Exam (elaborations) NURSING CRITICAL C QUESTIONS AND ANSWERS LATEST 2021 GRADED A

Exam (elaborations) NURSING CRITICAL C QUESTIONS AND ANSWERS Question 1 See full question 20s Which client is at highest risk for developing a urinary tract infection? You Selected:  a man with an indwelling urinary catheter Correct response:  a man with an indwelling urinary catheter Explanation: Remediation: Add a Note Question 2 See full question 6m 8s A client is recovering from a bacterial infection with intravenous antibiotics. The healthcare team is planning for the client to be discharged tomorrow. However, the client wants to leave today because the client’s animals do not have someone to feed them tomorrow. What is the nurse’s best response to this client? You Selected:  “You have a right to leave early, but let us make sure you are aware of all the complications that can occur.” Correct response:  “You have a right to leave early, but let us make sure you are aware of all the complications that can occur.” Explanation: Remediation: Add a Note Question 3 See full question 2m 3s A neonate born at 40 weeks' gestation admitted to the nursery is found to be hypoglycemic. At 4 hours of age, the neonate appears pale and his pulse oximeter is reading 75% on room air. What should the nurse do? You Selected:  Provide supplemental oxygen. Correct response:  Provide supplemental oxygen. Explanation: Remediation: Add a Note Question 4 See full question 2m 22s A client fears chemotherapy because of the side effects. What is the nurse's best response to the client's concerns? You Selected:  “We’ll give you medications to prevent the side effects, so you shouldn’t be too concerned.” Correct response:  “Each person responds differently to chemotherapy treatments. We’ll monitor your responses closely.” Explanation: Remediation: Add a Note Question 5 See full question 38s The nurse teaches the client with chronic cancer pain about optimal pain control. Which recommendation is most effective for pain control? You Selected:  Take prescribed analgesics on an around-the-clock schedule to prevent recurrent pain. Correct response:  Take prescribed analgesics on an around-the-clock schedule to prevent recurrent pain. Explanation: Remediation: Add a Note Question 6 See full question 30s A client received chemotherapy 24 hours ago. Which precautions are necessary when caring for the client? You Selected:  Wear personal protective equipment when handling blood, body fluids, and feces. Correct response:  Wear personal protective equipment when handling blood, body fluids, and feces. Explanation: Remediation: Add a Note Question 7 See full question 31s A client with dysphagia is being prepared for discharge. Which outcome indicates that the client is ready for discharge? You Selected:  The client is free from esophagitis and achalasia. Correct response:  The client is free from esophagitis and achalasia. Explanation: Remediation: Add a Note Question 8 See full question 9s A physician orders a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance? You Selected:  hypokalemia Correct response:  hypokalemia Explanation: Remediation: Add a Note Question 9 See full question 39s A hospitalized client with end-stage heart failure does not want to be resuscitated. The health care provider (HCP) has written the do-not-resuscitate (DNR) prescription on the client’s record. The client has a cardiac arrest, and the wife tells the nurse she wants the client to be resuscitated and asks the nurse to “do something.” What should the nurse do? You Selected:  Discuss the DNR prescription with the wife. Correct response:  Discuss the DNR prescription with the wife. Explanation: Remediation: Add a Note Question 10 See full question 1m 43s During the discharge planning teaching process, a client who has been prescribed tranylocypromine states that he enjoys a beer or two in the evenings. Which of the following is the nurse's most appropriate response? You Selected:  “Beer contains tyramine, which must be avoided when on this medication.” Correct response:  “Beer contains tyramine, which must be avoided when on this medication.” Explanation: Remediation: Add a Note Question 11 See full question 46s The staff of an outpatient clinic has formed a task force to develop new procedures for swift, safe evacuation of the unit. The new procedures haven't been reviewed, approved, or shared with all personnel. When a nurse-manager receives word of a bomb threat, the task force members push for evacuating the unit using the new procedures. Which action should the nurse-manager take? You Selected:  Determine that the procedures currently in place must be followed and direct staff to follow them without question. Correct response:  Determine that the procedures currently in place must be followed and direct staff to follow them without question. Explanation: Add a Note Question 12 See full question 1m 17s A client with cancer-related pain has been prescribed a narcotic analgesic to be given around the clock. The client is competent and has been actively involved in decisions regarding care. What should the nurse do if the client refuses the next dose of analgesia? You Selected:  Document the client’s choice and re-assess pain in 1 hour. Correct response:  Document the client’s choice and re-assess pain in 1 hour. Explanation: Add a Note Question 13 See full question 1m 30s A client was admitted for a 3-day stay on the psychiatric inpatient unit. At the time of discharge, the client says to the nurse, "It would nice to go out some time; tell me how I can reach you outside of the hospital." Which response by the nurse is most appropriate? You Selected:  "My relationship with you is professional and not social." Correct response:  "My relationship with you is professional and not social." Explanation: Remediation: Add a Note Question 14 See full question 34s The nurse is caring for an adolescent who has been admitted several times with uncontrolled type 1 diabetes. The child is now stabilized and is preparing for discharge. Which of the following should be the priority focus for the nurse when conducting discharge teaching? You Selected:  management of the therapeutic regimen Correct response:  management of the therapeutic regimen Explanation: Remediation: Add a Note Question 15 See full question 17s The nurse understands that client position is important when treating dyspnea. What position would be contraindicated for a client who has dyspnea? You Selected:  supine Correct response:  supine Explanation: Remediation: Add a Note Question 16 See full question 35s A 25-year-old primiparous client who gave birth 2 hours ago has decided to breastfeed her neonate. Which instruction should the nurse address as the highest priority in the teaching plan about preventing nipple soreness? You Selected:  placing as much of the areola as possible into the baby’s mouth Correct response:  placing as much of the areola as possible into the baby’s mouth Explanation: Remediation: Add a Note Question 17 See full question 35s Accompanied by her partner, a client seeks admission to the labor and delivery area. She states that she's in labor and says she attended the facility clinic for prenatal care. Which question should the nurse ask her first? You Selected:  "What is your expected due date?" Correct response:  "What is your expected due date?" Explanation: Remediation: Add a Note Question 18 See full question 1m 17s A first-time mother is concerned that her 6-month-old infant is not gaining enough weight. What should the nurse tell the mother? You Selected:  "Birth weight doubles by 6 months of age." Correct response:  "Birth weight doubles by 6 months of age." Explanation: Remediation: Add a Note Question 19 See full question 41s A nurse is admitting a client to the palliative unit and discussing advanced directives. Which of the following statements made by the client leads the nurse to believe the client requires clarification around advanced directives? You Selected:  “This will stop my daughter-in-law from putting me in a home.” Correct response:  “This will stop my daughter-in-law from putting me in a home.” Explanation: Remediation: Add a Note Question 20 See full question 37s The nurse preceptor overhears a student nurse talking to a grieving mother, whose child was stillborn, about her own pregnancy and fears about experiencing a loss. The student nurse and mother make arrangements for the student to pick up the client’s maternity clothes and baby furniture on the weekend. What is the preceptor’s most appropriate action? You Selected:  Discuss the situation with the nursing student after the visit has ended. Correct response:  Discuss the situation with the nursing student after the visit has ended. Explanation: Add a Note Question 21 See full question 29s The nurse is evaluating a parent’s understanding of measuring one tablespoon of medication in a medicine cup. At which level on the medicine cup would the nurse confirm an appropriate dose? You Selected:  Your selection and the correct area, market by the green box. Explanation: Add a Note Question 22 See full question 53s A client has just been admitted with acute delirium of unknown etiology. The client's daughter states that she is worried about her mom because she has never been this sick before. Which would be the most helpful statement to make to the daughter? You Selected:  “The health care provider will prescribe tests to find out what’s causing her condition.” Correct response:  “The health care provider will prescribe tests to find out what’s causing her condition.” Explanation: Remediation: Add a Note Question 23 See full question 31s When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first? You Selected:  Check the equipment. Correct response:  Check the equipment. Explanation: Remediation: Add a Note Question 24 See full question 2m The nurse is assessing a client, who has lung cancer with spinal metastasis, for pain. The client tells the nurse that the ordered opioid medication helps, but there is still a shooting pain down the client’s left leg. Identify the best pharmacologic measure to address this pain. You Selected:  an adjuvant, such as gabapentin Correct response:  an adjuvant, such as gabapentin Explanation: Add a Note Question 25 See full question 2m 38s A nurse counsels a mother with young children after leaving her abusive husband 6 months ago. The mother says, “My 6-year-old is starting to act just like his father. I just don’t know how to handle this.” Which response by the nurse is most appropriate? You Selected:  "Counseling for your son would be helpful." Correct response:  "Counseling for your son would be helpful." Explanation: Add a Note Question 26 See full question 32s A client with Addison's disease comes to the clinic for a follow-up visit. When assessing this client, the nurse should stay alert for signs and symptoms of: You Selected:  sodium and potassium abnormalities. Correct response:  sodium and potassium abnormalities. Explanation: Remediation: Add a Note Question 27 See full question 52s The health care provider (HCP) is calling in a prescription for ampicillin for a neonate. What should the nurse do? Select all that apply. You Selected:  Write down the prescription.  Repeat the prescription to the HCP over the telephone.  Ask the HCP to confirm that the prescription is correct. Correct response:  Write down the prescription.  Repeat the prescription to the HCP over the telephone.  Ask the HCP to confirm that the prescription is correct. Explanation: Remediation: Add a Note Question 28 See full question 1m 41s The nurse is notifying the health care provider via telephone of a change in condition of a client diagnosed with an exacerbation of asthma. Arrange the nursing statements in order as they would be communicated using the SBAR method. All options must be used. You Selected:  Hello. My name is Nurse Jones from Unit D.  I am notifying you because Bob Smith has become increasingly short of breath with audible wheezing this afternoon.  Mr. Smith was admitted yesterday with an exacerbation of asthma. He typically controls his asthma with oral medication and inhalers at home. He is ordered albuterol treatments twice daily. Oxygen is prescribed at 2 liters.  Respirations are now 32 breaths/minute. The pulse oximeter is 89%. Lungs reveal wheezing in all lung fields. Slight nasal flaring is noted.  I recommend that we increase his oxygen dose and prescribe an extra albuterol treatment. Correct response:  Hello. My name is Nurse Jones from Unit D.  I am notifying you because Bob Smith has become increasingly short of breath with audible wheezing this afternoon.  Mr. Smith was admitted yesterday with an exacerbation of asthma. He typically controls his asthma with oral medication and inhalers at home. He is ordered albuterol treatments twice daily. Oxygen is prescribed at 2 liters.  Respirations are now 32 breaths/minute. The pulse oximeter is 89%. Lungs reveal wheezing in all lung fields. Slight nasal flaring is noted.  I recommend that we increase his oxygen dose and prescribe an extra albuterol treatment. Explanation: Add a Note Question 29 See full question 52s Which type of solution, when administered I.V., would cause fluid to shift from body tissues to the bloodstream? You Selected:  hypertonic Correct response:  hypertonic Explanation: Add a Note Question 30 See full question 1m 12s A hospital employee asks the nurse if another hospital employee is a client on the medical unit. What statements made by the nurse protect client privacy? Select all that apply. You Selected:  "Client privacy is part of the hospital code of conduct."  "I am not able to provide that information." Correct response:  "I am not able to provide that information."  "Client privacy is part of the hospital code of conduct." Explanation: Add a Note Question 31 See full question 1m 25s A client who has skeletal traction to stabilize a fractured femur has not had a bowel movement for 2 days. The nurse should: You Selected:  increase the client’s fluid intake to 3,000 mL/day. Correct response:  increase the client’s fluid intake to 3,000 mL/day. Explanation: Remediation: Add a Note Question 32 See full question 2m 58s A client is using an over-the-counter nasal spray containing pseudoephedrine to treat allergic rhinitis. Which instruction about this medication would be most appropriate for the nurse to provide for the client? You Selected:  Overuse of pseudoephedrine can lead to increased nasal congestion. Correct response:  Overuse of pseudoephedrine can lead to increased nasal congestion. Explanation: Remediation: Add a Note Question 33 See full question 44s The client with a depressive disorder has been consistent with taking 12.5 mg of paroxetine extended release daily. The nurse judges the client to be benefiting from this drug therapy when the client demonstrates which behaviors? Select all that apply. You Selected:  completes homework assignments  decreases pacing  verbalizes feelings Correct response:  completes homework assignments  decreases pacing  verbalizes feelings Explanation: Remediation: Add a Note Question 34 See full question 26s The nurse is reviewing laboratory values of a client receiving clozapine. Which laboratory value should the nurse report to the health care provider (HCP)? You Selected:  WBC of 3,500/μL (3.5 X 109/L) Correct response:  WBC of 3,500/μL (3.5 X 109/L) Explanation: Remediation: Add a Note Question 35 See full question 2m 11s The nurse conducts a wellness screening on a 9-year-old client Which finding most suggests that that the client has typical social development? You Selected:  enjoys active play Correct response:  has a best friend Explanation: Add a Note Question 36 See full question 41s After being examined by a forensic nurse in the emergency department, a rape victim is prepared for discharge. Because of the nature of the attack, this client is at risk for posttraumatic stress disorder (PTSD). Which symptoms are associated with PTSD? Select all that apply. You Selected:  Sleep disturbances  Recurrent, intrusive recollections or nightmares  Difficulty concentrating Correct response:  Recurrent, intrusive recollections or nightmares  Sleep disturbances  Difficulty concentrating Explanation: Remediation: Add a Note Question 37 See full question 39s What should the nurse expect to include as a priority in the plan of care for a client with delirium based on the nurse’s understanding of the disturbances in orientation associated with this disorder? You Selected:  identifying self and making sure that the nurse has the client's attention Correct response:  identifying self and making sure that the nurse has the client's attention Explanation: Remediation: Add a Note Question 38 See full question 17s When caring for a client who has overdosed on phencyclidine (PCP), the nurse should be especially cautious about which client behavior? You Selected:  violent behavior Correct response:  violent behavior Explanation: Remediation: Add a Note Question 39 See full question 21s A nurse is caring for a client in acute addisonian crisis. Which test result does the nurse expect to see? You Selected:  Serum potassium level of 6.8 mEq/L (6.8 mmol/L) Correct response:  Serum potassium level of 6.8 mEq/L (6.8 mmol/L) Explanation: Remediation: Add a Note Question 40 See full question 3m 22s The following clients are in the intermediate care unit. After receiving change of shift report who should the nurse assess first? You Selected:  a client with infective endocarditis who has a murmur and a heart rate of 58 Correct response:  a client with aortic stenosis who has a blood pressure of 84/52 mm Hg Explanation: Remediation: Add a Note Question 41 See full question 18s A client undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction? You Selected:  "Keep the stoma moist." Correct response:  "Keep the stoma moist." Explanation: Remediation: Add a Note Question 42 See full question 2m 57s A student nurse is questioning a nursing instructor about the responsibility to have malpractice insurance. The nursing instructor confirms the safeguard of malpractice insurance by emphasizing which points regarding student liability? Select all that apply. You Selected:  The student nurse is held to the same standard of care as a nurse.  The nursing instructor can be liable if the assignment is above the student’s competency.  The student nurse is responsible for his or her actions. Correct response:  The student nurse is responsible for his or her actions.  The student nurse is held to the same standard of care as a nurse.  The nursing instructor can be liable if the assignment is above the student’s competency. Explanation: Add a Note Question 43 See full question 1m 57s The family members of a client with mild dementia are asking the nurse about permitting the elderly father to prepare an advance directive. Which information would be essential for the nurse to include in a discussion with this family? You Selected:  Suggest to the family that the client be evaluated psychiatrically to determine if the client should construct an advance directive. Correct response:  Explain that the client may have some ideas and some ability to make certain decisions about what is wanted at end of life. Explanation: Remediation: Add a Note Question 44 See full question 1m 28s In which phase of postpartal psychological adaption would discharge teaching regarding infant care most likely be successful? You Selected:  taking hold Correct response:  taking hold Explanation: Remediation: Add a Note Question 45 See full question 21s An adolescent who is depressed and whose parents report as having difficulty in school is brought to the community mental health center to be evaluated. Which additional problem would the nurse expect the client to have? You Selected:  Behavioral difficulties Correct response:  Behavioral difficulties Explanation: Remediation: Add a Note Question 46 See full question 2m 36s The nurse is inserting a nasogastric (NG) tube in a child admitted with head trauma. The nurse should explain to the parents that the NG tube will be used for what purpose? You Selected:  Decompress the stomach. Correct response:  Decompress the stomach. Explanation: Remediation: Add a Note Question 47 See full question 1m 19s What occurs during the working phase of the nurse-client relationship? You Selected:  A nurse and a client discuss their feelings about terminating the relationship. Correct response:  A nurse and a client evaluate and modify the goals of the relationship. Explanation: Add a Note Question 48 See full question 30s A child is diagnosed with pituitary dwarfism. Which pituitary agent will the primary care provider most likely order to treat this condition? You Selected:  somatotropin Correct response:  somatotropin Explanation: Add a Note Question 49 See full question 17s A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by: You Selected:  first intention. Correct response:  first intention. Explanation: Remediation: Add a Note Question 50 See full question 4m 36s An adult client had an abdominal perineal resection with a colostomy 4 days ago and is ready for discharge. Which is an expected outcome at this point? You Selected:  The client maintains a high-fiber diet. Correct response:  The client discusses concerns about sexual functioning. Explanation: Remediation: Add a Note Question 51 See full question 4m 14s A client undergoing a bilateral adrenalectomy has postoperative prescriptions for hydromorphone hydrochloride 2 mg to be administered subcutaneously every 4 hours as needed for pain. Why should the nurse administer hydromorphone in small doses? A small dose is: You Selected:  as potent as morphine in larger doses. Correct response:  as potent as morphine in larger doses. Explanation: Remediation: Add a Note Question 52 See full question 23s The client with Addison's disease is taking glucocorticoids at home. Which statement indicates that the client understands how to take the medication? You Selected:  "Various circumstances increase the need for glucocorticoids, so I will need to adjust the dosage." Correct response:  "Various circumstances increase the need for glucocorticoids, so I will need to adjust the dosage." Explanation: Remediation: Add a Note Question 53 See full question 1m 27s The nurse is to administer an enteral feeding to an adult client. Prior to initiating the feeding, the nurse evaluates the gastric residual. What should the nurse determine from evaluating the gastric residual? You Selected:  how well nutrients are being absorbed Correct response:  extent of overdistention of the stomach Explanation: Remediation: Add a Note Question 54 See full question 1m 42s A client who is an Orthodox Jew follows a Kosher diet. To ensure adequate nutritional intake, the nurse and client work with the dietician to incorporate the client’s nutritional preferences for meals. Which intervention would be most appropriate? You Selected:  providing separate eating utensils for meat and dairy items Correct response:  providing separate eating utensils for meat and dairy items Explanation: Remediation: Add a Note Question 55 See full question 1m 37s Which type of mouth care is most appropriate when the nurse is caring for a client with dentures who has severe stomatitis? You Selected:  using a soft toothbrush to provide oral hygiene Correct response:  using a soft toothbrush to provide oral hygiene Explanation: Remediation: Add a Note Question 56 See full question 48s The nurse is providing discharge teaching for a client who will be taking lithium. Which condition would necessitate a call to the client’s health care provider? You Selected:  Persistent gastrointestinal upset. Correct response:  Persistent gastrointestinal upset. Explanation: Remediation: Add a Note Question 57 See full question 19s Every day for the past 2 weeks, a client with schizophrenia has stood during group therapy and screamed, "Get out of here right now! The elevator bombs are going to explode in 3 minutes!" The next time this happens, how should the nurse respond? You Selected:  "I know you think there are bombs in the elevator, but there aren't." Correct response:  "I know you think there are bombs in the elevator, but there aren't." Explanation: Remediation: Add a Note Question 58 See full question 3m 34s A client in surgery has an endotracheal tube (ET) in place. The nurse should call a timeout if which requirements are not in place? Select all that apply. You Selected:  oxygen administration  an IV line  an identification band Correct response:  an identification band  an IV line  oxygen administration  an anesthetist/anesthesiologist Explanation: Remediation: Add a Note Question 59 See full question 2m 54s The family member of a client diagnosed with dissociative identity disorder (DID) asks a nurse if hypnotic therapy might help the client. How should the nurse respond? You Selected:  “Yes, a client is often not consciously aware of alter personalities.” Correct response:  “Yes, a client is often not consciously aware of alter personalities.” Explanation: Remediation: Add a Note Question 60 See full question 22s After being treated for minor cuts, a client appears confused and has trouble focusing on what the nurse is saying. The client reports nausea and dizziness, has tachycardia, and is hyperventilating during the nursing assessment. The nurse would interpret the level of anxiety as which of the following? You Selected:  Severe Correct response:  Severe Explanation: Remediation: Add a Note Question 61 See full question 20s When developing the plan of care for a newly admitted 2-year-old child with the diagnosis of Kawasaki disease, which intervention should be the priority? You Selected:  monitoring intake and output every hour Correct response:  monitoring intake and output every hour Explanation: Remediation: Add a Note Question 62 See full question 25s The client with an abdominal perineal resection and colostomy had a nasogastric (NG) tube inserted during surgery. The NG tube will most likely be removed when the client demonstrates: You Selected:  passage of flatus from the colostomy Correct response:  passage of flatus from the colostomy Explanation: Remediation: Add a Note Question 63 See full question 5m 40s The nurse is administering a subcutaneous injection (see accompanying figure). After releasing the skin, prior to injecting the medication, the needle pulls out of the skin. The nurse should: You Selected:  discard the needle and syringe, obtain new needle and syringe, and draw a new dose of the medication. Correct response:  discard the needle, attach a new needle to the syringe, and administer the medication. Explanation: Remediation: Add a Note Question 64 See full question 22s A client is admitted to the oncology unit with an infection. It is suspected that the infection may be related to the vascular access device (VAD). The nurse should draw the blood cultures from which site? You Selected:  a peripheral site and all lumens of the VAD Correct response:  a peripheral site and all lumens of the VAD Explanation: Remediation: Add a Note Question 65 See full question 1m 4s A registered nurse is mentoring a new graduate nurse. Which action by the new graduate demonstrates a need for further teaching? You Selected:  Turns the defibrillator to synchronize before defibrillating a client with ventricular fibrillation. Correct response:  Turns the defibrillator to synchronize before defibrillating a client with ventricular fibrillation. Explanation: Add a Note Question 66 See full question 1m 5s Which of the following may occur with respiratory acidosis? You Selected:  Increased intracranial pressure (ICP) Correct response:  Increased intracranial pressure (ICP) Explanation: Remediation: Add a Note Question 67 See full question 1m 29s The nurse in a mental health clinic assesses an adolescent client for a suspected eating disorder. What question by the nurse will gather the most useful information for designing the treatment plan? You Selected:  "Do you ever eat to regulate your emotions?" Correct response:  "What do you think of your body?" Explanation: Remediation: Add a Note Question 68 See full question 18s The nurse is teaching two unlicensed assistive personnel who are new to the inpatient unit about caring for a client who is suicidal. The nurse determines that additional teaching is needed when which statement is made? You Selected:  "I need to check the client precisely at 15-minute intervals." Correct response:  "I need to check the client precisely at 15-minute intervals." Explanation: Remediation: Add a Note Question 69 See full question 18s A client with decreased urine output refractory to fluid challenges is evaluated for renal failure. Which condition may cause the intrinsic (intrarenal) form of acute renal failure? You Selected:  Nephrotoxic injury secondary to use of contrast media Correct response:  Nephrotoxic injury secondary to use of contrast media Explanation: Remediation: Add a Note Question 70 See full question 30s A client comes to the clinic for diagnostic allergy testing. The nurse understands that intradermal injections are used for such testing based on which principle? You Selected:  Intradermal drugs diffuse more slowly. Correct response:  Intradermal drugs diffuse more slowly. Explanation: Remediation: Add a Note Question 71 See full question 1m 10s When magnesium sulfate is administered to a client in labor, its action occurs at which site? You Selected:  neural-muscular junctions Correct response:  neural-muscular junctions Explanation: Remediation: Add a Note Question 72 See full question 19s