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Q&A Random -5
Question Number 1 of 40
The nurse observes a staff member caring for a client with a left
unilateral mastectomy. The nurse would intervene if she notices the
staff member is
The correct answer is B: Taking the blood pressure in the left arm
Question Number 2 of 40
A 70 year-old post-operative client has elevated serum BUN, Hct, Cl,
and Na+. Creatinine and K+ are within normal limits. The nurse should
perform additional assessments to confirm that an actual problem is:
Question Number 3 of 40
The nurse is caring for an acutely ill 10 year-old client. Which of the
following assessments would require the nurses immediate attention?
Question Number 5 of 40
The nurse is assessing a client with portal hypertension. Which of the
following findings would the nurse expect?
A) Expiratory wheezes
B) Blurred vision
C) Acites
D) Dilated pupils
Your response was "A".
Question Number 6 of 40
A 67 year-old client with non-insulin dependent diabetes should be
instructed to contact the out-patient clinic immediately if the
following findings are present
When signs of infection occur in their feet, elderly clients who have
diabetes and/or vascular disease should seek health care quickly and
continue treatment until the infection is resolved. Without treatment,
serious infection, gangrene, limb loss, and death may result.
Question Number 7 of 40
A client who is terminally ill has been receiving high doses of an opiod
analgesic for the past month. As death approaches and the client
becomes unresponsive to verbal stimuli,what orders would the nurse
expect from the health care provider?
Dying patients who have been in chronic pain will probably continue to
experience pain even though unresponsive. Pain medication should be
continued at the same dose, if effective
Question Number 8 of 40
A newborn presents with a pronounced cephalhematoma following a
birth in the posterior position. Which nursing diagnosis should guide
the plan of care?
Question Number 9 of 40
While caring for a child with Reye's Syndrome, the nurse should give
which action the highest priority?
Question Number 10 of 40
A nurse manager is using the technique of brainstorming to help solve
a problem. One nurse criticizes another nurse’s contribution and
begins to find objections to the suggestion. The nurse manager's best
response is to
Question Number 12 of 40
The nurse has identified what appears to be ventricular tachycardia on
the cardiac monitor of a client being evaluated for possible myocardial
infarction. The first action the nurse would perform is to
The nurse must first assess the client to determine the appropriate
next step. In this case the first step the nurse must take is to evaluate
the A, B, C''s.
Question Number 13 of 40
The nurse is caring for a client with active tuberculosis who has a
history of noncompliance. Which of the following actions by the nurse
would represent appropriate care for this client?
Question Number 14 of 40
A woman who delivered 5 days ago and had been diagnosed with
preeclampsia calls the hospital triage nurse hotline to ask for advice.
She states “ I have had the worst headache for the past 2 days. It
pounds and by the middle of the afternoon everything I look at looks
wavy. Nothing I have taken helps.” What should the nurse do next?
Advise the client that the swings in her hormones may have
A) that effect. However, suggest for her to call her health care
provider within the next day.
Advise the client to have someone bring her to the emergency
B)
room as soon as possible
Ask the client to stay on the line, get the address and send an
C)
ambulance to the home
Ask what the client has taken? How often? Ask about other
D)
specific complaints.
Your response was "A".
The correct answer is C: Ask the client to stay on the line, get the
address and send an ambulance to the home
The correct response is C. The woman is at risk for seizure activity.
The ambulance needs to bring the woman to the hospital. For at risk
clients, preeclampsia and eclampsia may occur prior to, during or after
delivery. After delivery the window of time can be up to ten days.
Question Number 15 of 40
A child is diagnosed with poison ivy. The mother tells the nurse that
she does not know how her child contracted the rash since he had not
been playing in wooded areas. As the nurse asks questions about
possible contact, which of the following would the nurse recognize as
highest risk for exposure?
Smoke from burning leaves or stems of the poison ivy plant can
produce a reaction. Direct contact with the toxic oil, urushiol, is the
most common cause for this dermatitis.
Question Number 16 of 40
The nurse manager identifies that time spent by staff in charting is
excessive, requiring overtime for completion. The nurse manager
states that "staff will form a task force to investigate and develop
potential solutions to the problem, and report on this at the next staff
meeting." The nurse manager's leadership style is best described as
A) Laissez-faire
B) Autocratic
C) Participative
D) Group
Your response was "A".
Question Number 18 of 40
A client with hepatitis A (HAV) is newly admitted to the unit. Which
action would be the priority to include in the plan of care within the
initial 24 hours for this client?
The correct answer is C: Wear gown and gloves during client contact
HAV is usually transmitted via the fecal-oral route. That means that
someone with the virus handles food without washing his or her hands
after using the bathroom. The virus can also be contracted by drinking
contaminated water, eating raw shellfish from water polluted with
sewage or being in close contact with a person who''s infected — even
if that person has no signs and symptoms. In fact, the disease is most
contagious before signs and symptoms ever appear. The nurse should
recognize the importance of isolation precautions from the initial
contact with the client on admission until the noncontagious
convalescence period.
Question Number 19 of 40
A confused client has been placed in physical restraints by order of the
health care provider. Which task could be assigned to an unlicensed
assistive personnel (UAP)?
Question Number 20 of 40
The nurse admits an elderly Mexican-American migrant worker after
an accident that occurred during work. To facilitate communication the
nurse should initially
Question Number 21 of 40
The nurse is working with parents to plan home care for a 2 year-old
with a heart problem. A priority nursing intervention would be to
Question Number 22 of 40
The nurse notes an abrupt onset of confusion in an elderly patient.
Which of the following recently-ordered medications would most likely
contribute to this change?
A) Anticoagulant
B) Liquid antacid
C) Antihistamine
D) Cardiac glycoside
Your response was "A".
Question Number 23 of 40
An infant has just returned from surgery for placement of a
gastrostomy tube as an initial treatment for tracheoesophageal fistula.
The mother asks:”When can the tube can be used for feeding?” The
nurse's best response would be which of these comments?
".
A) Feedings can begin in 5 to 7 days.
B) The use of the feeding tube can begin immediately.
C) The stomach contents and air must be drained first.
D) The incision healing must be complete before feeding.
Your response was "A".
Question Number 24 of 40
The nurse is teaching a 27 year-old client with asthma about
management of their therapeutic regime. Which statement would
indicate the need for additional instruction?
Question Number 25 of 40
A nurse caring for premature newborns in an intensive care setting
carefully monitors oxygen concentration. What is the most common
complication of this therapy?
A) Intraventricular hemorrhage
B) Retinopathy of prematurity
C) Bronchial pulmonary dysplasia
D) Necrotizing enterocolitis
Your response was "A".
While there are other causes for retinal damage in the premature
infant, maintaining the oxygen concentration below 40% reduces one
risk factor
Question Number 26 of 40
The nurse is caring for a child with cystic fibrosis. The nurse would
anticipate that the child would be deficient in which vitamins?
A) B, D, and K
B) A, D, and K
C) A, C, and D
D) A, B, and C
Your response was "A".
Question Number 27 of 40
The nurse is caring for a client with Rheumatoid Arthritis. Which
nursing diagnosis should receive priority in the plan of care?
Relieving pain is the number one objective of this client''s plan of care
Question Number 28 of 40
The nurse is teaching a client with atrial fibrillation about the use of
Coumadin (warfarin) at home. Which of these should be emphasized to
the client to avoid?
Question Number 29 of 40
To prevent keratitis in an unconscious client, the nurse should apply
moisturizing ointment to the
".
A) Finger and toenail quicks
B) Eyes
C) Perianal area
D) External ear canals
Your response was "A".
Question Number 30 of 40
The nurse is caring for a 75 year old client in congestive heart failure.
Which finding suggests that digitalis levels should be reviewed?
A) Extreme fatigue
B) Increased appetite
C) Intense itching
D) Constipation
Your response was "A".
Question Number 31 of 40
The nurse is providing foot care instructions to a client with arterial
insufficiency. The nurse would identify the need for additional
teaching if the client stated
The correct answer is C: "I will trim corns and calluses regularly."
Clients who are elderly, have diabetes, and/or have vascular disease
often have decreased circulation and sensation in one or both feet.
Their vision may also be impaired. Therefore, they need to be taught
to examine their feet daily or have someone else do so. They should
wear cotton socks which have not been mended, and always wear
shoes when out of bed. They should not cut their nails, corns, and
calluses, but should have them trimmed by their health care provider,
nurse, or other provider who specializes in foot care.
Question Number 32 of 40
A client has been taking alprazolam (Xanax) for 3 days. Nursing
assessment should reveal which expected effect of the drug?
The anti-anxiety drugs produce tranquilizing effects and may numb the
emotions.
Question Number 33 of 40
The primary teaching for a client following an extracorporeal shock-
wave lithotripsy (ESWL) procedure is
The correct answer is A: Drink 3000 to 4000 cc of fluid each day for 1
month
Drinking three to four quarts (3000 to 4000 cc) of fluid each day will
aid passage of fragments and help prevent formation of new calculi
Question Number 34 of 40
A pre-term baby develops nasal flaring, cyanosis and diminished
breath sounds on one side. The provider's diagnosis is spontaneous
pneumothorax. Which procedure should the nurse prepare for first?
A) Cardiopulmonary resuscitation
B) Insertion of a chest tube
C) Oxygen therapy
D) Assisted ventilation
Your response was "A". The correct answer is B: Insertion of a chest
tube Because a portion of the lung has collapsed, a chest tube will be
inserted to restore negative pressure in the chest cavity.
Question Number 35 of 40
The nurse is teaching a group of adults about modifiable cardiac risk
factors. Which of the following should the nurse focus on first?
A) Weight reduction
B) Stress management
C) Physical exercise
D) Smoking cessation
Your response was "A".
Stopping smoking is the priority for clients at risk for cardiac disease,
because of the effect to reduce oxygenation and constrict blood
vessels
Question Number 36 of 40
The nurse is caring for a 5 year-old child who has the left leg in
skeletal traction. Which of the following activities would be an
appropriate diversional activity?
Question Number 37 of 40
A client is scheduled to have a blood test for cholesterol and
triglycerides the next day. The nurse would tell the client
The correct answer is B: "Do not eat or drink anything but water for 12
hours before the blood test."
Question Number 38 of 40
Which of these clients would the triage nurse request for the health
care provider to examine immediately?
".
A) A 5 month-old infant who has audible wheezing and grunting
B) An adolescent who has soot over the face and shirt
A middle-aged man with second degree burns over the right
C)
hand
D) A toddler with singed ends of long hair that extends to the waist
Your response was "A".
The age and the findings puts this client at immediate risk for
respiratory complications.
Question Number 39 of 40
In assessing a post partum client, the nurse palpates a firm fundus
and observes a constant trickle of bright red blood from the vagina.
What is the most likely cause of these findings?
A) Uterine atony
B) Genital lacerations
C) Retained placenta
D) Clotting disorder
Your response was "A".
Question Number 40 of 40
The community health nurse has been following the care for an
adolescent with a history of morbid obesity, asthma, hypertension and
is 22 weeks in to a pregnancy. Which of these lab reports sent to the
clinic need to be called to the teens health care provider within the
next hour?
The client’s lab values are all abnormal except for the platelets. The
magnesium is low and the creatinine is high which indicates renal
failure. With the history of hypertension the findings exhibit the risk of
preeclampsia. The client needs to be referred for immediate follow up
with a health care provider.