Nursing Exam Questions and Answers: RELIAS Medical Surgical RN Form A & B 2023, Exams of Nursing

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ANSWERS WITH 100% CORRECT ANSWERS VERIFIED 102 - ANS 1.2 Milligrams is equal to how many micrograms - ANS1200 mcg a patient on warfarin(Coumadin/jantoven) has an INR of 6. Which medication would you anticipate administering? - ANSVitamin K A patient with diabetes who is receiving peritoneal dialysis Is at risk for which of the following? - ANS? After scrolling through your social media, you notice a coworker posted a photo with a patient from your unit. What is the most appropriate action to take? - ANSReport the situation to the hospital compliance officer. Black and tarry Colored stools are classic symptoms of what condition? - ANSBleeding gastric ulcer dietary teaching for a patient with chronic renal failure should include choices that are: - ANSLow potassium, low protein, moderate fat Failed to capture question - ANSFailed to capture answer Failed to capture question - ANSFailed to capture answer In addition to pain, pallor, and pulselssness, a neurovascular assessment Also includes checking for - ANSParasthesia and paralysis Is a patient with peritonitis Presents with tachycardia, hypotension , and dehydration. What other assessment finding would you anticipate as part of your physical assessment? - ANSSevere abdominal pain or rebound tenderness Is the provider gives you a telephone order to explain a surgical procedure to your patient and obtain surgical consent. How should you respond? - ANSInform the provider that explaining the procedure is outside the nurse's scope of practice. Is what is the earliest sign indicating increased intracranial pressure(ICP)? - ANSLevel of consciousness Is your patient with hepatitis C Exhibits signs of jaundice and a distended abdomen. What procedure would you anticipate being performed by the provider at the bedside for this patient? - ANSParacentesis Is your patient with stage IV Terminal lung cancer continues to experience increasing pain as each day passes. What would you anticipate the provider ordering for this patient? - ANSPalliative care consult

ANSWERS WITH 100% CORRECT ANSWERS VERIFIED Patients with diabetes are at a high risk for complications for damage in what body areas? - ANSNerve and kidney damage To reduce the risk of infection and phlebotomy in an adult patient with a peripherL IV, What is the minimum duration the catheter should remain in place before routine replacement. - ANS72 hours Upon entering your patient's room you note that they are having a seizure. What is your 1st action? - ANSPosition the patient on their side to maintain the airway Upon entry to your patient's room, you find her sitting in high Fowler's Position and complaining of shortness of breath. Her respiratory rate is 34 breaths/minute And 02 sat is 84%. Which mode of oxygen delivery would most likely reverse the symptoms? - ANSNon rebreather mask What are the most common causes of acute onset pancreatitis? - ANSAlcoholism and gallstones What is a proton pump inhibitor, such as pantoprazole (protonix) used for? - ANSReduce gastric acid secretion What is an early symptom that a patient is developing a complication of heart failure? - ANSEdema in the legs and feet What is clubbing of the fingers most likely associated with? - ANSChronic oxygen deficiency What is the best indication of an acute neurological problem? - ANSChange in level of consciousness What lab values are expected to be in a patient with end stage renal disease on hemodialysis - ANSBUN 32, CREATNINE 8. What medication is contraindicated In a patient with A hemorrhagic CVA? - ANSHeparin What patient population is the pneumococcal vaccine PPSV23 indicated for? - ANSAdults aged 65 years and older What type of personal protective equipment(Ppe) Is applied prior to entering a room for a patient with with C diff? - ANSGown and gloves When would sucralfate(Carafate) 4 times daily be scheduled for? - ANS1 hour before meals and at bedtime

ANSWERS WITH 100% CORRECT ANSWERS VERIFIED Which adaptive equipment would be most appropriate to use for a severely contracted patient who is unable to bear weight when transferring from bed to chair - ANSPatient Lift example hoyer Which of the following nursing diagnosis is most important for a patient with chronic obstructive pulmonary disease(COPD) - ANSImpaired gas exchange Which tool should you use to assess pain in your 80 year old patient with severe dementia? - ANS? While in a supine position your patient States" I'm tired and cannot catch my breath". Physical assessment reveals juggler vein distention and a 3rd heart sound(S3). These symptoms are indicative of what condition? - ANSHeart failure You are caring for a patient post lobotomy With a chest tube in place for drainage. What is a priority in caring for this patient? - ANSEncourage the patient to cough and deep breathe. You are caring for a patient with history of diabetes mellitus. You walk into the room and find the patient lethargic and diaphoretic. What is your 1st action? - ANSObtain capillary blood glucose level You are ordered to give Digoxin(lanoxin). Your patience vital signs are BP 130/75, temp 97.9F, HR 52, RR 16, o2 sat 100% on room air. What should you do next? - ANSHOLD DIGOXIN AND CALL PROVIDER You find your coworker looking through your patient's medical record.. She States how is Mr. Smith doing? He is my best friend's dad. We are so worried about him. What is the best course of action? - ANSTell her you cannot give her information and report her actions to your manager. You have 4 patients who have high priority needs. One needs to go to surgery, 1 needs stat lab draws From a PICC line, Another has chest pain rated 8/10 And another needs toileting. Which patient should you tend to 1st? - ANSThe patient with chest pain You have a patient going for dialysis. There are medications include Lisinopril(prinivil), ondansetron (zofran), famotidine(pepcid) and atorvastatin(lipitor). Which medication would you possibly hold and seek clarification? - ANSLISINOPRIL(PRINIVIL) You receive a provider's order that is not consistent with evidence based practice.What is your 1st step? - ANSClarify the order with the provider You received a report on a patient that sustained a right hemisphere CVA 48 hours ago. What do you expect the patient to exhibit? - ANSLift sided weakness of the leg, arm, and face and face

ANSWERS WITH 100% CORRECT ANSWERS VERIFIED You were hired to work the medical unit and when you arrive at work the charge nurse has assigned you to the post surgical unit since they are under staffed. Which is the most appropriate action? - ANSReport to the post surgical unit You're patient Recently had a G Tube Placed and interminent enteral Feedings have been initiated. What symptoms may indicate intolerance to the feedings? - ANSVomiting and diarrhea Your 18 year old female patient was admitted with dehydration secondary to anorexia nervosa. During your assessment you note she has a flat effect and says" I just want to die, I'm tired of my life ". What should be your 1st intervention? - ANSStay with the patient and ask if she has a plan to carry out this wish Your 68 year old patient is a is a Type one diabetic with a history of schizophrenia And exhibit signs and symptoms of tardiness dyskinesia. Is what long term medication is associated with signs and symptoms of tardive dyskinesia? - ANSChlorpromazine(thorazine) Your 72 Year old male patient is admitted for colon cancer Related complications and has a history of CHF, stroke and a recent Knee replacement.Based on your patient's risk assessment,You determine he is at risk for Venous thromboembolism (VTE) What is an appropriate VTE prophylaxis prophylaxis order for this patient? - ANSEnoxaparin(Lovenox) once daily and intermittent pneumatic compressions(IPC) Your 85 year old patient with atrial fibrillation fell at home 3 days ago. You notice she has been having several episodes of acute confusion since being admitted to your unit. What is the most important order you should anticipate from the provider? You're? - ANSHold wayfaring (coumadin) for the next 48 hours Your coworker posted photos on social media from a birthday party they had for her in the unit break room. What should be your next course of action? - ANSNo action is necessary because no PHI was displayed. Your male patient complaints of discomfort while inflating the balloon during insertion of a endwelling urinary catheter. What would be the most appropriate action? - ANSDeflate the balloon, advance the catheter further, then reinflate the balloon. Your new admission presents with a cough, unintentional weight loss, frequent knot sweats, and bloody sputum. What type of isolation precautions should you initiate, if any? - ANSAirborne precautions Your new patient understands very limited English. How should you communicate with them when completing the admission assessment? - ANSUse the organizations interpreter services

ANSWERS WITH 100% CORRECT ANSWERS VERIFIED Your new patient was admitted with Blunt force trauma to the abdomen Following a motor vehicle accident. A NG Tube is in place for decompression, however, you note during the assessment that the stomach is rigid and hard during palpation. What condition do you suspect. - ANSHemorrhage Your patient appears dusky colored and you cannot palpate a pulse. What is the 1st thing you should do? - ANSInitiate a code per facility protocol and begin CPR Your patient continues to pull at their iv located in their left forearm despite verbal reminders And increased observation. The nursing assistant recommends using soft mitt Restraints on the patient. What is your recommendation? - ANSRequest and order for soft mitts As they are the least restrictive.. Your patient has a non productive cough and presence of secretions in his tracheostomy. Prior to sectioning the patient, what should you do 1st? - ANSHyperoxygenate patient Your patient has a temp of 102.3 F, HR 122, and has had 15ml of urine from the indwelling urinary catheter in the last 2 hours. What is your patient most likely experiencing? - ANS? Your patient has symptomatic anemia but is refusing a blood transfusion for religious reasons. What is an appropriate response? - ANSRespect his wishes and notify the provider Your patient is 4 hours post open appendectomy Anne has not voided yet. You note his lower abdomen is distended. What should you do next? - ANSPerform a bladder scan Your patient is admitted from the ED with failure to thrive and advanced dementia. You note he is extremely underweight, appears unbathed for some time, and has a stage 4 pressure injury to his coccyx. You were told in report that he lives at home with family members. What should you do? - ANSNotify the charge nurse and social worker of your concerns. Your patient is admitted with diverticulitis. What type of diet do you expect to be ordered for the patient? - ANSClear liquids Your patient is on contact precautions for active MRSA. What proper PPE should you use before entering the room? - ANSGown and gloves Your patient takes 5 mg of warfarin(coumadin) day and reports having black cored stool today. What do you most likely suspect? - ANSGastrointestinal bleeding Your patient takes regular insulin and NPH twice A-day for glucose control. What times should the patient be taught to be alert for signs of hypoglycemia? - ANSIs late afternoon and early morning

ANSWERS WITH 100% CORRECT ANSWERS VERIFIED Your patient tells you I hope I don't die, but if I do I don't want to be brought back. You notice on her chart and wrist band that she is a full code. What would be the most appropriate action? - ANSDiscuss code status with the patient and follow up with the provider to ensure the medical record reflects her wishes Your patient was admitted for a hypertensive crisis and has a history of HTN. Parkinson disease, depression and alcohol use. On his 2nd hospitalized day, you notice he is more anxious and restless than his baseline. What would be your 1st nursing intervention? - ANSAsk the patient when his last drink of alcohol was Your patient with a known history of diabetes is displaying symptoms of diaphoresis, Cool skin, lethargy, And shakiness. What is your 1st action? - ANSCheck the patient's blood glucose level Your patient's morning labs revealed a hemoglobin level of 6.3 and hematocrit of 18. What blood product do you expect to administer? - ANSPRBCs Your post op patient has a Jackson - Pratt drain in place. how do you ensure effective drain function? - ANSCompress the drain, then plug the bulb to establish suction. A client is about to undergo an elective surgical procedure. Which of the following actions are appropriate for the nurse who is providing preop care regarding informed consent? Select all. A. Make sure the surgeon obtained the client's consent B. Witness the client's signature on the consent form C. Explain the risks and benefits of the procedure D. Describe the consequences of choosing not to have the surgery E. Tell the client about alternatives to having the surgery - ANSA, B The rest of the choices are the surgeon's responsibility, not the nurse A client who had abd. surgery 24 hr ago reports a pulling sensation & pain in his surgical incision. The nurse checks the client's surgical wound & finds the wound separated w/viscera protruding. Which of the following interventions is appropriate? Select all. A. Cover the area w/saline-soaked sterile dressings B. Apply an abdominal binder snugly around the abd. C. Use sterile gloves to apply gentle pressure to the exposed tissues D. Position the client supine w/his hips & knees bent E. Offer the client a warm beverage, such as herbal tea - ANSA, D A client who has had a cerebrovascular accident has persistent problems w/dysphagia. The nurse caring for the client should initiate a referral w/which of the following members of the interprofessional care team?

ANSWERS WITH 100% CORRECT ANSWERS VERIFIED A. Social worker B. CNA C. Occupational therapist D. Speech-language pathologist - ANSD A speech-language pathologist can initiate specific therapy for clients who have difficulty feeding due to swallowing difficulties A client who is postop following a knee arthroplasty is concerned about the adverse effects of the medication he is receiving for pain management. Which of the following members of the interprofessional care team may assist the client in understanding the medication's effects? Select all. A. Provider B. CNA C. Pharmacist D. RN E. Respiratory therapist - ANSA, C, D A client who will undergo neurosurgery the following week tells the nurse in the surgeon's office that he will prepare his advance directives before he goes to the hospital. Which of the following statements by the client indicates to the nurse that he understands advance directives? A. "I'd rather have my brother make decisions for me, but I know it has to be my wife." B. "I know they won't go ahead w/the surgery unless I prepare these forms." C. "I plan to write that I don't want them to keep me on a breathing machine." D. "I will get my regular doctor to approve my plan before I hand it in at the hospital." - ANSC. The client has the right to decide and specify which medical procedures he wants when a life-threatening situation arrives A goal for a client who has difficulty w/self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral w/which of the following members of the interprofessional care team? A. Social worker B. Certified nursing assistant C. Registered dietitian D. Occupational therapist - ANSD. An occupational therapist can assist clients who have physical challenges to use adaptive devices & strategies to help w/self-care activities A home health nurse is discussing the dangers of carbon monoxide poisoning w/a client. Which of the following information should the nurse include in her counseling? A. Carbon monoxide has a distinct odor

ANSWERS WITH 100% CORRECT ANSWERS VERIFIED B. Water heaters should be inspected every 5 years C. The lungs are damaged from carbon monoxide inhalation D. Carbon monoxide binds w/hemoglobin in the body - ANSD. Carbon monoxide is a very dangerous gas because it binds w/hemoglobin & ultimately reduces the oxygen supplied to the tissues in the body. Carbon monoxide is tasteless, has no scent, and cannot be seen. The water heaters, gas-burning furnances, and appliances should be inspected annually The lungs are not damaged in the process of inhalation A home health nurse is discussing the dangers of food poisoning w/a client. Which of the following info should the nurse include in her counseling? Select all. A. Most food poisoning is caused by a virus B. Immunocompromised individuals are at risk for complications from food poisoning C. Clients who are especially at risk are instructed to eat or drink only pasteurized milk, yogurt, cheese, or other dairy products D. Healthy individuals usually recover from the illness in a few weeks E. Handling raw & fresh food separately to avoid cross contamination may prevent food poisoning - ANSB, C, E Most food poisoning is caused by a bacteria such as E. coli. Healthy individuals usually recover in a few days. A nurse educator is conducting a parenting class for new parents. Which of the following statements made by a participant indicates a need for further clarification & instruction? A. "I will begin swimming lessons as soon as my baby can close her mouth under water." B. "Once my baby can sit up, he should be safe in the bathtub." C. "I will test the temp of the water before placing my baby in the bath." D. "Once my infant starts to push up, I will remove the mobile from over the bed." - ANSB Although the baby can hold his head above the water by sitting up, this does not make the baby safe in the tub. Parents should never leave a child unattended in a tub. A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea - ANSA. Hypotension Tachycardia, hot dry skin, and tachypnea are other manifestations of heat stroke

ANSWERS WITH 100% CORRECT ANSWERS VERIFIED A nurse educator is reviewing w/a newly hired nurse the difference in clinical manifestations of a localized vs. a systemic infection. The nurse indicates understanding when she states that which of the following are clinical manifestations of a systemic infection? Select all. A. Fever B. Malaise C. Edema D. Pain or tenderness E. Increase in pulse & respiratory rate - ANSA, B, E Edema and pain and tenderness is localized A nurse educator is teaching a module on pharmacokinetics to a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates an understanding of the 1st-pass effecct? A. "Some meds block normal receptor activity regulated by endogenous compounds or receptor activity caused by other meds." B. "Some meds may have to be administered by a nonenteral route to avoid inactivation as they travel through the liver." C. "Some meds leave the body more slowly & therefore have a greater risk of accumulation & toxicity." D. "Some meds have a wide safety margin, so there is no need for routine serum medication level monitoring." - ANSB. first pass deals with the liver A nurse educator is teaching a module on safe med administration to newly hired nurses. Which of the following statements by the newly hired nurse indicate understanding of the nurse's responsibility when implementing med therapy? Select all. A. "I will observe for med side effects." B. "I will monitor for therapeutic effects." C. "I will prescribe the appropriate dose." D. "I will change the dose if adverse effects occur." E. "I will refuse to give a med if I believe it is unsafe." - ANSA, B, E A nurse enters a client's room & finds him sitting in his chair. He states, "I fell in the shower, but I got myself back up & into my chair." How should the nurse document this in the client's chart? A. The client fell in the shower. B. The client states he fell in the shower & was able to get himself back into his chair C. The nurse should not document this info because she did not witness the fall D. The client fell in the shower & is now resting comfortably - ANSB.

ANSWERS WITH 100% CORRECT ANSWERS VERIFIED By writing what the client states, the info is subjective data A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy & unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on break. Which of the following actions should the nurse take? A. Remind the nurse that safe client care is a priority on the unit B. Ask others on the team whether they have observed the same behavior C. Report observations to the nurse manager on the unit D. Conclude that her coworker's fatigue is not her problem to solve - ANSC. Any nurse who notices behavior that could possibly jeopardize client care or indicate a substance abuse problem has a duty to report the situation immediately to the nurse manager A nurse in a provider's office is preparing to assess a young adult male client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? Select all. A. A concave thoracic spine posteriorly B. An exaggerated lumbar curvature C. A concave lumbar spine posteriorly D. An exaggerated thoracic curvature E. Muscles slightly larger on his dominant side - ANSC, E A nurse in a senior center is counseling a group of older adults about their nutritional needs & considerations. Which of the following info should the nurse include? Select all. A. Older adults are more prone to dehydration than younger adults are B. Older adults need the same amount of most vitamins & minerals as younger adults do C. Many older men & women need calcium supplementation D. Older adults need more calories than they did when they were younger E. Older adults should consume a diet low in carbs - ANSA, B, C D-they need fewer calories not more E-they need more carbs & fiber A nurse in an outpatient clinic is caring for a client who states she is trying to get pregnant. The client currently takes a Category D pregnancy risk med for the control of seizures. Which of the following statements by the nurse is appropriate? A. "This med is prescribed if necessary but it is known to cause adverse effects to the fetus." B. "This med has evidence indicating that it is safe to take during pregnancy & will not harm the fetus."

ANSWERS WITH 100% CORRECT ANSWERS VERIFIED C. "This med cannot be taken during pregnancy because the risk outweighs the potential benefits." D. "This med hasn't been studied in pregnant women but is believed to be safe for the fetus." - ANSA. Category D meds are known to cause harm to fetuses, however the use during pregnancy may be warranted based on potential benefits. A nurse in an outpatient surgical center is admitting a client for a laproscopic procedure. The client has a prescription for preoperative diazepam (Valium). Prior to administering the med, which of the following actions is the highest priority? A. Teaching the client about the purpose of the med B. Administering the med to the client at the prescribed time C. Identifying the client's med allergies D. Documenting the client's anxiety level - ANSC. The greatest risk to the client is an allergic reaction to the med A nurse is assessing a client who has an acute resp. infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? Select all. A. Restlessness B. Tachypnea C. Bradycardia D. Confusion E. Pallor - ANSA, B, E C and D are late manifestations of hypoxemia. A nurse is assessing a client who is 5 days post op following abd. surgery. The surgeon suspects an incisional wound infection & has prescribed antibiotic therapy for the nurse to initiate after collecting wound & blood specimens for culture & sensitivity. Which of the following assessment findings should the nurse expect? Select all. A. Increase in incisional pain B. Fever & chills C. Reddened wound edges D. Increase in serosanguineous drainage E. Decrease in thirst - ANSA, B, C A nurse is assessing a client who is reporting severe pain despite analgesia. The nurse can best assess the intensity of the client's pain by: A. asking what precipitates the pain B. questioning the client about the location of the pain C. offering the client a pain scale to measure his pain

ANSWERS WITH 100% CORRECT ANSWERS VERIFIED D. using open-ended questions to identify the situation - ANSC. pain scale can measure the amount and intensity of the pain A nurse is assessing a client who reports pain when the nurse evaluates the internal rotation of her right shoulder. Which of the following activities is this problem likely to affect? A. Mopping her floors B. Brushing the back of her hair C. Fastening her bra behind her back D. Reaching into a cabinet above her sink - ANSC. Fastening a bra from behind requires internal rotation of the shoulder, so this activity will illicit pain A nurse is assessing a client who takes haloperidol (Haldol) for the tx of schizophrenia. Which of the following findings should the nurse document as extrapyramidal symptoms (EPS)? Select all. A. Orthostatic hypotension B. Fine motor tremors C. Acute dystonias D. Decreased level of consciousness E. Uncontrollable restlessness - ANSB, C, E A and D are adverse effects, but not EPS A nurse is assessing the pain level of a client who has come to the ER reporting severe abd. pain. The nurse asks the client whether he has nausea & has been vomiting. The nurse is assessing which of the following? A. Presence of associated symptoms B. Location of the pain C. Pain quality D. Aggravating & relieving factors - ANSA. this is a common symptom people have when experiencing pain A nurse is caring for a client diagnosed w/severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable & infectious diseases. Which of the following illustrate the rationale for reporting? Select all. A. Planning & evaluating control & prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment D. Identifying endemic disease E. Monitoring for common-source outbreaks - ANSA, B, C, E

ANSWERS WITH 100% CORRECT ANSWERS VERIFIED Not D because endemic disease is already prevalent within a population, so reporting is not necessary A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via NG tube. Which of the following is an appropriate nursing action prior to administering the tube feeding? Select all. A. Auscultate bowel sounds. B. Assist the client to an upright position. C. Test the pH of gastric aspirate. D. Warm the formula to body temp. E. Discard any residual gastric contents. - ANSA, B, C D-the formula should be room temp not body E-unless the volume of the contents is more than 250 mL, the nurse should return the residual content to the client's stomach A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take each time he provides tracheostomy care? Select all. A. Apply the oxygen source loosely if the SPO2 decreases during the procedure B. Use surgical asepsis to remove & clean the inner cannula C. Clean the outer surfaces in a circular motion from the stoma site onward D. Replace the tracheostomy ties w/new ties E. Cut a slit in gauze squares to place beneath the tube holder. - ANSA, B, C D-only replace ties if soiled or wet E-use a commercially prepared gauze w/slit not one nurse makes A nurse is caring for a client who has been sitting in a chair for 3 hrs. Which of the following problems is the client at risk for developing? A. Stasis of secretions B. Muscle atrophy C. Pressure ulcer D. Fecal impaction - ANSAnswer: C Unrelieved pressure over a bony prominence for too long increases the risk of a pressure ulcer A-sitting will help prevent stasis of secretions B and D-these are from prolonged bed rest A nurse is caring for a client who has had diarrhea for the past 4 days. When assessing the client, the nurse should expect which of the following findings? Select all.

ANSWERS WITH 100% CORRECT ANSWERS VERIFIED A. Bradycardia B. Hypotension C. Fever D. Poor skin turgor E. Peripheral edema - ANSB, C, D fever=caused by dehydration tachycardia not brady hypotension because of decreased BP from dehydration fluid overload=peripheral edema A nurse is caring for a client who is 1 day postop following a total knee arthroplasty. The client states his pain level is a 10 on a scale of 0-10. After reviewing the client's medication administration record, which of the following medications should the nurse administer? A. Meperidine (Demerol) 75 mg IM B. Fentanyl 50 mcg/hr transdermal patch C. Morphine 2 mg IV D. Oxycodone 10 mg PO - ANSC. IV morphine is the best because the onset is rapid and absorption to the blood is immediate, which is adequate for a client with a 10 pain severity A nurse is caring for a client who is at high risk for aspiration. Which of the following is an appropriate nursing intervention? A. Give the client thin liquids. B. Instruct the client to tuck her chin when swallowing. C. Have the client use a straw. D. Encourage the client to lie down & rest after meals. - ANSB. Tucking when swallowing allows food to pass down esophagus more easily. A nurse is caring for a client who is having difficulty breathing. The client is lying in bed & is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority? A. Increase the oxygen flow B. Assist the client to Fowler's position C. Promote removal of pulmonary secretions D. Obtain a specimen for arterial blood gases - ANSB Fowler's facilitates better breathing A nurse is caring for a client who is on a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray? A. Cooked barley

ANSWERS WITH 100% CORRECT ANSWERS VERIFIED B. Pureed broccoli C. Vanilla custard D. Lentil soup - ANSC. low-residue diets are low in fiber and easy to digest: dairy products especially A nurse is caring for a client who is on bed rest. Which of the following interventions should the nurse implement to maintain the patency of the client's airway? A. Encourage isometric exercises B. Suction Q8 hr C. Give low-dose heparin D. Promote incentive spirometer use - ANSAnswer: D. it helps keep airways open and prevent atelectasis A-this strengthens skeletal muscles B-this is not indicated C-helps prevent thrombus formation A nurse is caring for a client who is postop. Which of the following nursing interventions reduce the risk of thrombus development? Select all. A. Instruct the client not to use the Valsalva maneuver B. Apply elastic stockings C. Review lab values for total protein level D. Place pillows under the client's knees & lower extremities E. Assist the client to change position often - ANSB, E A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? A. Auscultate breath sounds B. Stop the feeding C. Obtain a chest xray D. Initiate oxygen therapy - ANSB. Stop the feeding A nurse is caring for a client who is receiving morphine via a PCA infusion device after abd. surgery. Which of the following statements indicates that the client knows how to use the device? A. "I'll wait to use the device until it's absolutely necessary." B. "I'll be careful about pushing the button so I don't get an overdose." C. "I should tell the nurse if the pain doesn't stop after I use this device." D. "I will ask my son to push the dose button when I am sleeping." - ANSC. The client should let the nurse know if not receiving adequate pain control, so they can reevaluate the pain control plan

ANSWERS WITH 100% CORRECT ANSWERS VERIFIED A nurse is caring for a client who presents w/linear clusters of fluid-containing vesicles w/some crustings. Which of the following should the nurse suspect? A. Allergic reaction B. Ringworm C. Systemic lupus erythematosus D. Herpes zoster - ANSD. Herpes zoster pink body rash=allergic reaction red circles w/white centers=ringworm red cheek rash bilaterally=lupus A nurse is caring for a client who reports severe sore throat, pain when swallowing, & swollen lymph nodes. The client is experiencing which of the following stages of infection? A. Prodromal B. Incubation C. Convalescence D. Illness - ANSD. Illness specific s/s present is the illness stage A nurse is caring for a client who weighs 80 kg (176 lb) and is 1.6 m ( 5 ft 3 in) tall. Calculate her BMI & determine whether this client is obese based on her BMI. - ANSBMI= above 30 equals obese so yes. A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following info should the nurse include when explaining the procedure to the client? A. Eating more protein is optimal prior to testing B. One stool specimen is sufficient for testing C. A red color change indicates a positive test D. The specimen cannot be contaminated - ANSD. The stool specimens cannot be contaminated with water or urine A nurse is caring for an 82-yr-old client in the ER who has an oral body temp of 38.3 C (101 F), a pulse rate of 114/min, & a RR of 22/min. He is restless & his skin is warm. Which of the following are appropriate nursing interventions for this client? Select all. A. Obtain culture specimens before initiating antimicrobials B. Restrict the client's oral fluid intake C. Encourage the client to limit activity & rest D. Allow the client to shiver to dispel excess heat

ANSWERS WITH 100% CORRECT ANSWERS VERIFIED E. Assist the client w/oral hygiene frequently - ANSA, C, E The nurse should prevent shivering & encourage the client to increase fluids. Why E-Oral hygiene helps prevent cracking of dry mucous membranes of the mouth & lips. A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? Select all. A. Keep the head of the bed elevated 30 degrees B. Massage the client's bony prominences often C. Apply cornstarch liberally to the skin after bathing D. Have the client sit on a gel cushion when in a chair E. Reposition the client at least Q 3 hr while in bed - ANSA, D not E because it should be at least every 2 hours A nurse is caring for an older adult client who lives alone & is to be discharged in 3 days. He states that it is difficult to prepare adequate nutritious meals at home for just 1 person. To which of the following members of the health care team should the nurse refer him? A. Registered dietitian B. Occupational therapist C. Physical therapist D. Social worker - ANSD. social worker A social worker can make arrangements for a meal delivery service to provide nutritious meals daily, or recommend a congregate meal site near the client's home A nurse is collecting data from an older adult client as part of a neurosensory examination. Which of the following findings should the nurse expect as changes associated w/aging? Select all. A. Slower light touch sensation B. Some vision & hearing decline C. Slower fine finger movement D. Some short-term memory decline E. Slower superficial pain sensation - ANSB, C, D A nurse is contributing to the plan of care for a client who is being admitted to the facility w/a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? Select all.

ANSWERS WITH 100% CORRECT ANSWERS VERIFIED A. Place the client in a room that has negative air pressure of at least 6 exchanges/hr B. Wear a mask when providing care within 3 ft of the client C. Place a surgical mask on the client if transportation to another dept is unavoidable D. Use sterile gloves when handling soiled linens E. Wear a gown when preforming care that may result in contamination from secretions

• ANSB, C, E Private room w/droplet precautions indicated for this client. The nurse should wear a gown when contamination from body fluids might happen A nurse is counseling a young adult who describes having difficulty dealing w/several issues. Which of the following problems the client verbalized should the nurse identify as the priority for further assessment & intervention? A. "I have my own apartment now, but it's not easy living away from my parents." B. "It's been so stressful for me to even think about having my own family." C. "I don't even know who I am yet, & now I'm supposed to know what to do." D. "My girlfriend is pregnant, & I don't think I have what it takes to be a good father." - ANSC. Applying Erikson stages of development, knowing oneself is done in adolescence, and this requires the most urgent help A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? Select All. A. The roommate is up independently. B. The client ambulates w/his slippers on over his antiembolic stockings C. The client uses a front-wheeled walker when ambulating D. The client had pain medication 30 min ago E. The client is allergic to codeine F. The client ate 50% of his breakfast this morning - ANSB, C, D A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following is an appropriate response by the nurse? A. "Water helps clear the tube so it doesn't get clogged." B. "Flushing helps make sure the tube stays in place." C. "This will help you get enough fluids." D. "Adding water makes the formula less concentrated." - ANSA this action clears the excess formula preventing any clumps/clogging A nurse is evaluating a client's neurosensory system. To evaluate stereognosis, she would ask the client to close his eyes & identify which of the following items?

ANSWERS WITH 100% CORRECT ANSWERS VERIFIED A. A word she whispers 30cm from his ear B. A number she traces on the palm of his hand C. The vibration of a tuning fork she places on his foot D. A familiar object she places in his hand - ANSD. Stereognosis is tactile recognition A nurse is instructing a group of nursing students in measuring a client's RR. Which of the following guidelines should the nurse include? Select all. A. Place the client in semi-Fowler's position B. Have the client rest an arm across the abdomen C. Observe 1 full respiratory cycle before counting the rate D. Count the rate for 1 min if it is regular E. Count & report any signs the client demonstrates - ANSA, B, C For D, this is if the rate is irregular after initial count, for E, sighs are expected & don't need to be reported A nurse is instructing a postop client about the sequential compression device the provider has prescribed. Which of the following statements should indicate to the nurse that the client understands the teaching? A. "This device will keep me from getting sores on my skin." B. "This thing will keep the blood pumping through my leg." C. "With this thing on, my leg muscles won't get weak." D. "This device is going to keep my joints in good shape." - ANSB. sequential pressure devices promote venous return in the deep veins of the legs & thus help prevent thrombus formation A nurse is instructing an AP in caring for a client who has a low platelet count as a result of chemo. Which of the following is the nurse's priority instruction for measuring vital signs for this client? A. "Don't measure the client's temp rectally." B. "Count the client's radial pulse for 30 sec & multiply by 2." C. "Don't let the client know you are counting her respirations." D. "Let the client rest for 5 mins before you measure her BP." - ANSA. "Don't measure the client's temp rectally." The greatest risk to a client w/a low platelet count is injury that results in bleeding, obtaining a temp this way increases the risk for bleeding. A nurse is monitoring a client who is receiving opioid analgesia for adv effects of the med. Which of the following effects should the nurse anticipate? Select all. A. Urinary incontinence

ANSWERS WITH 100% CORRECT ANSWERS VERIFIED B. Diarrhea C. Bradypnea D. Orthostatic hypotension E. Nausea - ANSC, D, E Urinary retention, not incontinence is an adv effect of these meds as well as constipation, not diarrhea. A nurse is obtaining hx from a client who has pain. The nurse's guiding principle throughout this process should be that: A. some clients exaggerate their level of pain B. pain must have an identifiable source to justify the use of opioids. C. objective data are essential in assessing pain D. pain is whatever the client says it is - ANSD the client is the best source of information in their pain, it is a subjective experience A nurse is performing an admission assessment on a client. When measuring her vital signs, the nurse finds that her radial pulse rate 68/min & her simultaneous apical pulse rate is 84/min. What is the client's pulse deficit? - ANS16/min the pulse deficit is the difference between the apical & radial pulse rates. 84-68= A nurse is preforming a neurosensory examination for a client. Which of the following tests should the nurse preform to test the client's balance? Select all. A. Romberg test B. Heel-to-toe walk C. Snellen test D. Spinal accessory function E. Rosenbaum test - ANSA, B C and E test visual acuity , D tests cranial nerve XI is intact by asking the client to shrug shoulders without complication. A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following is the body's priority energy reserve? A. Fat B. Protein C. Glycogen D. Carbohydrates - ANSD. carbs provide glucose

ANSWERS WITH 100% CORRECT ANSWERS VERIFIED A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the 5 rights of delegation? Select all. A. Right client B. Right supervision/evaluation C. Right direction/communication D. Right time E. Right circumstances - ANSB, C, E A and D are rights of medication administration A nurse is preparing info for a change-of-shift report. Which of the following info should the nurse include in the report? A. The client's input & output for the shift B. The client's BP from the previous day C. A bone scan that is scheduled for today D. The med routine from the med administration record - ANSC. A bone scan that is scheduled for today This is important because the nurse might have to modify the client's care to accommodate them leaving the unit A nurse is preparing to administer 0.9% sodium chloride (0.9% NaCl) 250 mL IV to infuse over 30min. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (round to nearest whole number) - ANS83 gtt/min A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following are appropriate steps for the nurse to take? Select all. A. Warm the enema prior to instillation B. Position the client on the left side w/the right leg flexed forward C. Lubricate the rectal tube or nozzle D. Slowly insert the rectal tube about 2 inches E. Hang the enema container 24 inches above the client's anus - ANSA, B, C -D is the appropriate length of insertion for a child, 3-4 for an adult. -24 inches is too high & will cause it to run to fast & possible painful distention of the colon, 18 inches is the recommended height A nurse is preparing to administer a med to a client. The med was scheduled for administration at 0900. Which of the following are acceptable administration times for this med? Select all.

ANSWERS WITH 100% CORRECT ANSWERS VERIFIED A. 0905 B. 0825 C. 1000 D. 0840 E. 0935 - ANSA, D 30min time frame for meds A nurse is preparing to administer digoxin (Lanoxin) to a client who states, "I don't want to take that med. I do not want one more pill." Which of the following responses by the nurse is appropriate in this situation? A. "Your physician prescribed it for you, so you really should take it." B. "Well, let's just get it over w/quickly then." C. "Okay, I'll just give you your other meds." D. "Tell me your concerns w/taking this med." - ANSD. A nurse is preparing to administer lactated Ringer's (LR) IV 100 mL over 15min. The nurse should set the infusion pump to deliver how many mL/hr? (round to nearest whole number) - ANS400 mL/hr A nurse is preparing to administer methylprednisolone acetate (Depo-Medrol) 10 mg by IV bolus. The amount available is 40 mg/mL. How many mL should the nurse administer? (round to nearest tenth) - ANS0.3 mL A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform prior to beginning the procedure? Select all. A. Review a signal the client can use if feeling any distress B. Lay a towel across the client's chest C. Administer oral pain meds D. Obtain a Dobhoff tube for insertion E. Have a petroleum-based lubricant available - ANSA, B A nurse is preparing to instill an enteral feeding to a client who has an NG tube in place. Which of the following is the nurse's highest assessment priority before performing this procedure? A. Check how long the feeding container has been opened B. Verify the placement of the NG tube C. Confirm that the client doesn't have diarrhea D. Make sure the client is alert & oriented - ANSB the greatest risk is aspiration so verifying the placement of the tube is most important

ANSWERS WITH 100% CORRECT ANSWERS VERIFIED A nurse is preparing to preform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow? Select all. A. Apply suction while withdrawing the catheter B. Perform suctioning on a routine basis, Q2-3 hours C. Maintain medical asepsis during suctioning D. Use a new catheter for each suctioning attempt E. Limit suctioning to 2-3 attempts - ANSA, D, E B-Suctioning is not w/out risk so it should be done as needed, not routinely. C-endotracheal suctioning requires surgical asepsis A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home? Select all. A. Family members who smoke must be at least 10 ft from the client when the oxygen is in use B. Nail polish should not be used near a client who is receiving oxygen C. A "No smoking" sign should be placed on the front door D. Cotton bedding & clothing should be replaced w/items made from wool E. A fire extinguisher should be readily available in the home - ANSB, C, E Family members that smoke should do so outside, and wool creates static electricity so it should be avoided. A nurse is providing teaching about managing anticholinergic effects for a client who has a new prescription for oxybutunin (Ditropan XL). Which of the following are appropriate to include in the teaching? Select all. A. Take frequent sips of water B. Wear sunglasses when exposed to sunlight C. Use a soft toothbrush when brushing teeth D. Take the medication w/an antacid E. Urinate prior to taking the med - ANSA, B, E side effects of this med include: dry mouth, photophobia, and urinary retention A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? Select all. A. Repeat the details of the prescription back to the provider B. Have another nurse listen to the telephone prescription C. Obtain the prescriber's signature on the prescription within 24hrs D. Decline the verbal prescription because it is not an emergency situation

ANSWERS WITH 100% CORRECT ANSWERS VERIFIED E. Tell the charge nurse that the provider has prescribed morphine by telephone - ANSA, B, C A nurse is reviewing safety precautions w/a group of young adults at a community health fair. Which of the following recommendations should the nurse include specifically for this age group? Select all. A. Install bath rails & grab bars in bathrooms B. Wear a helmet while skiing C. Install a carbon monoxide detector D. Secure firearms in a safe location E. Remove throw rugs from the home - ANSB, C, D A is recommended for older adults and E as well for risk of falls A nurse is reviewing the CDC's immunization recommendations w/a young adult client. Which of the following recommendations should the nurse include in this discussion? Select all. A. Human papillomavirus B. Measles, mumps, rubella C. Varicella D. Haemophilus influenzae type b E. Polio - ANSA, B, C D is not for after 18 months of age and polio is also given as a child and not usually beyond 18 yrs old A nurse is reviewing the reported meds of a client who was recently admitted. The meds include cimetidine (Tagamet) & imipramine hydrochloride (Tofranil). Knowing that cimetidine decreases the metabolism of imipramine hydrochloride, the nurse should identify that this combination is likely to result in which of the following effects? A. Decreased therapeutic effects of cimetidine B. Increased risk of imipramine hydrochloride toxicity C. Decreased risk of adv effects of cimetidine D. Increased therapeutic effects of imipramine hydrochloride - ANSB. A med that decreases the metabolism of a 2nd med increases the serum level of the 2nd med, increasing risk for toxicity A nurse is talking w/a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend? A. Macaroni & cheese B. Fresh fruit & whole wheat toast

ANSWERS WITH 100% CORRECT ANSWERS VERIFIED C. Rice pudding & ripe bananas D. Roast chicken & white rice - ANSB. A high-fiber diet promotes normal bowel elimination A nurse is teaching a client about taking multiple oral meds at home to include time- release capsules, liquid meds, enteric-coated pills, & narcotics. Which of the following statements by the client indicates an understanding of the teaching? A. "I can open the capsule w/the beads in it & sprinkle them on my oatmeal." B. "If I am having difficulty swallowing, I will add the liquid meds to a batch of pudding." C. "The pills w/the coating on them can be crushed." D. "I will eat 2 crackers w/the pain pills." - ANSD. this will prevent N&V from the narcotic A nurse is teaching a client how to administer medication through a jejunostomy tube. Which of the following instructions should the nurse include in the teaching? A. "Flush the tube before & after each med." B. "Administer your meds w/your enteral feeding." C. "Administer tablets through the tube slowly." D. "Mix all the crushed meds prior to dissolving in water." - ANSA The client should flush the tube w/15-30 mL of water to prevent clogging of the tube A nurse is teaching a young adult client about health promotion & illness prevention. Which of the following statements by the client indicates an understanding of the teaching? A. "I already had my immunizations as a child, so I'm protected in that area." B. "It is important to schedule routine health care visits even if I'm feeling well." C. "If I'm having any discomfort, I'll just got to an urgent care center." D. "If I am felling stressed, I will remind myself that this is something I should expect." - ANSB. routine health screenings are important at any age A nurse is teaching an adult client how to administer ear drops. Which of the following statements by the client indicates understanding of the proper technique? A. "I will straighten my ear canal by pulling my ear down & back." B. "I will gently apply pressure w/my finger to the tragus of my ear after putting in the drops." C. "I will insert the nozzle of the ear drop bottle snug into my ear before squeezing the drops in." D. "After the drops are in, I will place a cotton ball all the way into my ear canal." - ANSB. The client should apply gentle pressure w/the finger to the tragus of the ear after administering the drops to help the drops go into the ear canal.