Trad Practice Exam - Which of the following devices should the nurse...

Trad Practice Exam

• A nurse is assisting an older adult client who sometimes loses her balance while walking.

Which of the following devices should the nurse use when helping the client ambulate?

• Gait belt
• Jacket harness
• Four-wheel walker
• Cane

Answer: Gait belt

• A nurse is caring for an older adult client. The nurse should recognize the client is at risk

for which of the following physiological changes? (Select all that apply.)

• Decreased gastric motility
• Decreased skin elasticity
• Increased pain threshold
• Increased metabolic rate
• Increased cardiac output

Answer: Decreased gastric motility,

Decreased skin elasticity, Increased pain threshold

• A charge nurse notes that a staff nurse delegates an unfair share of tasks to the assistive

personnel (AP) and the nurses on the next shift report the staff nurse frequently leaves tasks uncompleted. Which of the following statements should the charge nurse make to resolve this conflict?

• "I need to talk to you about unit expectations regarding delegating and completing tasks."
• "Several staff members have commented that you don't do your fair share of the work."
• "If you don't do your share of the work, I will have to inform the nurse manager."
• "You have been very inconsiderate of others by not completing your share of the work."

Answer: "I need to talk to you about unit expectations regarding delegating and completing tasks."

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• A nurse is documenting the intake for a client who is scheduled for an abdominal

computed axial tomography (CT) scan. Prior to the scan, the client consumes 12 oz sodium diatrizoate and meglumine diatrizoate. The client has an IV of D5 1/2 NS running at 75 ml per hour from 0700 until 1200. The IV runs at 30 ml per hour from 1200 to 1500. At 1500, the client has 6 oz of juice. How many milliliters should the nurse document as the client intake for the shift?

Answer: 1005 mL

• A nurse is planning care for a client who has end-stage cirrhosis of the liver with

encephalopathy. Which of the following interventions should the nurse plan to implement to decreased the client's ammonia level?

• Administer diuretics.
• Restrict the client's intake of fluids.
• Reduce the client's intake of protein.
• Administer vitamin K.

Answer: Reduce the client's intake of protein.

• A nurse is teaching the partner of a client who had an acute myocardial infarction (MI)

about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies?

• "These tests help determine the degree of damage to the heart tissues."
• "Cardiac enzymes will identify the location of the MI."
• "These tests will enable the provider to determine the heart structure and mobility of the

heart valves."

• "Cardiac enzymes assist in diagnosing the presence of pulmonary congestion."

Answer: "These tests help determine the degree of damage to the heart tissues."

• A nurse is preparing to initiate a continuous enteral feeding through an open system to a

client. Which of the following actions should the nurse take?

• Reconstitute the formula with tap water.
• Discard unused formula after 8 hr.
• Administer 200 mL of formula during the initial infusion.
• Give the initial feeding over 15 min.

Answer: Discard unused formula after 8 hr. 2 / 3

• A nurse is providing instruction to a new nurse about caring for clients who are receiving

diuretic therapy to treat heart failure. The nurse should explain which of the following medications puts clients at risk for both hyperkalemia and hyponatremia?

• Furosemide
• Hydrochlorothiazide
• Metolazone
• Spironolactone

Answer: Spironolactone

• A nurse is admitting a client who has acute pancreatitis. Which of the following provider

prescriptions should the nurse anticipate?

• Initiate a low-residue diet.
• Pantoprazole 80 mg IV bolus twice daily
• Ambulate twice daily.
• Pancrelipase 500 units/kg PO three times daily with meals

Answer: Pantoprazole 80 mg IV bolus twice daily

• The family of an older adult brings him to the emergency department after finding him

wandering outside. During the initial assessment, the nurse notes that the client flinches when she palpates his abdomen yet responds to questions only by nodding and smiling. Which of the following factors should the nurse identify as a likely explanation for the client's behavior?

• He is hard of hearing
• Pain
• Confusion
• Language barrier

Answer: Confusion

• A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally

inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first?

• Measure the circumference of both upper arms.
• Notify the provider who inserted the PICC line.
• Remove the PICC line.
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