Fundamentals
The nurse is performing an assessment on an older adult client. Which assessment data would indicate a potential complication associated with the skin?
A. Crusting
B. Wrinkling
C. Deeping of expression lines
D. Thinning and loss of elasticity in the skin
A. (286)
The nurse provides instructions to a client who is taking levothyroxine for hypothyroidism. The nurse should tell the client to take the medication in which way?
A. With food
B. At lunchtime
C. On an empty stomach
D. At bedtime with a snack
C (667)
The nurse is providing medication instructions to a parent. Which statement by the parent indicates a need for further instruction?
A "I should cuddly by child after giving the medication"
B "I can give my child a frozen juice bar after he swallows the medication"
C "I should mix the medication in the baby food and give it when I feed my child"
D "If my child does not like the tast of the medicine, I sould encourage him to pinch his nose and drink the medication through a straw."
C (541)
A client says to the nurse, "the federal guards were sent to kill me". Which is the best response by the nurse to the client's concern?
A. I believe you see guards, but I do not. Do not be afraid.
B. The guards are not out to kill you.
C. Do you feel afraid that the people are trying to hurt you?
D. What makes you think the guards were sent to hurt you?
C (1016)
The home health nurse visits a client at home and dtermines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care?
A. Ask the client why he starting taking illegal drugs
B. Ask the client about the amount of drug taken and its effect
C. Ask the client if family members are aware that they are taking drugs
D. Avoid asking questions about drugs at this visit to not risk being asked to leave the home
B (1027)
A. Decreased absorption of digoxin
B. Increased risk for digoxin toxicity
C. Decreased therapeutic effect of digoxin
D. Increased risk of side effects related to digoxin
B ((287)
The nurse is caring for a client following a gastrojejunostomy (Billroth II). Which post-op order should the nurse question and verify?
A. Leg exercises
B. Early ambulation
C. Irrigate the nasogastric tube
D. Coughing and deep breathing exercises
C (695)
DAILY DOUBLE
The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that the bleeding is excessive. Which should be the initial nursing action?
A. Record the findings.
B. Massage the fundus.
C. Notify the health care provider (HCP)
D. Pace the cleint in Trendelenberg's position
C (369)
A client is admitted to medical nursing unit with a diagnosis of acute blindness after involvement in a hit-and-run accident. Diagnostic testing can not identify any organic reason why this client cannot see. The nurse plans care based on which condition that may be the cause?
A. Psychosis
B. Repression
C. Conversion disorder
D. Dissociative disorder
C (1017)
The home health nurse is visiting a client who was recently diagnosed with type 2 diabetes. THe clinet is prescribed repaglinide and metformin. The nurse should provide which instructions to the client? SELECT ALL THAT APPLY
A. Diarrhea may occur secondary to the metformin
B. The repaglinide is not taken if a meal is skipped
C. The repaglinide is taken 30 mins before eating
D. A simple sugar food item is carried and used to treat mild hypoglycemia episodes
E. Muscle pain is an expected effect of metformin and should be treated with acetaminophen
F. Metformin increases hepatic glucose production to prevent hypoglycemia associated with repaglinide.
A,B,C,D (666)
The nurse is providing instructions to the unlicensed assistive personnel (UAP) regarding care of an older adult client with hearing loss. What should the nurse tell the UAP about older clients with hearing loss?
A. They are often distracted
B. They have middle ear changes.
C. They respond to low-pitched tones.
D. They develop moist cerumen production
C (287)
A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the cleint's breath sounds?
A. Stridor
B. Crackles
C. Shattered rhonchi
D. Diminished breath sounds
A client in a postpartum unit complains of sudden shapr chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action?
A. Initiate an intravenous line.
B. Assess the client's blood pressure.
C. Prepare to administer morphine sulfate.
D. Administer oxygen, 8 to 10L/minute by face mask.
D (369)
The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought process. In formulating a nursing plan of care, which best intervention should the nurse include?
A. Increase socialization with peers.
B. Avoid using a whisper voice in front of the client.
C. Begin to educate the client about social supports in the community.
D. Have the client sign a release of information and discuss the paranoia with their family.
B (1018)
0.925mL (541)
The home care nurse is visiting an older adult client whose spouse died 6 months ago. Which behaviors by the client indicates effective coping? SELECT ALL THAT APPLY
A. Neglecting Personal grooming.
C. Looking at old snapshots of family.
C. Participating in a senior citizens program.
D. Visiting the spouse's grave once a month.
E. Decorating a wall with the spouse's pictures and awards received.
B, C, D, E (287)
The low-pressure alarm sounds on a ventilator. The nurse assess the client and then attempts to dtermine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should take which initial action?
A. Administer Oxygen
B. Check the clients vital signs
C. Ventilate the client manually
D. Start Cardiopulmonary Resuscitation
C ( 736)
A postpartum client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client?
A Provide sitz baths
B Encourage fluid intake
C Place ice on the perineum
D Increase ambulation as tolerated
DAILY DOUBLE
Which of the following interventions are most appropriate for caring for a client in acute alcohol withdrawal? SELECT ALL THAT APPLY
A Monitor vital signs
B. Provide a safe environment
C. Address hallucinations therepeutically
D. Provide stimulation to distract from symptoms
E. Provide reality orientation as appropriate
F. Maintain NPO status
A,B,C,E (1027)
The home health nurse is visiting a client for the first time. Whiel assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which intervention should the nurse implement first?
A. Check for medication interactions.
B. Determine whether there are medication duplications
C. Call the prescribing health care provider and report polypharmacy
D. Determine whether a family member supervises medication administration.
B (288)
The long-term care nurse is performing assessments on severl of the residents. Which are normal age-related physiological changes the nurse should expect to note? SELECT ALL THAT APPLY
A. Increase heart rate
B. Decline in visual acuity
C. Decreased respiratory rate
D. Decline in long-term memory
E. Increased susceptibility to infections
F. Increased incidence of awakening upon sleep onset.
B, E, F (288)
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? SELECT ALL THAT APPLY.
A. Keeping the linens wrinkle free under the client
B. Preventing unnecessary pressure on the lower limbs.
C. Providing bladder catheterization every 12 hours
D. Turning and respositioning the client at least every 2 hrours
E. Ensuring the client has had a bowel movement weekly
A,B,D (918)
A pediatric client with a ventricular septal defect repair is placed on a maintenance dosage of digoxin. The dose is 8mcg/kg/day, and the client's weight is 7.2kg. The health care provider prscribes the digoxin to be given twice daily. The nurse prepares to administer how many mcg of digoxin at each dose?
28.8mcg per dose (541)
Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? SELECT ALL THAT APPLY
A. Communicate expected behaviors
B. Ensure the client knows they are not in charge of the unit
C. Assist the client in identifying ways of setting limits on personal behaviors
D. Follow through about consequences of behaviors in a nonpunitive manner
E Enforce rules by informing the client that he/she will not be allowed to attend therapy groups
F. Have the client state the consequences for behaving in ways that are viewed as unacceptable
A,C,D,F (1017)
The client has begun therapy with theophylline. The nurse should plan to teach the client to limit the intake of which items while taking this medication?
A. Coffee, cola, and chocolate
B. Oysters, lobster, and shrimp
C. Melons, organges, and pineapple
D. Cottage cheese, cream cheese, and dairy creamers
A (752)