1. The nurse is caring for an older adult client who was admitted to the telemetry unit following a minor

PREBOARD 11

1.) The nurse is caring for an older adult client who was admitted to the telemetry unit following a minor surgical procedure. The client’s history includes insulin-dependent diabetes and a previous myocardial infarction. The client’s telemetry monitor alarms and the rhythm shows asystole. Prioritize the actions the nurse should take from highest priority (top to lowest priority (bottom).

• Confirm ECG lead placement
• Obtain a blood glucose level
• Check level of consciousness
• Assess respiration and pulse
• Initiate emergency response system if indicated

2.) The nurse is preparing to administer a feeding through a percutaneous endoscopic gastrostomy tube.What nursing action is needed before starting the feeding? Select all that apply.

• Keep the feeding product refrigerated until ready to use
• Verify the length and placement of the tube
• Milk or massage the tube
• Flush the tube with 30 mL of warm water
• Elevate the head of the bed 30 to 45 degrees
• Palpate the abdomen

3.) A client who previously had a stroke refuses to take the daily aspirin prescribed by their health care provider. Which statements should the nurse include in her response to the client? Select all that apply.

• “Can you tell me what concerns you have about the aspirin?”
• “Would you like to take aspirin at another time of day?”
• “If you don’t take aspirin every day, you might die.”
• “Do you take your other medications as prescribed by your provider?”
• “Do you experience any nausea when you take the aspirin?”

4.) The nurse asks an unlicensed assistive person (UAP) to help with repositioning of a client in bed.Which actions by the nursing staff support correct ergonomics and safe client handling? Select all that apply.

• Use a friction-reducing device/sheet underneath the client.
• Instruct the client to hold their breath.
• Coordinate lifting together by counting to three.
• Ask a visiting family member to help.
• Adjust the height of the bed to hip level.
• Lower the head of the bed into a flat position.

5.) The nurse who cares for clients undergoing treatment for cancer might expect clients diagnosed with cancer to make the following statements about their grief. Based on an understanding of the Kubler/Ross stages of grief, place the statements in the correct order.

• “If I eat a more balanced diet, I can live longer.”
• “I think the tests got mixed up.”
• “I don’t know where to go or what to do.”
• “I will just go on with my life.”
• “I am so mad at everyone for always reminding me that I have it.”

6.) The nurse working in a community clinic is administering an influenza vaccine. Which is the appropriate IM injection site on an adult client? Use your cursor to select an area on the image below.

7.) Following a surgical procedure, pneumatic compression devices are applied to both lower extremities of an adult client. The client reports that the device is hot and the client is sweating and itching.Which steps should the nurse take? Select all that apply.

• Inform the client that removing the device will likely result in the formation of DVT
• Collaborate with the primary health care provider for anti-embolism stockings to be worm

under the sleeves of the device.

• Explain that the primary health care provider ordered the device and it cannot be removed.
• Confirm pressure setting of 45 mm Hg
• Check for appropriate fit

8.) While being admitted for surgery, a client refuses to sign the surgical consent form. Which nursing actions should the nurse take? Select all that apply.

• Have a family member sign the consent form.
• Inform the unit charge nurse.
• Document the client’s refusal in the medical record.
• Notify the health care provider.
• Convince the client to sign the consent form.

9.) The nurse is evaluating the plan of care for a client who has been requesting a daily laxative to aid in having a bowel movement. What additional interventions should the nurse include in the client’s plan of care? Select all that apply.

• Instruct the client to walk at least 30 minutes 3 to 5 times per week.
• Encourage the client to drink more caffeinated beverages.
• Have the client keep a bowel elimination record.
• Request a prescription for psyllium.
• Encourage the client to drink 2 to 3 liters of fluids a day.

10.) The parent of an 8-month-old infant asks the nurse if the child’s language development is appropriate for this age. Which sounds should the nurse anticipate at this age? Select all that apply.

• Babbles in a rhythm similar to spoken language
• Squeals and yells to signal happiness or displeasure
• Meaningful words single vowel sounds such as ah, eh and uh
• Cooing, gurgling and laughing aloud
• Vocalizes in response to voices

11.) The nurse is collecting data form an adolescent client. Which of the following issues should the nurse address? Select all that apply.

• “Have you decided what you are going to do after high school?”
• “Have you gotten in any trouble lately?”
• “Are you currently having conflicts with someone close to you?”
• “Where are you currently living?”
• “How many sexual partners have you had in the past six months?”
• “How are things going at home?”

12.) The nurse is counselling a postpartum client who has a history of a substance-abuse problem. Which question is a priority when interviewing the client?

• When was the last time you used illegal substances?
• Do you feel that you have bonded with your infant?
• How have you managed the stress of being a new mother?
• Have you attended any support groups related to substance abuse?

13.) The home health nurse is developing a plan of care for a 3-year-old client diagnosed with cerebral palsy (CP). Which goals are the priority for this client? Select all that apply.

• Promote locomotion
• Prevent seizures
• Arrange for genetic counseling
• Select appropriate school environment
• Treat muscle spasms

14.) The client is admitted in stable condition from the emergency department. Based on the ECG strip, the nurse anticipates which of the following types of medications will be ordered? Select all that apply.

• Vasodilator
• An anticoagulant
• Calcium channel blocker
• Cardiac glycoside
• Beta blocker
• Diuretic

15.) A client is transported to the emergency department following a boating accident and submersion in cold water. The client is conscious, shivering and confused. What interventions should the nurse implement? Select all that apply.

• Massage extremities
• Monitor vital signs
• Administer warmed IV fluids as ordered
• Give the client warm tea
• Monitor level of consciousness
• Provide warmed blankets
• Remove wet clothing

16.) The nurse is caring for a newly admitted 6 month-old infant diagnosed with nonorganic failure-to- thrive (NOFTT). What findings would the nurse expect to observe during the initial assessment?

• Irritable and “colicky,” making no attempts to turn or sit up
• Pale skin, thin arms and legs and uninterested in surroundings
• Alert, laughing, playing with a rattle and sitting with support
• Dusky in color with poor skin turgor over abdomen

17.) The nurse is caring for a client receiving mechanical ventilation when the device signals a high- pressure alarm. The nurse should include what assessments in addressing this alarm? Select all that apply.

• Assess client for partial or total extubation
• Assess client for signs of bronchospasm
• Assess tubing to ensure it is not kinked
• Assess for obstructing secretions
• Assess the client’s behaviour (coughing, biting, gagging, etc.)

18.) The nurse on the mental health unit is assigned to a client diagnosed with post-traumatic stress disorder (PTSD). What priority interventions shall the nurse include in the client’s plan of care? Select all that apply.

• Medicate the client with a sedative while they experience flashbacks.
• Place the client in a secluded area away from others.
• Discuss the coping strategies the client is using in response to the trauma.
• Stay with the client during periods of flashbacks and nightmares.
• Encourage the client to talk about the trauma at their own pace.
• Assign the same staff to the client as often as possible.

19.) The nurse is caring for a client who is receiving isoniazid for tuberculosis (TB). Which assessment finding would indicate the client is having a possible adverse response to this medication?

• Headache and nausea
• Tinnitus and decreased hearing
• Tingling in extremities
• Yellowing of the sclera

20.) The nurse is caring for a client who has end-stage renal disease and is scheduled for hemodialysis later today. The client has an arteriovenous fistula. Which interventions should the nurse implement to help prepare the client for dialysis? Select all that apply.

• Ensure the client eats a high fiber, high protein breakfast
• Weigh the client
• Hold all oral medications
• Assess the patency of the fistula
• Administer Vitamin D, as prescribed
• Administer the phosphate binder, as prescribed