Units 3, 4, & 5
What measures should the nurse implement if the nurse is concerned about potential, or unknown infectious agents transmitted by a client?
A. Isolation techniques
B. Medical aseptic techniques
C. Standard precautions
D. Surgical aseptic techniques
A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 10%. Based on the result, the nurse plans to teach the client about the importance of:
A. Maintaining the result
B. Preventing hypoglycemia
C. Preventing hyperglycemia
D. Avoiding infection
C. Preventing hyperglycemia
A nursing student has just inserted an indwelling catheter into a female client. What step should the student take next?
A. Tape the tubing to the client's abdomen.
B. Tape the tubing to the client's genitalia.
C. Tape the tubing to the client's perineum.
D. Tape the tubing to the client's thigh.
D. Tape the tubing to the client's thigh.
The nurse reviews the results of a developmental screening tool for a 9-month-old. The results indicate the infant is at the 6-month level. What client information does the nurse identify may contribute to this finding?
A. The infant has been enrolled in daycare.
B. The infant still drinks bottles of sensitive formula.
C. The infant was born at 37 weeks' gestation.
D. The infant has a known serious heart disease.
D. The infant has a known serious heart disease.
A client is admitted for observation after a minor automobile accident. On the basis of an understanding of the sympathetic nervous system's response to stress, what would the nurse expect to find during assessment? Select all that apply.
A. Decreased heart rate
B. Rapid respirations
C. Skeletal muscle tension
D. Seizure activity
E. Hyperactive bowel sounds
B. Rapid respirations
C. Skeletal muscle tension
Following a cerebrovascular accident (CVA), a client has right-sided weakness and will use a cane to assist with his mobility. How should the nurse should reinforce teaching the client to correctly use the cane?
A. The client should use the cane in the strong hand and move the cane with both feet.
B. The client should use the cane in the strong hand and move the cane the weak extremity.
C. The client should use the cane in the strong hand and move the cane with the strong extremity.
D. The client should use the cane in the weak hand and move the cane with the weak extremity.
B. The client should use the cane in the strong hand and move the cane the weak extremity.
When providing care for a female client with Addison disease, the nurse should be alert for which of the following laboratory values?
A. Hematocrit level of 25%.
B. Potassium level of 3.2 mEq/L.
C. Calcium level of 3.3 mEq/L.
D. Sodium level of 150 mg/dL.
A. Hematocrit level of 25%.
When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result?
A. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP).
B. Emergent; the client is poorly oxygenated.
C. Normal
D. Significant; the client has alveolar hypoventilation.
A. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP).
While teaching a 10-year-old child about their impending heart surgery, the nurse should:
A. Explain the surgery using a model of the heart
B. Provide a verbal explanation just prior to the surgery
C. Introduce the child to another child who had heart surgery three days ago
D. Provide the child with a booklet to read about the surgery
A. Explain the surgery using a model of the heart
The nurse is completing a neurologic examination on a client. Which question is essential for the nurse to include to evaluate the accuracy of a neurologic assessment?
A. "When, if any, was your last narcotic use?"
B. "Do you have any family history of dementia?"
C. "Have you been diagnosed with any anxiety or depression?"
D. "Have you experienced any palpitations before?"
A. "When, if any, was your last narcotic use?"
The nurse is performing an assessment of the cardiovascular system. Where should the nurse assess arterial pulse points?
A. Radial, uvular, and femoral
B. Carotid, plantar, and radial
C. Brachioradialis, femoral, and dorsalis pedis
D. Radial, posterior tibial, and femoral
D. Radial, posterior tibial, and femoral
A client with diabetes is admitted appearing pale, cold, diaphoretic, and unconscious. What should the nurse anticipate to be ordered for this client? Select all that apply.
A. Regular Insulin IV STAT
B. Epinephrine IM STAT
C. 50% Dextrose IV STAT
D. Glucagon injection IM STAT
E. 50 mL of orange juice PO STAT
C. 50% Dextrose IV STAT
D. Glucagon injection IM STAT
Before feeding a client via NGT, the nurse checks for residual and obtains a residual amount of 90ml. What is the appropriate action for the nurse to take?
A. Discard the residual amount.
B. Hold the due feeding.
C. Skip the feeding and administer the next feeding due in 4 hours.
D. Reinstall the amount and continue with administering the feeding.
D. Reinstall the amount and continue with administering the feeding.
The nurse is assessing a six-month-old child. Which developmental skills are normal and should be expected?
A. Pulling up to a standing position
B. Can feed self with a spoon
C. Sits alone
D. Speaks in short sentences
C. Sits alone
The nurse is performing a neurological assessment. When assessing the eyes, what should the nurse assess? Select all that apply.
A. Pupils
B. Sclera
C. Accommodation
D. Pinna
E. Nare
A. Pupils
B. Sclera
C. Accommodation
A nurse is contributing to the plan of care for a client who has a pressure ulcer on their heel. Which of the following should the nurse include in the planning? Select all that apply.
A. Keep the ulcer bed moist.
B. Clean the wound from the outer edge towards the center.
C. Provide the client a diet high in protein.
D. Reposition the client at least every 4 hr.
E. Encourage the client to elevate foot on pillows.
A. Keep the ulcer bed moist.
C. Provide the client a diet high in protein.
E. Encourage the client to elevate foot on pillows.
The nurse cares for clients of various cultural backgrounds. Which action by the nurse represents cultural sensitivity for nutrition?
A. Reinforce what foods should be eaten to improve weight.
B. Ask the client to provide a list of foods they avoid.
C. Provide a standard food tray and allow the client to remove foods they do not eat.
D. Emphasize that fasting is not allowed in the hospital setting.
B. Ask the client to provide a list of foods they avoid.
A client went to the emergency room with a sudden onset of high fever and diaphoresis. Serum sodium was one of the laboratory tests taken. Which of the following values would you expect to see?
A. 130 mEq/L
B. 148 mEq/L
C. 143 mEq/L
D. 139 mEq/L
B. 148 mEq/L
A 24-year-old client comes into the clinic complaining of right-sided chest pain and shortness of breath. He reports that it started suddenly. The assessment should include which of the following interventions?
A. Auscultation of breath sounds
B. Chest x-ray
C. Echocardiogram
D. Electrocardiogram (ECG)
A. Auscultation of breath sounds
A mother rescues two of her four children from a house fire. In the emergency department, she cries, “I should have gone back in to get them. I should have died, not them.” What is the nurse’s best response?
A. "The smoke was too thick. You couldn't have gone back in."
B. "You're feeling guilty because you weren't able to save your children."
C. "Focus on the fact that you could have lost all four of your children."
D. "It's best if you try not to think about what happened. Try to move on."
B. "You're feeling guilty because you weren't able to save your children."
The nurse is preparing to give bolus enteral feedings via a nasogastric tube to a comatose client. Which of the following actions is an inappropriate practice by the nurse?
A. If bowel sounds are absent, hold the feeding and notify the physician.
B. Assess tube placement by aspirating gastric content and check the PH level.
C. Warm the feeding to room temperature to prevent the occurrence of diarrhea and cramps.
D. Elevate the head of the bed to 45 degrees and maintain for 30 minutes after installation of feeding.
C. Warm the feeding to room temperature to prevent the occurrence of diarrhea and cramps.
D. Elevate the head of the bed to 45 degrees and maintain for 30 minutes after installation of feeding.
What is a fixed concept of how all members of an ethnic group act or think?
A. Variations within a cultural group
B. Identical practices
C. Holistic nursing
D. Ethnic stereotypes
D. Ethnic stereotypes
A client with Congestive heart failure is about to take a dose of furosemide (Lasix). Which of the following potassium levels, if noted in the client’s record, should be reported before giving the due medication?
A. 5.1 mEq/L.
B. 3.3 mEq/L.
C. 4.9 mEq/L.
D. 3.9 mEq/L.
B. 3.3 mEq/L.
A pulse oximetry gives what type of information about the client?
A. Amount of carbon dioxide in the blood
B. Amount of oxygen in the blood
C. Percentage of hemoglobin carrying oxygen
D. Respiratory rate
C. Percentage of hemoglobin carrying oxygen
A client with a C6 spinal injury would most likely have which of the following symptoms?
A. Aphasia
B. Hemiparesis
C. Paraplegia
D. Tetraplegia
D. Tetraplegia