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A nurse in the emergency department is assessing a client. Which of the following
actions should the nurse take first? Exhibit
a. Obtain a sputum sample for culture
b. Administer ondansetron
c. Initiate airborne precautions
d. Prepare the client for a chest x-ray - ANS... -c. Initiate airborne precautions
A nurse is reviewing the medical record of a client to identify risk factors for
colorectal cancer. The nurse should identify which of the following findings as
increasing the client's risk?
a. History of Crohn's disease
b. BMI of 24
c. Diet high in fiber
d. Age 46 years - ANS... -a. History of Crohn's disease
A nurse is caring for a client who is scheduled for a mastectomy. The client tells
the nurse, "I'm not sure I want to have a mastectomy." Which of the following
statements should the nurse make?
a. "I can give you a list of other people who had the same procedure"
b. "You will be cancer-free if you have the procedure"
c. "I can give you additional information about the procedure"
d. "You should should get a second opinion regarding the procedure" - ANS... -c.
"I can give you additional information about the procedure"
A nurse is preparing to administer a unit of packed RBCs to a client who is anemic.
Identify the sequence of steps the nurse should follow.
a. Obtain venous access using 19-gauge needle
c. Verify blood compatibility with another nurse
d. Initiate transfusion of the unit of packed RBCs
e. Remain with the client for the first 15 to 30 min of the infusion ANS... -a.
Obtain venous access using 19-gauge needle
A nurse is preparing a teaching plan for a client who has mucositis related to
chemotherapy treatment. Which of the following instructions should the nurse
include?
,a. "rinse your mouth with hydrogen peroxide"
b. "brush your teeth for 60 seconds twice daily"
c. "wear your dentures only during meals"
d. "floss your teeth following each meals" - ANS... -d. "floss your teeth following
each meals"
A critical care nurse is assessing a client who has severe head injury. In response to
painful stimuli, the client does not open her eyes, displays decerebrate posturing,
and makes incomprehensible sounds. Which of the following Glasgow Coma Scale
scores should the nurse assign the client?
a. 5
b. 2
c. 13
d. 10 - ANS... -a. 5
A nurse is providing discharge teaching to a client who has heart failure and
instructs him to limit sodium intake to 2 g per day. Which of the following
statements by the client indicates an understanding of the teaching?
a. "I can season my foods with garlic and onion salts"
b. "I can have mayonnaise on my sandwiches"
c. "I can have a frozen fruit juice bar for dessert"
d. "I can drink vegetable juice with a meal" - ANS... -c. "I can have a frozen fruit
juice bar for dessert"
A nurse is preparing to perform ocular irrigation for a client following chemical
splash to the eye. Which of the following actions should the nurse plan to take
first?
a. Instill 0.9% sodium chloride solution into the affected eye
b. Administer proparacaine eyedrops into the affected eye
c. Collect information about the irritant that caused the injury - ANS... -c. Collect
information about the irritant that caused the injury
A nurse is assessing a client following extubation from a ventilator. For which of
the following findings should the nurse intervene immediately?
a. Rhonchi
b. SaO2 92%
c. Sore throat
d. Stridor - ANS... -d. Stridor
, A nurse is reviewing the laboratory reports of a client who has acute pancreatitis.
Which of the following findings should the nurse expect?
a. Elevated serum calcium
b. Elevated blood glucose
c. Decreased serum amylase
d. Decreased erythrocyte sedimentation rate - ANS... -b. Elevated blood glucose
A nurse is reviewing the medical record of a client who has diabetes insipidus.
Which of the following findings should the nurse expect?
a. Hypothermia
b. Urine specific gravity 1.001 (<1.005)
c. Elevated blood pressure
d. BUN 15 mg/dl - ANS... -b. Urine specific gravity 1.001 (<1.005)
A nurse in an emergency department is preparing to perform an ocular irrigation
for a client. Which of the following actions should the nurse plan to take?
a. Assess the client's visual acuity prior to irrigation
b. Have the client turn their head toward the unaffected eye
c. Hold the irrigator syringe 3.81 cm (1.5 in) above the eye
d. Perform the irrigation with sterile water for irrigation - ANS... -d. Perform the
irrigation with sterile water for irrigation
A nurse is preparing to administer lactated ringer's via continuous IV infusion at
200 ml/hr. The IV tubing has a drop factor of 10 drops/ml. How many gtt/min
should the nurse set the IV pump to administer? Round to near whole number -
ANS... -33 gtt/min
A nurse is providing discharge teaching to a client who has a new prescription for
sublingual nitroglycerin. Which of the following client statements indicates an
understanding of the teaching?
a. I can keep my medications for 1 year before replacing it
b. I should lie down when I take this medication
c. I should discontinue this medication if I develop a headache
d. I can take up to five tablets in 15 minutes before seeking medical attention -
ANS... -b. I should lie down when I take this medication
A nurse is providing discharge teaching to an older adult client following a left
total hip arthroplasty. Which of the following instructions should the nurse include
in the teaching?