A and B,[Questions and correct choices]..
1. A nurse is reviewing the medical record of a client who has schizophrenia. Which
of the following should the nurse report to the
provider?
Exhibit 1
Blood pressure: 102/56 mm Hg. Heart rate: 95/min
Respiratory rate: 18/min Temperature: 37.4C (99.3F)
Exhibit 2
Medication Administration Record
Clozapine 150 mg PO twice daily
Benztropine 0.5 mg PO twice daily as needed for tremors. Exhibit 3
Nurse's notes:
Client reports feeling dizzy when changing positions, Reports weight gain of 1kg (2.2 lb.)
in the past month. Also reports a sore throat for the past 3 days and dry mouth. Client
ate 75% of breakfast and reports slightly nauseous.
A. Dietary intake
B. Heart rate.
C. Sore throat.
D. Blood pressure.: C. Sore throat.
2. 3. A nurse is providing discharge teaching for a client who has an implantable
cardioverter defibrillator which of the following statements demonstrates
understanding of the teaching?
A. "I will soak in the tub rather and showering"
B. "I will wear loose clothing around my ICD"
C. "I will stop using my microwave oven at home because of my ICD"
D. "I can hold my cellphone on the same side of my body as the ICD": B. "I will wear loose
clothing around my ICD"
,3. 17. A nurse is assessing a newborn who has a blood glucose level of 30 mg/dl.
Which of the following manifestations should the nurse expect?
A. Loose stools
B. Jitteriness
C. Hypertonia
D. Abdominal distention: Jitteriness
4. 4. A nurse is caring for a client who is at 14 weeks gestation and reports feelings of
ambivalence about being pregnant. Which of the following responses should the nurse
make?
A. "Describe your feelings to me about being pregnant"
B. "You should discuss your feelings about being pregnant with yourprovider"
C. "Have you discussed these feelings with your partner?"
D. "When did you start having these feelings?": A. "Describe your feelings to me about
being pregnant"
5. 5. A nurse is planning care for a client who has a prescription for a boweltraining
program following a spinal cord injury. Which of the following actions should the nurse
include in the plan of care?
A. Encourage a maximum fluid intake of 1,500 ml per day.
B. Increase the amount of refined grains in the client's diet.
C. Provide the client with a cold drink prior to defecation.
D. Administer a rectal suppository 30 minutes prior to scheduled
defecation times.: D. Administer a rectal suppository 30 minutes prior to
scheduled defecation times.
6. 6. A nurse is caring for a client who is in active labor and requests pain
management. Which of the following actions should the nurse take?
A. Administer ondansetron.
B. Place the client in a warm shower.
C. Apply fundal pressure during contractions.
,D. Assist the client to a supine position.: B. Place the client in a warm shower.
7. 7. a nurse in an emergency department is performing triage for multiple clients
following a disaster in the community. To which of the following types of injuries should
the nurse assign the highest priority?
A. Below-the knee amputation
B. Fractured tibia
C. 95% full-thickness body burn
D. 10cm (4in) laceration to the forearm: A. Below-the knee amputation
8. 8. a nurse manager is updating protocols for the use of belt restraints. Which of the
following guidelines should the nurse include?
A. Remove the client's restraint every 4hr
B. Document the client's condition every 15 min
C. Attach the restrain to the bed's side rails
D. Request a PRN restrain prescription for clients who are aggressive: B. Document the
client's condition every 15 min
9. 9. A nurse is teaching an in-service about nursing leadership. Which of the
following information should the nurse include about an effective leader?
A. Acts as an advocate for the nursing unit. B. (Unable to read) for the unit
C. Priorities staff request over client needs.
D. Provides routine client care and documentation.: A. Acts as an advocate for the nursing
unit.
10. 10. A nurse is reviewing the laboratory findings of a client who has diabetes mellitus
and reports that she has been following her (unable to read) care. The nurse should
identify which of the following findings indicates a need to revise the client's plan of
care.
A. Serum sodium 144 mEq/
B. (Unable to read)
, C. Hba1c 10 %
D. Random serum glucose 190 mg/dl.: C. Hba1c 10 %
11. 11. A nurse in a provider's office is reviewing the laboratory results of a group of
clients. The nurse should identify that which of the following sexually transmitted
infections is a nationally notifiable infectious disease that should be reported to the
state health department?
A. Chlamydia
B. Human papillomavirus
C. Candidiasis
D. Herps simplex virus: A. Chlamydia
12. 12. A nurse is teaching a newly licensed nurse about therapeutic techniques to use
when leading a group on a mental health unit. Which of the following group facilitation
techniques should the nurse include in the teaching?
A. Share personal opinions to help influence the group's values
B. Measure the accomplishments of the group against a previous group
C. Yield in situations of conflicts to maintain group harmony
D. Use modeling to help the clients improve their interpersonal skills: D. Use modeling to
help the clients improve their interpersonal skills
13. 2. A nurse is caring for a client who has arteriovenous fistula Which of the
following findings should the nurse report?
A. Thrill upon palpation.
B. Absence of a bruit.
C. Distended blood vessels
D. Swishing sound upon auscultation.: B. Absence of a bruit.
14. A nurse is planning for a client who practices Orthodox Judaism. The client tells
the nurse that (Unable to read) Passover holiday. Which of the following action
should the nurse include in the plan of care?