Safe Effective Care
A nurse is providing discharge teaching to a client who had a gastrectomy for stomach cancer.
Which of the following information should be included in the teaching?
(Select all that apply.)
A. “You will need a monthly injection of vitamin B12 for the rest of your life.”
B. “Using the nasal spray form of vitamin B12 on a daily basis is an option.”
C. “An oral supplement of vitamin B12 taken on a daily basis may be an option.”
D. “You should increase your intake of animal proteins, legumes, and dairy products to increase vitamin B12 in your diet.”
E. “Add soy milk fortified with vitamin B12 to your diet to decrease the risk of pernicious anemia.”
what is A and B
A nurse is caring for an older adult client who has a new diagnosis of type 2 diabetes mellitus and reports difficulty following the diet and remembering to take the prescribed medication.
Which of the following are appropriate actions by the nurse? (Select all that apply.)
Ask the dietitian to assist with meal planning.
Contact the client’s support system.
Assess for age-related mobility restrictions.
Encourage the use of a daily medication dispenser.
Provide educational materials for home use.
A,B,D, E
A nurse is developing a plan of care for a client who is scheduled for a cerebral angiogram with contrast dye. Which of the following statements by the client should the nurse report to the provider?
(Select all that apply.)
A. “I think I may be pregnant.”
B. “I take Coumadin.”
C. “I take antihypertensive medication.”
D. “I am allergic to shrimp.”
E. “I am allergic to latex.”
A, B, D
The nurse understands there is no contraindication related to contrast dye for a client who is taking antihypertensive medication or who has an allergy to latex.
A nurse in the emergency department is caring for a client who fell through the ice on a pond and is unresponsive and breathing slowly. Which of the following are appropriate actions by the nurse? (Select all that apply.)
A. Remove wet clothing.
B. Maintain normal room temperature.
C. Apply warm blankets.
D. Apply a heat lamp.
E. Infuse warmed IV fluids.
A, C, D, E
B. Incorrect: The nurse should increase the temperature of the room to help return the client to a normal body temperature.
A nurse is caring for a client who has cirrhosis. Which of the following medications can the nurse expect to administer to this client? (Select all that apply.)
A. Diuretic
B. Beta-blocking agent
C. Opioid analgesic
D. Lactulose (Cephulac)
E. Sedative
A, B, D.
Opioid analgesics and sedatives are metabolized in the liver. Therefore, they should not be administered to a client who has cirrhosis.
Beta-blocking agents are prescribed for a client who has cirrhosis to prevent bleeding
from varices.
A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the client’s chest tube was accidentally removed.
Which of the following actions should the nurse take first?
A. Obtain a chest x-ray
B. Apply sterile gauze to the insertion site.
C. Place tape around the insertion site.
D. Assess the client’ s respiratory status.
B.
Using the airway, breathing, and circulation (ABC) priority-setting framework, the application of a sterile gauze to the site should be the first action for the nurse to take. This allows air to escape and reduces the risk for development of a tension pneumothorax
A nurse is evaluating clients at a health fair for modifiable variables affecting health and wellness. The nurse identifies which of the following as a modifiable variable?
(Select all that apply.)
A male who smokes on social occasions
A female with a BMI of 28
An adult with alopecia
An adolescent with Trisomy 21
An infant with reflux
A, B, E.
(C and D are genetic disorders).
A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform first?
A. Keep the client in a side-lying position.
B. Monitor the client’s vital signs.
C. Reorient the client to the environment.
D. Check the client for injuries.
A
The greatest risk to the client is aspiration during the postictal phase
Monitoring vital signs to determine the stability of the client is important, but it is not the priority nursing action.
A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? (Select all that apply.)
A. Continuous bubbling in the water seal chamber
B. Gentle constant bubbling in the suction control chamber
C. Rise and fall in the level of water in the water seal chamber with inspiration and expiration
D. Exposed sutures without dressing
E. Drainage system upright at chest level
B and C
A.INCORRECT: Continuous bubbling in the water seal chamber indicates an air leak
D.INCORRECT: The nurse should cover the sutures at the insertion site with an airtight dressing.
E.INCORRECT: The drainage system should be maintained in an upright position below the level of
the client’s chest.
A nurse is providing teaching to a client who has a new prescription for amitriptyline (Elavil) for treatment
of depression. Which of the following should the nurse include in the teaching? (Select all that apply.)
A. Expect therapeutic effects in 24 to 48 hr.
B. Discontinue the medication after a week of improved mood.
C. Change positions slowly to minimize dizziness.
D. Decrease dietary fiber intake to control diarrhea.
E. Chew sugarless gum to prevent dry mouth.
C, E
Therapeutic effects are expected after several weeks of taking amitriptyline
Stopping amitriptyline abruptly can result in relapse.
Clients should increase dietary fiber to prevent constipation, which is an adverse effect of amitriptyline.
A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies
should the nurse ensure is in the client’
s room? (Select all that apply.)
A. Oxygen equipment
B. Incentive spirometer
C. Pulse oximeter
D. Sterile dressing
E. Suture removal kit
A, C, D
B.INCORRECT: An incentive spirometer is indicated for a client following thoracic surgery to promote improved oxygenation and pulmonary function.
E.INCORRECT: A suture removal kit is needed to remove sutures following surgery
A nurse on a medical-surgical unit has received change-of-shift report
and will care for four clients.
Which of the following client’s needs may the nurse assign
to an assistive personnel (AP)?
A. Feeding a client who was admitted 24 hr ago with aspiration pneumonia
B. Reinforcing teaching with a client who is learning to walk using a quad cane
C. Reapplying a condom catheter for a client who has urinary incontinence
D. Applying a sterile dressing to a pressure ulcer
C. Reapplying a condom catheter for a client who has urinary incontinence
A nurse is caring for a client who has postpartum depression. Which of the following are expected findings?
(Select all that apply.)
A. Disappointment in the characteristics of the infant
B. Concerns about lack of income to pay bills
C. Anxiety about assuming a new role as a mother
D. Rapid decline in estrogen and progesterone
E. Postpartum physical discomfort and/or pain
B,C,D,E
A-INCORRECT: Disappointment in the characteristics of the infant would be an indication of impaired mother-infant bonding.
A nurse is reviewing care of the umbilical cord with the parent of a newborn.
Which of the following should be included in the teaching?
A. Cover the cord with a small gauze square.
B. Trickle clean water over the cord with each diaper change.
C. Apply hydrogen peroxide to the cord twice a day.
D. Keep the diaper folded below the cord.
D. Keep the diaper folded below the cord.
(Folding the diaper below the cord prevents urine from the diaper penetrating the cord site)
A nurse is providing teaching for a client who is withdrawing from alcohol and has a new prescription
for propranolol (Inderal). Which of the following is appropriate for the nurse to include in the teaching?
A. Increases the risk for seizure activity
B. Provides a form of aversion therapy
C. Decreases cravings
D. Results in mild hypertension
C
A nurse is caring for a client following a thoracentesis. Which of the following clinical manifestations should the nurse recognize as risks for complications? (Select all that apply.)
A. Dyspnea
B. Localized bloody drainage on the dressing
C. Fever
D. Hypotension
E. Report of pain at the puncture site
A, C, D
Localized bloody drainage and pain are expected finding following a thoracentesis.
An RN is making assignments for client care to a licensed practical nurse (LPN) at the beginning of the shift.
Which of the following assignments should the LPN question?
A. Assisting a client who is 24 hr postoperative to use an incentive spirometer
B. Collecting a clean-catch urine specimen from a client who was admitted on the previous shift
C. Providing nasopharyngeal suctioning for a client who has pneumonia
D. Replacing the cartridge and tubing on a patient-controlled analgesia (PCA) pump
D
The RN is responsible for maintaining the PCA pump.
A nurse is caring for a client who is pregnant and is to undergo a contraction stress test (CST). Which of the following findings are indications for this procedure? (Select all that apply.)
A. Decreased fetal movement
B. Intrauterine growth restriction (IUGR)
C. Post maturity
D. Advanced maternal age
E. Amniotic fluid emboli
A, B, C, D
Amniotic fluid emboli are a complication of an amniocentesis.
A nurse is called to the birthing room to assist with the assessment of a newborn who was born at 32 weeks of gestation. The newborn’s birth weight is 1,100 g.
Which of the following are expected findings in this newborn?
(Select all that apply.)
A. Lanugo
B. Long nails
C. Weak grasp reflex
D. Translucent skin
E. Plump face
A, C, D.
Long nails are findings in a newborn who is post term, A plump face would be observed in a newborn who is macrosomic.
A nurse in an acute mental health facility is caring for a client who is experiencing withdrawal from opiod use and has a new prescription for clonidine (Catapres).
Which of the following is the priority nursing action?
A. Administer the clonidine as prescribed schedule.
B. Provide ice chips at the client’s bedside.
C. Educate the client on the effects of clonidine.
D. Obtain the client’s baseline vital signs.
D
A nurse is caring for a pregnant woman who has a prescription for magnesium sulfate. The nurse should recognize
that which of the following are contraindications for use of this medication. (Select all that apply.)
A. Acute fetal distress
B. Preterm labor
C. Vaginal bleeding
D. Cervical dilation greater than 6 cm
E. Severe gestational hypertension
A, C, D
Preterm labor and severe gestational hypertension are indications for the use of magnesium sulfate.
A nurse is transferring a client from an acute-care hospital to a rehabilitation facility. Which of the following information about the client should the nurse include in the transfer report?
(Select all that apply.)
A. Alert and oriented
B. Refuses to eat spinach
C. Has a shellfish allergy
D. Requests morphine every 4 hr
E. Misses the two cats he has at home
A, C, D
A nurse is completing discharge instructions with a client who has spontaneously passed a calcium oxalate stone. Which of the following foods should the nurse instruct the client to avoid? (Select all that apply.)
A. Red meat
B. Black tea
C. Cheese
D. Whole grains
E. Spinach
B, E
A nurse is completing an assessment of a client who has a gastric ulcer. Which of the following are expected findings? (Select all that apply.)
A. Client reports pain relieved by eating.
B. Client states that pain often occurs at night.
C. Client reports a sensation of bloating.
D. Client states that pain occurs ½ to 1 hr after a meal.
E. Client experiences pain upon palpation of the epigastric region
C,D,E
A client who has a duodenal ulcer will report that pain is relieved by eating. Pain that rarely occurs at night is an expected finding.
An adult client is taking diphenhydramine (Benadryl) for symptoms of allergic rhinitis. For which of the
following adverse reactions should the nurse teach the client to watch? (Select all that apply.)
A. Dry mouth
B. Nonproductive cough
C. Skin rash
D. Diarrhea
E. Urinary hesitation
A, E
Constipation, rather than diarrhea, is an adverse reaction of this medication.