GI
A client has an NG tube for gastric decompression. Which finding indicates the tube is functioning correctly?
A. Increasing abdominal distension
B. Decreased nausea and vomiting
C. No drainage in the suction catheter
D. Hyperactive bowel sounds
B. Decreased nausea and vomiting
Which client should the nurse assess first?
A. Fever of 38.1C after surgery
B. Oxygen saturation of 86% on room air
C. Pain rated 7/10
D. Wants discharge instructions
B. Oxygen saturation of 86% on room air
Which toy is most appropriate for a hospitalized toddler?
A. 500-piece puzzle
B. Building blocks
C. Monopoly
D. Playing cards
B. Building blocks
Which medication requires monitoring for bleeding?
A. Metformin
B. Warfarin
C. Furosemide
D. Omeprazole
B. Warfarin
A nurse is assessing a healthy term newborn. Which finding is expected?
A. Central cyanosis 2 hours after birth
B. Respiratory rate of 65/min with grunting
C. Acrocyanosis of the hands and feet
D. Generalized hypotonia
C. Acrocyanosis of the hands and feet
A nurse is caring for a client with acute pancreatitis. Which intervention is the priority?
A. Encourage oral fluids
B. Maintain the client NPO
C. Administer laxatives
D. Place the client in Trendelenburg
B. Maintain the client NPO
Which task can be delegated to an unlicensed assistive personnel (UAP)?
A. Assess pain
B. Teach incentive spirometer
C. Obtain routine vital signs on a stable client
D. Evaluate effectiveness of medication
C. Obtain routine vital signs on a stable client
A child with epiglottis is arrives in the emergency department. What should the nurse avoid?
A. Providing humidified oxygen
B. Keeping the child calm
C. Using a tongue depressor
D. Allowing the parent to stay
C. Using a tongue depressor to inspect the throat
A client taking furosemide is at greatest risk for which electrolyte imbalance?
A. Hypernatremia
B. Hypokalemia
C. HypercalcemiaD. Hypermagnesemia
B. Hypokalemia
A newborn delivered to a mother with diabetes is at highest risk for which complication during the first few hours of life?
A. Hypercalcemia
B. Hypoglycemia
C. Hypernatremia
D. Hyperthermia
B. Hypoglycemia
Which assessment finding is most concerning in a client with a GI bleed?
A. Black, tarry stool
B. Heart rate of 126/min and BP 84/50 mmHg
C. Mild abdominal discomfort
D. Hemoglobin of 11.5 g/dL
B. Heart rate of 126/min and BP 84/50 mmHg
The nurse receives report on four clients. Which client should be seen first?
A. Chest pain rated 9/10 with diaphoresis
B. Blood glucose 250 mg/dL
C. New colostomy requesting teaching
D. Scheduled dressing change
A. Chest pain rated 9/10 with diaphroesis
Which finding indicates dehydration in an infant?
A. Tears while crying
B. Sunken fontanelles
C. Wet diaper every two hours
D. Moist mucous membranes
B. Sunken fontanelles
Which medication should be held if the clients apical pulse is 52/min?
A. Digoxin
B. Acetaminophen
C. Pantoprazole
D. Ondansetron
A. Digoxin
A nurse is caring for a newborn who is 12 hours old. Which finding requires immediate follow-up?
A. Mild acrocyanosis
B. Heart rate of 140/min
C. Grunting and nasal flaring
D. Temperature of 36.8C (98.2F)
C. Grunting and nasal flaring
A client with cirrhosis suddenly becomes confused and drowsy. Which complication should the nurse expect.
A. Hypoglycemia
B. Hepatic encephalopathy
C. Appendicitis
D. Kidney stones
B. Hepatic encephalopathy
Which client can safely be assigned to the LPN?
A. Newly admitted stroke client
B. Stable client needing routine wound care
C. Client requiring discharge teaching
D. Client receiving blood transfusion
B. Stable client needing routine wound care
A child with Kawasaki disease is at greatest risk for which complication?
A. Pneumonia
B. Coronary artery aneurysm
C. Meningitis
D. Kidney failure
B. Coronary artery aneurysm
A client receiving heparin develops significant bleeding. Which medication should the nurse anticipate administering?
A. Vitamin K
B. Protamine sulfate
C. Nalixone
D. FlumazenilB. Protamine sulfate
A nurse is preparing to administer vitamin K to a newborn. What is the primary reason for giving this medication?
A. Prevent neonatal jaundice
B. Prevent hemorrhagic disease due to low clotting factors
C. Improve oxygenation
D. Prevent infection
B. Prevent hemorrhagic disease due to low clotting factors
A nurse is caring for four clients. Which client should be assessed first?
A. Chron disease with four loose stools today
B. Diverticulitis reporting pain 5/10C. Ulcerative colitis with new rigid abdomen and rebound tenderness
D. GERD requesting antacids
C. Ulcerative colitis with new rigid abdomen and rebound tenderness
A client suddenly becomes confused and restless after surgery. What is the nurse’s priority action?
A. Call the provider
B. Check oxygenation and vital signs
C. Administer pain medication
D. Document the change
B. Check oxygenation and vital signs
A child with bacterial meningitis suddenly becomes difficult to arouse. What is the priority action?
A. Lower the lights
B. Notify the provider immediately and prepare for emergency interventions
C. Encourage oral fluids
D. Administer acetaminophen
B. Notify the provider immediately and prepare for emergency interventions
The nurse is administering insulin lispro. When should the meal be available?
A. In 1 hour
B. Within 15 minutes
C. In 2 hours
D. At bedtime
B. Within 15 minutes
The nurse is assessing four newborns. Which newborn should the nurse see first?
A. A 6-hour-old newborn with acrocyanosis
B. A 24-hour-old newborn with a blood glucose of 42 mg/dL who is feeding well
C. A 2-hour-old newborn with a respiratory rate of 72/min, grunting, and intercostal retractions
D. A 12-hour-old newborn with a small amount of white vaginal discharge
C. A 2-hour-old newborn with a respiratory rate of 72/min, grunting, and intercostal retractions