous catheter Correct C. Checking the client's blood pressure D. Obtaining an arterial blood gas specimen Awarded 1.0 points out of 1.0 possible points. L. 46.ID: 383710053 Oral candidiasis (thrush) develops in a client infected with HIV, and the nurse provides instruction to the client about measures to relieve the discomfort. Which statement by the client indicates a need for further instruction? A. "I should avoid spicy foods." B. "I should eat foods with a soft texture." C. "I should use a soft-bristled toothbrush." D. "I should put ice in my drinks to help soothe the discomfort." Correct Awarded 1.0 points out of 1.0 possible points. M. 47.ID: 383706640 A nurse has provided nutrition instructions to a mother of an infant. Which statement by the mother indicates to the nurse that the mother requires further instruction? A. "It’s best to use cow's milk, as long as it’s whole milk and not skim." Correct B. "When I start feeding solid foods, I might need
Awarded 1.0 points out of 1.0 possible points. O. 49.ID: 383703659 The blood serum level of imipramine is determined in a client who is being treated for depression with Tofranil-PM. The laboratory test indicates a concentration of 250 ng/mL. On the basis of this result, the nurse should: A. Contact the physician B. Hold the next dose of imipramine C. Document the laboratory result in the client's record Correct D. Have another blood sample drawn and ask the laboratory to recheck the imipramine level Awarded 1.0 points out of 1.0 possible points. P. 50.ID: 383709219 A nurse is monitoring a pregnant client with suspected partial placenta previa who is experiencing vaginal bleeding. Which of the following findings would the nurse expect to note on assessment of the client? A. Painful vaginal bleeding B. Sustained tetanic contractions C. Complaints of abdominal pain D. Soft, relaxed, nontender uterus Correct Awarded 1.0 points out of 1.0 possible points. Q. 51.ID: 383704521 A client with chronic back pain asks a nurse about the use of complementary and alternative therapies to treat the pain. The nurse would initially: A. Identify the client's treatment goals Correct B. Share current research outcomes with the client C. Offer options that may be beneficial to the client D. Tell the client that the physician does not believe in these therapies Awarded 1.0 points out of 1.0 possible points.
R. 52.ID: 383710516
A client with HIV infection who has been found to have histoplasmosis is being treated with intravenous amphotericin B (Fungizone). Which parameter does the nurse check to detect the most common adverse effect of this medication? A. Temperature B. Blood pressure C. Peripheral pulses D. Intake and output Correct Awarded 1.0 points out of 1.0 possible points. S. 53.ID: 383710579 A school nurse observing a child with Down syndrome is participating in a physical education class and notes that the child is experiencing a diminution in motor abilities. The nurse asks to see the child and conducts an assessment, during which the child complains of neck pain and loss of bladder control. What is the appropriate action by the nurse in this situation? A. Contacting the child's physician to report the findings Correct B. Administering acetaminophen (Tylenol) to the child to relieve the pain C. Asking that the child not attend the physical education class until the neck pain has subsided D. Teaching the child how to use peripads to prevent embarrassment resulting from loss of bladder control Awarded 1.0 points out of 1.0 possible points. T. 54.ID: 383706078 A nurse transcribing the prescriptions of a client admitted to the nursing unit notes that metformin (Glucophage) 850 mg/day has been prescribed. The nurse makes a note in the client's medication record that the medication should be administered: A. At noon B. With supper C. With the morning meal Correct D. With the midafternoon snack Awarded 1.0 points out of 1.0 possible points. U. 55.ID: 383712464 A nurse provides skin care instructions to a client with acne vulgaris. Which statement by the client indicates a need for
