A nurse is caring for a client who had a partial laryngectomy and is receiving
continuous enteral feedings at 65 mL\/hr through a gastrostomy tube. Which of the
following findings requires immediate intervention by the nurse? Correct Ans –
The infusion pump for administering contimuous feeding is turned off.
A nurse is assessing a client who has a magnesium level of 4.4 mEq\/L. Which of the
following findings should the nurse expect? Correct Ans – Hypotension
A nurse is providing dietary teaching to a client who has an increased cholesterol
level. Which of the following foods should the nurse recommend? Correct Ans –
Egg whites
A nurse is caring for a toddler who has respiratory syncytial virus. Which of the
following actions should the nurse plan to take? Correct Ans – Use a designated
stethoscope when caring for the toddler.
A nurse is assessing a client who has a chest tube following a thoracotomy. Which of
the following findings requires intervention by the nurse? Correct Ans – 1 cm of
water present in the water seal
A nurse is reviewing the medical history of a client who is taking garlic supplement.
The nurse should identify that which of the following findings is a contraindication
for taking this supplement? Correct Ans – The client takes aspirin daily.
A nurse is planning to provide community education about viral hepatitis. Which of
the following should the nurse plan to include in the teaching? Correct Ans –
series of four hepatitis vaccines is recommended to prevent viral hepatitis.
A nurse is reviewing the history and physical of a client who has right ventricular
heart failure. Which of the following is an expected finding? Correct Ans –
Elevated pulmonary artery pressure
A home health nurse is conducting an initial home visit for a client who has terminal
breast cancer. The client has two school-age children and a limited support system.
Which of the following is the priority nursing action? Correct Ans – Inform the
client of available community resources.
A nurse is providing postoperative teaching to a client who has a newly-inserted
pacemaker. Which of the following statements by the client indicates that the
teaching has been effective? Correct Ans – “I will use my cell phone on the ear
opposite of my pacemaker.”
A nurse is caring for a client who has heart failure and has started taking a loop
diuretic. Which of the following findings indicates the client is experiencing an
adverse effect of the medication? Correct Ans – Decreased reflexes
A nurse is caring for a client who has neutropenia due to HIV. Which of the following
precautions should the nurse take while caring for this client? Correct Ans – Wear
an N95 respirator.
A nurse manager is presenting information to the nursing staff regarding the
appropriate use of client restraints. Which of the following should the nurse include?
(Select all that apply.) Correct Ans – The nurse should pad the bony
prominences. The nurse should remove the restraints every 2 hr. The provider’s
prescription should include the
A nurse is providing discharge teaching about disease prevention to a client who
has active tuberculosis. Which of the following should the nurse include? Correct
Ans – Educating the client how to cover nose and mouth with tissues when
coughing
A nurse is caring for a client who reports difficulty falling asleep at night. Which of
the following actions should the nurse take? Correct Ans – Schedule routine care
tasks during hours when the client is awake.
A nurse is preparing a client for surgery and has just administered the preoperative
injection. Which of the following actions should the nurse take? Correct Ans –
Review deep breathing and coughing exercises.
A nurse suspects another nurse is chemically impaired during their shift. Which of
the following is an appropriate action for the nurse to take? Correct Ans – Report
to the nurse manager.
A nurse in the recovery room is assessing a client who has a new chest tube. The
nurse finds that the water seal is no longer tidaling. The nurse should identify the
finding as resulting from which of the following? Correct Ans – The tubing may be
kinked.
A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive
personnel (AP). When admitting a client who is experiencing acute liver failure and
who has ascites and an NG tube, which of the following tasks is most appropriate for
the nurse to delegate to the LPN? Correct Ans – Measure the amount of gastric
drainage every 2 hr.
A nurse is assessing an adult male client who has a BMI of 20. The nurse should
identify that the client’s BMI falls within which of the following categories? Correct
Ans – Healthy weight
A nurse is assessing a client who has a long arm cast. For which of the following
findings should the nurse monitor when assessing for acute compartment
syndrome? Correct Ans – Change in mental status
A nurse is planning care for a newly admitted client. Which of the following
interventions should the nurse plan to take first? (Click on the “Exhibit” button for
additional information about the client. There are three tabs that contain separate
categories of data.) Correct Ans – Administer pain medication to the client.
A community health nurse is performing a vision screening on a 4-month-old infant.
When shining a light source into the infant’s visual field, which of the following is an
expected finding? Correct Ans – The infant closes their eyes.
A nurse is planning discharge teaching for a client who is scheduled to receive
intravenous infusions at home. Which of the following instructions should the nurse
plan to include? Correct Ans – Place the infusion pump cord against the
baseboards.
A nurse is caring for a client who has just returned to the unit following a
bronchoscopy. Which of the following actions by the assistive personnel requires the
nurse to intervene? Correct Ans – Offers oral fluids to the client
A nurse is assessing an infant who has water intoxication. Which of the following
findings should the nurse expect? Correct Ans – Generalized edema
A nurse is caring for a client who is in labor and receiving electronic fetal
monitoring. The nurse is reviewing the monitor tracing and notes early
decelerations. Which of the following should the nurse expect? Correct Ans –
Head compression
nurse in a pediatric unit is caring for a group of clients. For which of the following
diseases should the nurse implement droplet precautions? Correct Ans –
Pertussis
A client asks the nurse if it is safe to take a glucosamine supplement. The nurse
should assess for which of the following potential contraindications? Correct Ans –
Shellfish allergy
A nurse at the family planning clinic triages several clients over the phone. Which of
the following clients should the nurse instruct to come to the clinic? Correct Ans –
A client who has started taking oral contraceptives and is experiencing bright red
vaginal breakthrough bleeding
A nurse is caring for a client who has a hearing impairment. When speaking to the
client, the nurse should incorporate which of the following communication methods?
Correct Ans – Rephrase sentences the client does not understand.
A nurse in a mental health facility is interviewing a newly admitted client. Which of
the following actions should the nurse take when conducting the interview?
Correct Ans – Lean in slightly when speaking to the client.
A nurse is caring for a group of clients. Which of the following clients should the
nurse assign to an assistive personnel? Correct Ans – A client who had a stroke 2
days ago and needs help toileting<\/p>\n","protected":false},"excerpt":{"rendered":"
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