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A client with dyspnea is being admitted to the medical unit. To best prepare for the
client's arrival, the nurse should ensure that the client's bed is in which position?
A. Supine
B. supine; feet elevated higher than head
C. supine; head elevated higher than feet
D. Fowlers - ANSWERS-Fowlers
An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9, is
admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely
cause of the ketoacidosis?
A. Ate an extra peanut butter sandwich before gym class
B. incorrectly administered too much insulin
C. Had a cold and ear infection for the past two days
D. Skipped eating lunch - ANSWERS-C. Had a cold and ear infection for the past two
days
A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of
impending death. After notifying the family of the client's status, what priority action
should the nurse implement?
,A. The impending signs of death should be documented
B. The client's status should be conveyed to the chaplain
C. The client's need for pain medication should be determined
D. The nurse manager should be updated on the client's status - ANSWERS-C. The
client's need for pain medication should be determined
Which self care measure is most important for the nurse to include in the plan of care of
a client recently diagnosed with type 2 diabetes mellitus?
A. Self-injection techniques
B. Blood glucose monitoring
C. Diabetic diet meal planning
D. A realistic exercise plan - ANSWERS-B. Blood glucose monitoring
A client who gave birth 48 hours ago has decided to bottle feed the infant. During the
assessment, the nurse observes that both breasts are swollen, warm, and tender on
palpation. Which instruction should the nurse provide?
A. Apply ice to the breasts for comfort
B. Wear a loose-fitting bra during the day to prevent nipple irritation
C. Run warm water over breasts
D. Express small amounts of milk from the breasts to relieve pressure - ANSWERS-A.
Apply ice to the breasts for comfort
The nurse is preparing a client who had a below-the-knee (BKA) amputation for
discharge to home. Which recommendations should the nurse provide this client?
(Select all that apply)
A. Avoid range of motion exercises
B. Use a residual limb shrinker
C. Apply alcohol to the stump after bathing
D. Inspect skin for redness
E. Wash the stump with soap and water - ANSWERS-B. Use a residual limb shrinker
D. Inspect skin for redness
,E. Wash the stump with soap and water
A toddler presenting with a history of intermittent skin rashes, hives, abdominal pain,
and vomiting that occurs after ingesting of milk products arrives to the clinic
accompanied by the parents. Which type of testing should the nurse provide education
to the toddler's family about?
A. Serum immunoglobulin E (IgE)
B. Intradermal test
C. Atopy patch test
D. Placebo-controlled food challenge - ANSWERS-A. Serum immunoglobulin E (IgE)
A client who is scheduled for a bronchoscopy in the morning is anxious and asking the
nurse numerous questions about the procedure. In preparing the client for the
procedure, which intervention has the highest priority?
A. Allow client to gargle with warm salt water
B. Administer a sedative to alleviate anxiety
C. Instruct client to write down the questions
D. Deny client's request for a midnight snack - ANSWERS-C. Instruct client to write
down the questions
The nurse assesses a client one hour after starting a transfusion of packed red blood
cells and determines that there are no indications of a transfusion reaction. What
instruction should the nurse provide the unlicensed assistive personnel (UAP) who is
working with the nurse?
A. Notify the nurse when the transfusion has finished, so further client assessment can
be done
B. Continue to measure the client's vital signs every thirty minutes until the transfusion
is complete
C. Monitor the client carefully for the next three hours and report the onset of a reaction
immediately
D. Since a reaction did not occur, the priority is to maintain client comfort during the
transfusion - ANSWERS-B. Continue to measure the client's vital signs every thirty
minutes until the transfusion is complete
, The nurse is taking the blood pressure measurement of a client with Parkinson's
disease. Which information in the client's admission assessment is relevant to the
nurse's plan for taking the blood pressure reading? (Select all the apply)
A. Frequent syncope
B. Occasional nocturia
C. Flat affect
D. Blurred vision
E. Frequent drooling - ANSWERS-A. Frequent syncope
C. Flat affect
D. Blurred vision
While caring for a client's postoperative dressing, the nurse observes purulent drainage
at the wound. Before reporting this finding to the healthcare provider, the nurse should
review which of the client's laboratory values?
A. Serum albumin
B. Culture for sensitive organisms
C. Serum blood glucose level
D. Creatinine level - ANSWERS-B. Culture for sensitive organisms
A preschool-aged boy is admitted to the pediatric unit following successful resuscitation
from a near-drowning incident. While providing care to the child, the nurse begins
talking with his preadolescent brother who rescued the child from the swimming pool
and initiated resuscitation. The nurse notices the older boy becomes withdrawn when
asked about what happened. Which action should the nurse take?
A. Develop a water safety teaching plan for the family
B. Ask the older brother how he felt during the incident
C. Tell the older brother that he seems depressed
D. Commend the older brother for his heroic actions - ANSWERS-B. Ask the older
brother how he felt during the incident