Airway
The nurse is assessing a client who has an acute respiratory infection that puts her at risk for hypoxemia. Which of the following is the earliest finding for hypoxemia?
A. Restlessness.
B. Tachypnea.
C. Bradycardia.
D. Coughing
A. Restlessness.
The nurse is preparing to perform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow? Select all that apply.
A. Apply suction while withdrawing the catheter.
B. Perform suctioning on a routine basis, every 2 hours.
C. Maintain medical aseptic technique during suctioning.
D. Use a new catheter for each session
E. Limit suctioning to 2 to 3 attempts.
A. Apply suction while withdrawing the catheter.
D. Use a new catheter for each session
E. Limit suctioning to 2 to 3 attempts.
An elderly nursing home resident has refused to eat or drink for several days and is admitted to the hospital. The nurse should expect which assessment finding?
A. Increase blood pressure.
B. Weak, rapid pulse.
C. Moist mucous membranes.
D. Jugular vein distention.
B. Weak, rapid pulse.
A man brings his elderly wife to the emergency department. He states that she has been vomiting and has had diarrhea for the past two days. She appears lethargic and is complaining of leg cramps. What should the nurse do first?
A. Start an IV.
B. Review the results of serum electrolytes.
C. Offer the woman foods that are high in sodium and potassium content.
D. Administer an anti-emetic
C. Offer the woman foods that are high in sodium and potassium content.
A client exhibits all of the following during a physical assessment. Which of these is considered a primary defense against infection?
A. Fever
B. Intact skin
C. Inflammation
D. Lethargy
B. Intact skin
The nurse is caring for a client who is having difficulty breathing. The client is lying supine in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurses priority?
A. Increase the oxygen flow.
B. Assist the client to High Fowler's position.
C. Promote removal of pulmonary secretions.
D. Attain a specimen for arterial blood gases.
B. Assist the client to High Fowler's position.
A nurses caring for a client who has a tracheostomy. Which of the following actions should the nurse take each time he provides a tracheostomy care? Select all that apply.
A. Apply the oxygen source loosely if the SPO2 increases during the procedure.
B. Use surgical asepsis to remove and clean the inner cannula.
C. Clean the outer surfaces in a circular motion from the stoma site outward.
D. Replace the tracheostomy ties with new ties.
E. Cut a slit in gauze squares to place beneath the tube holder.
C. Clean the outer surfaces in a circular motion from the stoma site outward.
D. Replace the tracheostomy ties with new ties.
Pain tolerance in an elderly patient with cancer would:
A. stay the same.
B. be lowered.
C. be increased.
D. no effect on pain tolerance.
B. be lowered.
Which of the following interventions will help lessen the effect of GERD (acid reflux)?
A. Elevate the head of the bed on 4-6 inch blocks.
B. Lie down after eating.
C. Increase fluid intake just before bedtime.
D. Wear a girdle.
A. Elevate the head of the bed on 4-6 inch blocks.
A client with a stage 2 pressure ulcer has methicillin-resistant Staphylococcus aureus (MRSA) cultured from the wound. Contact precautions are initiated. Which rule must be observed to follow contact precautions?
A. A clean gown and gloves must be worn when in contact with the client.
B. Everyone who enters the room must wear a N-95 respirator mask.
C. All linen and trash must be marked as contaminated and send to biohazard waste.
D. Place the client in a room with a client with an upper respiratory infection.
A. A clean gown and gloves must be worn when in contact with the client.
A nurse is forming a educational pamphlet for a group of patients with asthma. The nurse decides to include information about the medication albuterol. Which of the following is true about albuterol?
SELECT ALL THAT APPLY
A. Main side effects are nervousness and bradycardia
B. The albuterol medication is taken PRN for SOB
C. The patient should take this medication every day
D. The patient can take this medication before coming in contact with known triggers to prevent attacks
E. Wheezing is an indicator of needing this medication
B. The albuterol medication is taken PRN for SOB
D. The patient can take this medication before coming in contact with known triggers to prevent attacks
E. Wheezing is an indicator of needing this medication
The nurse is caring for a patient who has an order to record intake and output.
The nurse notes the through out the day the patient has had:
32 mL of apple juice
1/2 cup of jello
1 hot dog
1 cup of ice cream
100 mL of water
8 oz of lemonade
Please calculate the patient's intake for that shift.
32 ml
1/2 cup = 118.5 ml
1 cup = 237
8 oz= 240 mL
TOTAL INTAKE 627.5 ML
A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers?
A. A 79 year-old malnourished client on bed rest
B. An obese client who uses a wheelchair
C. An incontinent client who has had 3 diarrhea stools
D. An 80 year-old ambulatory diabetic client
A. A 79 year-old malnourished client on bed rest
A client in a long term care facility complains of pain. The nurse collects data about the client’s pain. The first step in pain assessment is for the nurse to
A. have the client identify coping methods
B. get the description of the location and intensity of the pain
C. accept the client’s report of pain
D. determine the client’s status of pain
B. get the description of the location and intensity of the pain
The nurse is caring for a client recently diagnosed with a stroke. The nurse knows the biggest priority for this patient is which of the following:
A. Putting up side rails to prevent injuries
B. Educating patient about adhering to thickened liquid diet
C. Assessing the client for any physical deficiencies post stroke
D. Providing emotional support to the patient's family
A. Putting up side rails to prevent injuries
The nurse is giving instructions to her client who is taking antihistamine. Which of the following nurse teachings is appropriate for the client?
A. Avoid ingesting alcohol.
B. Be aware that you may need to take a decongestant.
C. Be aware that you may have increased saliva.
D. Expect a relief in 24 hours.
A. Avoid ingesting alcohol.
After a myocardial infarction, a client is placed on a sodium restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate to suggest?
A. 3 oz. broiled fish, 1 baked potato, ½ cup canned beets, 1 orange, and milk
B. 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple
C. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice
D. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange
D. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange
An 85-year-old male patient has been bedridden for two weeks. Which of the following complaints by the patient indicates to the nurse that he is developing a complication of immobility?
A. Stiffness of the right ankle joint
B. Soreness of the gums
C. Short-term memory loss.
D. Decreased appetite.
A. Stiffness of the right ankle joint
An eleven-month-old infant is brought to the pediatric clinic. The nurse suspects that the child has iron deficiency anemia. Because iron deficiency anemia is suspected, which of the following is the most important information to obtain from the infant’s parents?
A. Normal dietary intake.
B. Relevant socio cultural, economic, and educational background of the family.
C. Any evidence of blood in the stools
D. A history of maternal anemia during pregnancy
A. Normal dietary intake.
The nurse is instructing a 65-year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to
A. exercise doing weight bearing activities
B. exercise to reduce weight
C. avoid exercise activities that increase the risk of fracture
D. exercise to strengthen muscles and thereby protect bones
A. exercise doing weight bearing activities
The nurse should instruct a client who is taking an expectorant to:
A. restrict fluids.
B. increase fluids.
C. avoid vaporizers.
D. take antihistamines.
B. increase fluids.
Mrs. Kennedy had a CVA (cerebrovascular accident) and has severe right-sided weakness. She has been taught to walk with a cane. The nurse is evaluating her use of the cane prior to discharge. Which of the following reflects correct use of the cane?
A. Holding the cane in her left hand, Mrs. Kennedy moves the cane forward first, then her right leg, and finally her left leg
B. Holding the cane in her right hand, Mrs. Kennedy moves the cane forward first, then her left leg, and finally her right leg
C. Holding the cane in her right hand, Mrs. Kennedy moves the cane and her right leg forward, then moves her left leg forward.
D. Holding the cane in her left hand, Mrs. Kennedy moves the cane and her left leg forward, then moves her right leg forward
A. Holding the cane in her left hand, Mrs. Kennedy moves the cane forward first, then her right leg, and finally her left leg
A client has been admitted to the hospital with a leg ulcer that is infected with vancomycin-resistant S. aureus (VRSA). Which of these nursing actions can be delegated to an LPN?
A. Obtain wound cultures during dressing changes.
B. Plan ways to improve the client’s oral protein intake.
C. Assess risk for further skin breakdown.
D. Educate the client about home care of the leg ulcer.
A. Obtain wound cultures during dressing changes.
The nurse is inserting a nasogastric tube to a stroke client. He understands that the best position for the insertion is?
A. Low Fowlers.
B. Sims position.
C. Trendelenburg.
D. High Fowlers.
D. High Fowlers.
Which action will you take to most effectively reduce the incidence of hospital-associated urinary tract infections?
A. Teach assistive personnel how to provide good perineal hygiene.
B. Ensure that clients have enough adequate fluid intake.
C. Limit the use of indwelling foley catheter (IFC).
D. Perform dipstick urinalysis for clients with risk factors for UTI.
C. Limit the use of indwelling foley catheter (IFC).