Funds
The surgeon asks the nurse to obtain a urinary catheter that will be used for continuous bladder irrigation. Which urinary catheter would the nurse obtain?
A. a straight catheter
B. A Coude tip catheter
C. A triple-lumen catheter
D. A double-lumen catheter
C (232)
A client in shock develops a central venous pressure (CVP) of 2mmhg and a mean arterial pressure (MAP) of 60mmHg. Which prescribed intervention would the nurse initiate first?
A. Increase the rate of O2 flow
B. Obtain arterial blood gas results
C. Insert an indwelling urinary catheter
D. Increase the rate of intravenous (IV) fluids
D (1086)
The nurse is reviewing the record of a child with increased intracranial pressure from a head injury and notes the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this posturing?
A. Flaccid paralysis of all extremities
B. Adduction of the arms at the shoulders
C. Rigid extension and pronation of the arms and legs
D. Abnormal flexion of the upper extremities and extension and adduction of the lower extremities
C.
The nurse is volunteering with an outreach program to provide basic health care for the homeless population. Which finding if noted, should be addressed first?
A. Blood pressure 154/72
B. Visual acuity 20/200 in both eyes
C. Random blood glucose level of 206mg/dl
D. Complaints of pain associated with numbness and tingling in both feet
D. subjective findings to be addressed first
The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse plans to provide dietary teaching and would focus on foods high in which vitamin that may be lacking in a vegan diet?
A. Vitamin A
B. Vitamin B12
C. Vitamin C
D. Vitamin E
B- B12 found in animal products, important for cognitive function and neurovascular health
The nurse is creating a plan of care for a client scheduled for surgery. The nurse would include which activity in the nursing care plan for the client on the day of surgery?
A. Avoid oral hygiene
B. Verify the client has not eaten for 24 hours
C. Have the client void immediately prior to surgery
D. Immediately report any slight increase in blood pressure or pule
C (202)
The nurse is caring for a client hospitalized for heart failure exacerbation and suspects the client may be entering a state of shock. The nurse plans for which intervention as the priority for this client?
A. Administration of dopamine
B. Administration of packed red blood cells
C. Administration of diltizam
D. Administration of lorazepam
A (1086)
The nurse caring for a child diagnosed with rubeola (Measles) notes that the pediatrician has documented the prssence of Koplik's spots. On the basis of this documentation, which observation is expected?
A. Pinpoint petechiae noted on both legs
B. Whitish vescicles located across the chest
C. Petechiae spots that are reddish and pinpoint on the soft palate
D. Small blue-white spots with a red base found on the buccal mucosa
D (518)
The emergency department (ED) nurse received a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse should take which initial action?
A. Prepare the triage rooms with necessary supplies.
B. Activate the emergency response plan specific to the facility.
C. Obtain additional supplies from the central supply department to prepare for high patient volume
D. Obtain additional nursing staff to assist in treating the casualties
B (177) - umbrella option
A client with diabetes mellitus has a glycosylated hemoglobin A1C level of 8%. On the basis of this test result, the nurse plans to teach the client about the need for which measure?
A. Avoiding infection
B. Taking in adequate fluids
C. Preventing and recognizing hypoglycemia
D. Preventing and recognizing hyperglycemia
D (130)
The nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?
A. Twitching
B. Hypoactive bowel sounds
C. Negative Trousseau's sign
D. Hypoactive deep tendon reflexes
A (103)
A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level is 950mg/dL. A continuous IV infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240mg/dL. The nurse would prepare to administer which medication next?
A. An ambule of 50% dextrose
B. NPH insulin subcutaneously
C. IV Fluids containing dextrose
D. Phenytoin for the prevention of seizures
C (1085)
The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate?
A. Notify the primary health care provider of the findings.
B. Repositioning the client and check the monitor for changes in the fetal tracing
C. Take the client's vital signs and tell the client that bed rest is required to conserve oxygen
D. Document the findings and tell the client that the pattern on the monitor indicates fetal well-being
D (335)
The community health nurse is providing a teaching-session about anthrax to members of the community and asks the participants about the methods of transmission. WHich answers by the participants would indicate that teaching was effective? SELEC ALL THAT APPLY
A. Bites from ticks or deer flies
B. Inhalation of bacterial spores
C. Through a cut or abrasion on the skin
D. Sexual contact with an infected individual
E. Direct contact with an infected individual
B,C- infectious bacteria, not communicable from person to person (176)
The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a PaCO2 of 30mmHg. The nurse has determined that the client is experiencing respiratory alkalosis. Which lab value would most likely be noted in this condition?
A. Mg level of 1.8
B. Sodium level of 145
C. Potassium level of 3.0
D. Phosphorus level of 3.0
C- abnormal value
The nurse is performing a neurological assessment on a client and notes a positive Romberg's test. The nurse makes this determination based on which observation?
A. An involuntary rhythmic, rapid twitching of the eyeball
B. A dorsiflexion of the great toe with fanning of the other toes
C. A significant sway when the client stands erect with feet together, arms at sides and eyes closed
D. A lack of normal sense of position when the client is unable to return extended fingers to a point of reference
C
A client is brought to the emergency department with partial-thickness burns to the face, neck, arms, and chest after trying to put out a car fire. The nurse needs to implement which nursing actions for this client?
A. Restrict fluids
B. Assess for airway patency
C. Administer oxygen as prescribed
D. Place a cooling blanket on the client
E. Elevate the extremities if no fractures are present.
F. Prepare to give oral pain meds as prescribed
B,C,E
The maternity nurse is preparing the for admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the primary health care provider's prescriptions and would question which order?
A. Prepare the client for an ultrasound
B. Prepare equipment for a manual pelvic exam
C. Prepare to draw a hemoglobin and hematocrit blood sample
D. Prepare equipment for an external electronic fetal heart monitoring
B (321)
The nurse is preparing a client with schizophrenia and a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client needs further instruction?
A. My medications will help my anxious feelings
B. I'll go to a support group and talk about what I am feeling
C. When I have command hallucinations, I'll call a friend for help
D. I need to get enough sleep and eat well to help prevent feeling anxious
C- (973) needs medical professional
The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affect leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable. How would the nurse interpret the client's neurovascular status?
A. The status is expected because of increased blood flow through the leg
B. The status is moderately impaired, and the surgeon needs to be called
C. The status is slightly deteriorating and needs to be monitoring for another hour
D. The status shows adequate arterial flow, but venous complications are arising
A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions would the nurse take? SELECT ALL THAT APPLY
A. Contact the surgeon
B. Instruct the client to remain quiet
C. Prepare the client for wound closure
D. Document the findings and actions taken
E. Place a sterile dressing and ice packs over the wound
F. Place the client in a supine position without a pillow under the head
A,B,C,D (203)
Which findings are consistent with sepsis criteria? SELECT ALL THAT APPLY
A. urine output 50ml/hr
B. Hypoactive bowel sounds
C. Temperature of 102F
D. Heart rate of 96 BPM
E. Mean arterial pressure 65mmHg
F. Systolic Blood pressure 110mmhG
C,D,E febrile, HR > 90, MAP < 70
The clinic nurse is assessing a child who is scheduled to receive a live virus vaccine (immunization). What are the general contraindications associated with receiving a live virus vaccine? SELECT ALL THAT APPLY
A. The child has symptoms of a cold
B. The child had a previous anaphylactic reaction to the vaccine
C. The parent reports that the child is having intermittent episodes of diarrhea
D. The parent reports the child has not had an appetite and has been fussy
E. The child has a disorder that caused a severely deficient immune system
F. The parent reports that the child has recently been exposed to an infectious disease
B,E (265)
A. Constipation
B. Seizure activity
C. Increased weight
D. Dizziness when moving to an upright position
B. (1014)
A client arrives at the health care clinic and tells the nurse that they were just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that the tick was removed and flushed down the toilet. Which actions are most appropriate? SELECT ALL THAT APPLY
A. Tell the client that testing is not necessary unless arthralgia develops
B. Tell the client to avoid woody, grassy areas that may contain ticks
C. Instruct the client to immediately start to take the antibiotics that are prescribed
D. Inform the client to plan to have a blood test 4 to 6 weeks after the bite to detect the presence of the disease
E. Tell the client if this happens again to not remove the tick, but to scrub the area with antiseptic
B,C,D (932)