Fundamentals
A nurse provides care to a client who has a sealed radiation implant. Which of the following actions should be implemented? Select all that apply
A. Limit each visitor to 1 hr per day
B. Wear a lead apron when providing care
C. Instruct visitors to stand 6ft from client
D. Double glove to dispose of the radiation source
E. Place "Caution Radioactive Material" sign on the door
B. Wear a lead apron when providing care
C. Instruct visitors to stand 6ft from client
E. Place "Caution Radioactive Material" sign on the door
A client who has COPD is prescribed ipratropium bromide. The nurse should instruct the client to report which of the following symptoms immediately?
A. Nausea
B. Eye pain
C. Dry mouth
D. Constipation
B. Eye pain
A toddler has a two-day history of vomiting and diarrhea. Which of the following findings should the nurse immediately report to the health care provider?
A. BP 68/40 mm Hg
B. Dry mucous membrane
C. Decrease urinary output
D. Temperature 38.9 C (102 F)
A. BP 68/40 mm Hg
An expectant mother who plans to breastfeed is eager to learn about newborn care. Which of the following information should the nurse provide. Select all that apply.
A. Schedule feedings every 4 hr
B. Place bumper pads in the crib
C. Position on back when sleeping
D. Expect stools to be yellow in color
E. Anticipate three wet diapers in 24 hours
F. Delay tub bath until cord has fallen off
C. Position on back when sleeping
D. Expect stools to be yellow in color
E. Anticipate three wet diapers in 24 hours
A nurse provides care for a client who is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following laboratory values would be expected? Select all that apply
A. Sodium 128 mEq/L
B. Potassium 5.0 mEq/L
C. Magnesium 1.5 mEq/L
D. Urine specific gravity 1.035
E. Serum specific gravity 290 mOsm/kg
A. Sodium 128 mEq/L
D. Urine specific gravity 1.035
A nurse provides care to a client who is admitted for sepsis. Which of the following circumstances requires an occurrence report? Select all that apply
A. Eye glasses are lost
B. Visitor falls in hallway
C. Syncopal episode occurs
D. Oxygen therapy is refused
E. Blood cultures are positive
A. Eye glasses are lost
B. Visitor falls in hallway
A nurse provides teaching to a client who is prescribed spironolactone. The nurse should limit the intake of which of following foods? Select all that apply
A. Bananas
B. White rice
C. Tomatoes
D. Avocados
E. Sweet potatoes
A. Bananas
C. Tomatoes
D. Avocados
E. Sweet potatoes
A nurse teaches a parent how to successfully feed an infant who has an unrepaired cleft lip and palate. Which of the following instructions should the nurse provide? Select all that apply
A. Observe forehead for a wrinkled brow
B. Use a low-calorie formula for feedings
C. Burp frequently after every ounce of fluid
D. Hold in an upright position during feedings
E. Use a special feeder with a slit-cut tip nipple
A. Observe forehead for a wrinkled brow
C. Burp frequently after every ounce of fluid
D. Hold in an upright position during feedings
E. Use a special feeder with a slit-cut tip nipple
A nurse provides care for a newborn who is receiving phototherapy. Which of the following is an appropriate nursing intervention? Select all that apply
A. Weight weekly
B. Apply lotion to skin
C. Cover male genitalia
D. Place mask over eyes
E. Monitor frequency of stools
C. Cover male genitalia
D. Place mask over eyes
E. Monitor frequency of stools
A nurse plans care for a client who requires continuous ambulatory peritoneal dialysis. Which of the following actions is appropriate? Select all that apply
A. Notify provider of cloudy or opaque effluent
B. Prepare client for exchange two or three times weekly
C. Apply mask to client during system connect and disconnect
D. Require client to remain in reclining position during exchange
E. Warm dialysate bag by applying heating pad prior to installation
A. Notify provider of cloudy or opaque effluent
C. Apply mask to client during system connect and disconnect
E. Warm dialysate bag by applying heating pad prior to installation
A nurse provides discharge education to a client who has methicillin-resistant Staphylococcus aureus skin infection. Which of the following statements should be included? Select all that apply
A. Discontinue antibiotics after a scab forms
B. Do not share athletic equipment with others
C. Discard soiled bandages in a sealed plastic bag
D. Keep the infected area covered with a dry bandage
E. Showering is recommended rather than taking a bath
F. Wash all uninfected skin areas prior to infected areas
B. Do not share athletic equipment with others
C. Discard soiled bandages in a sealed plastic bag
D. Keep the infected area covered with a dry bandage
E. Showering is recommended rather than taking a bath
F. Wash all uninfected skin areas prior to infected areas
A client is prescribed acetaminophen 650mg PO every 4 hours PRN pain. Which of the following findings should alert the nurse to question this prescription?
A. Manual BP 145/86 mm Hg
B. Reports drinking six beers daily
C. Oral temperature of 37 C (98.6)
D. Smokes two packs of cigarettes weekly
B. Reports drinking six beers daily
A. Offer larger portions of food
B. Serve meals in the same dish
C. Introduce a new food each day
D. Promise a cookie after the meal
B. Serve meals in the same dish
A client who is Rh-negative should receive Rho(D) immune globulin at which of the following times. Select all that apply.
A. Following an amniocentesis
B. After a spontaneous abortion
C. Within 72 hr following delivery
D. During a nonstress test (NST)
E. Routinely at 28 weeks of gestation
A. Following an amniocentesis
B. After a spontaneous abortion
C. Within 72 hr following delivery
E. Routinely at 28 weeks of gestation
A nurse plans care for a client who has a serum potassium of 7 mEq/L. Which of the following actions should be implemented? Select all that apply
A. Place on a cardiac monitor
B. Obtain a serum creatinine level
C. Infuse 100 mL of 10% glucose IV
D. Begin IV infusion of regular insulin
E. Administer sodium polystyrene sulfonate
F. Initiate 0.33% sodium chloride IV fluid bolus
A. Place on a cardiac monitor
B. Obtain a serum creatinine level
C. Infuse 100 mL of 10% glucose IV
D. Begin IV infusion of regular insulin
E. Administer sodium polystyrene sulfonate
A nurse reviews client room assignments. Which of the following infectious diseases requires droplet precautions? Select all that apply
A. Mumps
B. Measles
C. Varicella
D. Pertussis
E. Pneumonia
A. Mumps
D. Pertussis
E. Pneumonia
An unresponsive client who has a respiratory rate of 8/min and pinpoints pupils is brought to the emergency department. The nurse should administer which of the following medications?
A. Naloxone
B. Disulfiram
C. Methadone
D. Succinylcholine
A. Naloxone
A nurse teaches a 10-year old child who has diabetes mellitus how to check blood glucose. Which of the following strategies would be the most effective method for learning?
A. Watch a video about the procedure
B. Read a pamphlet about diabetes mellitus
C. Create a poster with healthy food choices
D. Perform a procedure after watching the nurse
D. Perform a procedure after watching the nurse
A client who is at 16 weeks of gestation is scheduled for an amniocentesis. Which of the following instructions should the nurse provide?
A. Do not drink any liquids after midnight
B. Empty bladder prior to procedure
C. This test will determine how well your baby is breathing
D. You will need to hold your breath while the needle is inserted
B. Empty bladder prior to procedure
A nurse assesses a client who has acute pyelonephritis. Which of the following findings would be expected? Select all that apply
A. Fever
B. Flank Pain
C. Tachycardia
D. Cough and dyspnea
E. Nausea and vomiting
A. Fever
B. Flank Pain
C. Tachycardia
E. Nausea and vomiting
A nurse provides care for a client who has dementia and is recovering from knee arthroplasty. Which of the following findings requires intervention?
A. Hgb 14g d/L
B. Facial grimacing
C. Respirations 23/min
D. Serous drainage on dressing
B. Facial grimacing
Prior to administering a client's scheduled dose of enoxaparin sodium. Which laboratory finding should the nurse evaluate.
A. PT
B. INR
C. aPTT
D. Platelets
D. Platelets
A nurse completes vision screening for a 5-year old child. Which of the following findings requires further evaluation?
A. Visual acuity of 20/15 is demonstrated in both eyes
B. Pupils are 4 mm and react briskly to light
C. One eye deviates when the child fixates on an object
D. The uncovered eye does not move during the cover test
C. One eye deviates when the child fixates on an object
A nurse should recognize which of the following signs as a manifestations of sepsis in the neonate? Select all that apply
A. Lethargy
B. Tachypnea
C. Hypothermia
D. Sunken fontanel
E. Low serum blood glucose
A. Lethargy
B. Tachypnea
C. Hypothermia
E. Low serum blood glucose
A client had a modified radical mastectomy yesterday. Which of the following actions should the nurse implement to prevent transient edema of the affected arm? Select all that apply
A. Elevate arm on pillow
B. Administer furosemide
C. Apply heating pad to site
D. Milk drainage device tubing
E. Encourage gentle arm exercises
A. Elevate arm on pillow
E. Encourage gentle arm exercises