Management of Care
A client arrives to the emergency department and reports headache, neck stiffness, and sensitivity to light. Which of the following is the priority nursing action?
A. Notify recent contacts
B. Administer acetaminophen
C. Implement droplet precautions
D. Decrease environment stimuli
C. Implement droplet precautions
A client is 2 day postoperative following a surgical closure of an abdominal wound. The nurse should recognize which of the following findings is a sign of infection?
A. WBC of 8500
B Serousanguinous drainage
C. Approximation of the wound edges
D. Erythema of the incision line extending 2cm
D. Erythema of the incision line extending 2cm
A nurse provides education to a client who is diagnosed with myasthenia gravis. Which of the following statements indicates understanding of the disease management. Select all that apply.
A. Eating slowly
B. Difficulty breathing may occur
C. Resting helps when I feel weak.
D. Tearing of my eyes is a sign of crisis
E. Sitting in the hot tub helps my muscles
A. Eating slowly
B. Difficulty breathing may occur
C. Resting helps when I feel weak.
D. Tearing of my eyes is a sign of crisis
A nurse demonstrates how to use a metered dose inhaler with a spacer. Which of the following client statements indicates understanding?
A. It is important to wait 5 minutes between puffs
B. A whistling sound means I am breathing in too fast
C. The mouthpiece will be placed in front of my tongue
D. I will hold my breath for at least 3 seconds after inhaling
B. A whistling sound means I am breathing in too fast
A client who is 13 weeks of gestation reports persistent nausea and vomiting. The nurse should recognize which of the following findings requires additional investigation?
A. Urine with ketones
B. Brisk capillary refill
C. Weight gain of 0.45kg
D. Blood pressure 115/75mm hg
A. Urine with ketones
A nurse receives a client's medication prescription over the telephone from the provider. Which of the following actions should the nurse take?
A. Repeat the prescription back to the provider
B. Ensure the provider signs the prescription immediately
C. Instruct the provider to submit the prescription electronically
D. Request another nurse to witness the provider's prescription
A. Repeat the prescription back to the provider
A nurse prepares room assignments. Which if the following room would be appropriate for a client who has Alzheimer's disease and a history of wandering?
A. Private room away from exits
B. Private room with door closed
C. Semiprivate room at the end of the hall
D. Semiprivate room near the vending machine
A. Private room away from exits
A client who has a recent closed head injury reports a severe headache and is restless. Which of the following is an appropriate nursing intervention?
A. Elevate head of bed 30 degrees
B. Place a cool cloth to forehead
C. Administer morphine 2mg IV
D. Prepare for a lumbar puncture
A. Elevate head of bed 30 degrees
A client is scheduled to receive an IM injection. Which of the following actions should the nurse incorporate to safely administer the medication. Select all that apply
A. Apply clean gloves
B. Inject at a 90 degree angle
C. Use a 1/2 inch needle
D. Select a 22-gauge needle
E. Identify the dorsogluteal site
A. Apply clean gloves
B. Inject at a 90 degree angle
D. Select a 22-gauge needle
A nurse provides care for a client who is receiving TPN. Which of the following interventions reduces potential complications associated with administration?
A. Provides additional fluids by mouth
B. Monitors blood glucose every over day
C. Maintains client in a semi-fowler's position
D. Performs sterile central line dressing changes.
D. Performs sterile central line dressing changes.
A nurse reviews the plan of care for a client that has myasthenia gravis. Which of the following interventions requires a revision
A. Monitor for sudden increase in weakness
B. Perform pulmonary percussion and postural drainage
C. Refer to speech and occupational therapy for evaluation
D. Assist with daily activities prior to medication administration
D. Assist with daily activities prior to medication administration
A nurse providers care for a toddler who has impetigo. Which action is appropriate?
A. Allow time in the playroom
B. Don a mask when providing care
C. Place in a room with negative pressure
D. Wear a gown and gloves when in the room
D. Wear a gown and gloves when in the room
A visitor develops sudden cardiac arrest in the hospital cafeteria. Which of the following are appropriate nursing interventions? Select all that apply.
A. Calls for the rapid response team
B. Opens airway by tilting chin down
C. Gives two rescue breaths per minute
D. Compresses chest at rate of 100/min
E. Uses automated external defibrillator (AED)
A. Calls for the rapid response team
D. Compresses chest at rate of 100/min
E. Uses automated external defibrillator (AED)
A nurse provides discharge instructions to a client who is newly prescribed fluoxetine. Which of the following findings should the client immediately report to the health care provider? Select all that apply
A. Fever
B. Agitation
C. Diaphoresis
D. Hyporeflexia
E. Hallucinations
A. Fever
B. Agitation
C. Diaphoresis
E. Hallucinations
A. Digoxin 0.8
B. Hemoglobin 12g
C. Creatinine 1.9
D. Potassium 3.8
C. Creatinine 1.9
A client who is newly admitted requests information about advance directives. The nurse should include which of the following statements in the discussion?
A. An advance directive may not be changed
B. Advance directives are only discussed with terminally ill clients
C. You will need to designate a relative to act as your health care proxy
D. I will give you a pamphlet with written information about advance directives.
D. I will give you a pamphlet with written information about advance directives.
During the care of client who has a chest tube, the nurse should perform which of the following actions to maintain tube patency?
A. Strip the test tube
B. Provide intermittent suction
C. Maintain chamber at chest level
D. Position drainage tubing to prevent kinks
D. Position drainage tubing to prevent kinks
A nurse performs an ocular irrigation for a client who has a suspected corneal abrasion from an irritant in the eye. Identify the sequence the nurse should follow. Place steps in the selected order of performance. All steps must be used.
A. Instill eye drops
B. Check pH of eye
C. Place client supine
D. Obtain history of exposure
E. Direct flow of irrigation across affected eye.
A. Instill eye drops
B. Check pH of eye
C. Place client supine
D. Obtain history of exposure
E. Direct flow of irrigation across affected eye.
A client in preterm labor is receiving magnesium sulfate. The nurse should recognize which of the following findings indicates a therapeutic effect?
A. Cervix unchanged
B. Deep tendon reflexes 2+
C. Presence of contractions
D. Blood pressure 130/60 mm Hg
A. Cervix unchanged
A client is placed in the lithotomy position during a procedure. Which of the following actions should the nurse implement to prevent neurological complications?
A. check radial pulses
B. Avoid position changes
C. Monitor blood pressure
D. Ensure proper padding
D. Ensure proper padding
A nurse assigns care for a client who has diabetes mellitus to the licensed practical nurse (LPN) and assistive personnel (AP). Which of the following tasks should be delegated to the LPN?
A. Measure urinary output
B. Apply antiembolic stockings
C. Assist with bedside commode
D. Obtain capillary blood glucose
D. Obtain capillary blood glucose
A client reports continued fever and sore throat 24 hr after starting penicillin for tonsillitis. Which of the following information should the nurse provide?
A. Your antibiotics will need to be changed
B. Come to the clinic for a repeat throat culture
C. The provider will need to see you again today
D. It may take a few days before symptoms improve
D. It may take a few days before symptoms improve
A nurse plans care for a client who has COPD. Which of the following actions should the nurse include? Select all that apply.
A. Encourage oral fluid intake
B. Maintain bed rest in the supine position
C. Teach to avoid extreme heat and cold temperatures
D. Administer pneumococcal vaccination if not previously given
E. Implement postural drainage with percussion and vibration
A. Encourage oral fluid intake
C. Teach to avoid extreme heat and cold temperatures
D. Administer pneumococcal vaccination if not previously given
E. Implement postural drainage with percussion and vibration
A nurse provides care for a client who is receiving oxytocin for induction of labor. Which of the following findings requires the nurse to take action.
A. Urine output 120mL in 4 hr
B. FHR 110 bpm with variability
C. Six contractions in 10 min
D. Contraction duration 60 seconds.
C. Six contractions in 10 min
During the assessment of a client who is 1 day postoperative following a small bowel resection, the nurse observes petechiae scattered across the chest and abdomen. Which of the following lab values would be most important for the nurse to monitor?
A. Albumin
B. Bilirubin
C. Creatinine
D. Hemoglobin
D. Hemoglobin