Funds I
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?
A. Encourage the child to cough frequently to clear congestion from anesthesia
B. Place a heating pad at the Childs neck for comfort
C. Administer analgesics to the child on a routine schedule throughout the day and night
D. Provide the client with ice cream when oral intake is initiated
C. Administer analgesics to the child on a routine schedule throughout the day and night
A nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device?
A. Irrigate the tubing with sterile water once each shift
B. Cleanse the opening with soap and water after emptying
C. Maintain the tubing above the level of the surgical incision
D. Collapse the device of air after opening
D. Collapse the device of air after opening
A community health nurse is planning an educational program about hepatitis A. When preparing the material, the nurse should identify that whihc of the following groups is most at risk for developing hepatitis A
A. Children and young adults
B. Older adults.
C. Women who are preganany
D. Middle-aged men
Children and young adults
mode of transmission - Fecal oral route think poor hygeine
A nurse is caring for a client who has celiac disease. Which of the following foods should the nurse remove from the clients meal tray?
A. Wheat Toast
B. Tapioca Pudding
B. Hard-Boiled eggs
D. Mashed potatoes
Wheat toast
A nurse is reinforcing teaching about self administration of NPH Insulin with a client who has type 2 Diabetes mellitus. Which of the following instructions should the nurse include?
A. Alternate injecting into the abdomen and the thigh
B. Shake the vial before withdrawing the dosage
C. Rotate injection site within the same area
D. Discard the vial if the insulin is cloudy
Rotate injection site within the same area
A charge nurse is observing a newly license nurse perform tracheostomy care for a client. Which of t the following actions by the newly licensed nurse requires interventions?
A. Obtaining hydrogen peroxide for the tracheostomy care
B. Obtaining cotton balls for tracheostomy care
C. Obtaining sterile gloves for tracheostomy care
D. Obtaining a sterile brush for tracheostomy care
Obtaining cotton balls for tracheostomy care
A nurse is reinforcing teaching with a client who has a new colostomy about proper care. Which of the following information sgould the nurse include in the teaching?
A. Change the colostomy bag following breakfast
B Cleanse the skin around the stoma with warm water
C. Change the pouch everyday
D. Place an aspirin in the ostomy pouch to decrease odor
Cleanse the skin around the stoma with warm water
A nurse is caring for a group of client who are receving oxygen therapy. Which of the following clients should the nurse plan to see first?
A. A client who has heart failure and is receiving 100% oxygen therapy via a partial rebreather mask
B. A client who has emphysema and is receiving humidified oxygen at 3L/Min via a transtracheal oxygen canula
C. A client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar
D. A client who has COPD and is receiving oxygen at 2L/Min via nasal cannula
A client who has heart failure and is receiving 100% oxygen therapy via a partial rebreather mask
A nurse is caring for a client who is reciing peritoneal dialysis. The nurse should monitor the client for which of the following adverse effects?
A. Diarrhea
B. Increased serum albumin
C. Hypoglycemia
D. Respiratory distress
Respiratory distress
(Fluid overload )
A nurse reinforcing teaching about lifestyle changes with a client who has had a myocardial infarction and has a new prescription for a beta blocker. Which of the following client statement indicates an understanding of the teaching?
A. I should eat foods high in saturated fats
B. Before taking my medication, I will check my blood pressure
C. I will exercise once a week for a hour at the health club
D. I will stop taking my medication when my blood pressure is within normal range
Before taking my medication, I will check my blood pressure
A nurse is instructing a CNA about proper hand hygeine. Which of the following statements by the AP indicates an understanding of the teaching?
A. There are times I should use soap and water rather than an alcohol based hand rub to clean bmy hands
BI will use cold water when I wash my hands to protect my skin from becoming too dry
C. I will apply friction for at least 10 seconds while washing my hands
D. After washing my hands I will dry them from the elbows down
A. There are times I should use soap and water rather than an alcohol based hand rub to clean bmy hands
A nurse is caring for a client who postoperative following a vaginal hysterectomy and asks for a drink. He rpostoperative diet description reads: Clear liquids; advance diet as tolerated. Which of the following responses should the nurse make?
A. Lunch tray should be here within the hour
B. I am going to listen to your abdomen
C. I'll get you some water to drink
D. I would wait a bit, or you could feel sick
I am going to listen to your abdomen
A nurse is preparing to care for a client who is in balanced skeletal fraction to stabalize the femur fracture. Which of the following actions should the nurse recommend for the clients plan of care?
A. Offering a cthe cleint a fiest high in fluid and fiber
B. Encouraging active range of motion of the affected leg
C. Removing the weights prior to repositioning the client
D. Assisting the client to a lateral position every 4 hours
Offering the client a diet high in fluid and fiber
A nurse in a clinic is collecting data from a client who has a history of peripheral arterial disease. Which of the following findings on the clients lower extremities should the nurse expect?
A. Pitting edema
B. Areas of reddish-brown pigmentation
C. Cool-pale skin with minimal body hair
D. Sunburned appearance with desquamation
Cool pale skin with minimal body hair
A nurse is reinforcing teaching with a client who has a new prescription for hydrochlorothiazide 50mg PO daily to treat hypertension. Which of the following instructions should the nurse include in the teaching?
A. Take hydrochlorothiazide as needed for edema
B. Check your weight once each week
C. Take hydrochlorothiazide on an empty stomach
D. Take the hydrochlorothiazide in the morning
Take the hydrochlorothiazide in the morning
A Nurse is collecting data for the health hystory of a client who is postoperative and has a paralytic ileus. Which of the following findings should the nurse expect?
A. Frequent bowel sounds with flatulus
B. Absent bowel sounds with distention
C. Hyperactive bowel sounds with diarrhea
D. Normal bowel sounds with increase peristalsis
Absent bowel sounds with distention
A Nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions shoul the nurse take?
A. Auscultate for bowel sounds after each feeding
B. Ensure the formula is cold before administering
C. Elevate the clients head of the bed 45 degrees before the feeding
D. Flush the tubing with 15ml of water after the enteral feeding
Elevate the clients head of the bed 45 degrees before the feeding
A nurse is collecting datat from a client who has a closed head injury and is receiving mannitol for maniesfetations of increaees intracranial pressure (ICP). Which of the folowing findings indicates to the nurse that the medication is having a therapuetic effect?
A. The client s urine outpt is 250ml/hr
B. The clients pupils are dilated
C. The clients heart rate is 56bpm
D. The client is restless
A nurse is collecting data from a client who is postoperative following extracorporeal shockwave lithotripsy (ESWL) The nurse should identify that which of the following findings is the priority ?
A. Report of palpitations
B. Pink tinged urine
C. Bruising of the flank area
D. Stone fragments in the urine
Palpitations
A nurse is caring for a client who has anew prescription for Enalapril . The nurse should monitor the client for which of the following adverse effects of this medication?
A. Ecchymosis
B. Jaundice
C. Hypotension
D. Hypokalemia
Hypotension
A nurse is reinforcing teaching of post operative deep breathing and coughing excercises with a client who will have meergency sugrgery for appedicictis. Which of the following statements indicates a lack of readiness to lear by the client?
A. The client asks the nurse to repeat the instructions before attempting the excercises.
B. The client reports severe pain
C. AsThe client asks the nurse how often deep breathning should be done after surgery
D. The client tells the nurse that this excewrcise will probably be painful after surgery
The client reports severe pain
A nurse is checking the IV insertion site for infiltration for a client who is receiving fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site.
A. Redness at the IV site catheter entry site
B. A Palpable cord is felt along the vein used for the infusion
C. Taut skin around the IV Catheter site that is cool to the touch
D. Bleeding at the IV sit e
Taut skin around the IV catheter site that is cool to the touch
A nurse is assisting in the plan of care for a client who is having a percutaneous transluminal coronary angioplasty (PTCA) with stent placement. Which of the following actions should the nurse anticipate in the postoperative plan of care?
A. Reinforce teaching with the client about about a long term condition program
B. Administer schedule doses of acetaminophen
C. Check for peak laboratory markers of Myocardial damage
D. Initiate aspirin regimen
Iniitate asipirn regimin
A nurse in a rehabilitation center is collecting data from a client who is recovering from a left-hemispheric stroke. Which of the following findings should the nurse expect?
A. Reduced Left-Sided Motor function
B. Difficulty with speech
C. Impulsive bheavior
D. Neglect of the left side of the body
Difficulty with speech
A nurse us reinforcing teaching with an assistive personnel (AP) about dietary restrictions for a client who is taking phenelzine to treat depression. The APs selection of which o f the following foods for the clients lunch indicates an understanding of the instructions?
A. Bologna on Wheat bread
B. Chicken salad
C. Cheddar cheese and crackers
D. Pizza with pepperoni
Chicken salad
(tyramine - MAOI/SSRIs) Think first always with antidepressants - No highly processed foods Aged cheese )