NSG 321 V2 EXAM QUESTIONS AND ANSWERS

NSG 321 V2 EXAM QUESTIONS AND ANSWERS 1. A male client with Type 1 diabetes mellitus takes a combination of short-acting and intermediate-acting insulin drugs. The client complains of headaches when awakening and his blood glucose average for the past week has been 210 mg/dl. The nurse recognizes the client is experiencing a daily Somogyi, or rebound, effect. Which dosing method is likely to relieve these symptoms? A. Move the PM intermediate-acting dose to bedtime. 2. When obtaining a throat culture from a 6-year-old with possible streptococcal infection, which action is most important for the nurse to implement? A. Swab the child’s erythematous oropharyngeal surfaces or tonsilar pustules. 3. The nurse is caring for a 42-year-old male client who is excreting less sodium than he is consuming. If this condition continues, what complication can the nurse expect this client to exhibit? A. Edema. 4. Which condition would likely cause secondary polycythemia? A. High altitude exposure. 5. An infant is treated for intussusception with hydrostatic reduction. What instruction should the nurse include in the parents’ teaching plan? A. Signs and symptoms of recurrence. 6. A client with type 1 diabetes mellitus is prescribed 10 units of intermediate acting insulin to be administered at bedtime. For which health problem is the insulin being administered at this time of day? A. Dawn phenomenon. 7. The nurse is obtaining a throat culture of a client’s posterior oropharyngeal region. For which health problem will this specimen be used to diagnose? A.Strep throat. 8. A middle-aged male client is being evaluated for lower extremity edema. Which laboratory value will be used to aid in determining the cause of this client’s manifestation? A. Serum sodium. 9. A client is diagnosed with secondary polycythemia. Which health condition contributed to the development of this secondary problem? A. Hypovolemia. 10. A client in the oliguric phase of acute renal failure (ARF) has a 24 hour urine output of 400ml. nurse should allow this client to have how much oral intake during the next 24 hours? A. Limit oral intake to 900 to 1000 ml 11. A female client on the mental health unit tells the nurse that her roommate is sitting on the bathroom floor with superficial cuts on her wrists. The nurse cleans and assesses the client’s wrists and asks her what happened. She doesn’t respond. Next? A. Take the client to a room for supervision by staff 12. What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)? A. Inspection of the mouth 13. The nurse is preparing to administer an IM dose of Vitamin B1 (thiamine) to a male client experiencing acute alcohol withdrawal and peripheral neuritis. The client belligerently states, “what do you think you’re doing?” Response? A. “this shot will help relieve the pain in your feet” 14. When administering an intramuscular injection containing 3 ml of a painful medication, Intervention? A. Select a large, deep muscle mass 15. Nurses working in L & D are demanding a change in policy because they believe they are required to float more often than nurses on other units. However, floating to L & D is not reciprocated because other nurses are not competent to provide highly specialized obstetrical skills. Action? A. Propose a method for self-staffing labor and delivery 16. Locate the optic disk A. It is the really light area on the right 17. When completing a mental health assessment, the nurse wishes to obtain information about a client’s insight and judgment. Which interview technique is most useful in assessing these mental abilities A. have the client describe what should be done if a child was observed alone in a locked car on a hot day 18. An adult Muslim client with ulcerative colitis was admitted to the post-surgical unit earlier today following a bowel resection with temporary colostomy. Which intervention is most important for the nurse to implement A. assign a care provider of the same gender 19. The parents of a 6-year-old recently diagnosed with Duchene muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond A. encourage the parents to allow the child to continue attending swimming lessons with supervision 20. The nurse initiates a one-to-one relationship with a 35-year-old depressed female client who was recently admitted to the psychiatric facility. Which nursing action is most effective in promoting the development of a therapeutic relationship A. ensure that scheduled appointments begin according to the schedule 21. An 18-year-old female client is admitted to the unit after ingesting an overdose of Phenobarbital (Luminal). She is unresponsive and ABG results are: pH 7.18, PaCO2 60 mmHg, and HCO3 26 mEq/L. Which interpretation of the client’s ABG results by the nurse is accurate A. Respiratory acidosis, uncompensated 22. A male client with multiple myeloma is admitted with pneumonia and pancytopenia. The nurse reviews the complete blood cell count findings and identifies a platelet count of 20,000 cells/mm3. Which intervention should the nurse include in the client’s plan of care A. Avoid intramuscular injections 23. The nurse is planning care for a 48-year-old client, diagnosed with schizophrenia at age 25, who has been taking antipsychotic drugs since diagnosis. Long-term use of these drugs is associated with which side effect? A. Tardive dyskinesia. 24. What instruction is most important for the nurse to provide a client with neutropenia? A. Avoid sources of potential infection. 25. A client with acute laryngitis reports feeling “short of breath”. The nurse assesses that the client’s respiratory rate has increased from 16/minute to 28/minute. What intervention should the nurse implement? A. Assess the client for stridor and increased respiratory effort. 26. When caring for a client who had a craniotomy yesterday for removal of a pituitary tumor, which finding indicates to the nurse that further information is needed? A. Urine output for 8 hours is 2,000 ml with a specific gravity of 1.001. 27. The nurse is working with an interdisciplinary group to write procedures for assessment of clients from a multiracial inner city population. The guidelines include a statement that reads, “Remember that all Hispanic clients may not wish to give personal medical information to a stranger.” Which action should the nurse take? A. Recommend changing the language that stereotypes one ethnic group. 28. A 6-month-old client is diagnosed with intussusception. For which medical intervention will the nurse prepare this client? A. An enema. 29. The nurse is reviewing the medication history of a client who is demonstrating tardive dyskinesia. Which medication classification will the nurse focus on during this review? A. Antipsychotics. 30. A client receiving chemotherapy as part of cancer treatment has developed an upper respiratory infection. The nurse realizes the cause of this infection may be due to: Low white blood cell count. 31. The nurse has explained safety precautions and infant care to a primigravida mother and observes the mother as she gives care to her newborn during the first two days of rooming-in. which action indicates the mother understands instructions? A. Positions the infant supine in the crib to sleep 32. HCP prescribes amoxicillin (Amoxil) 1.5 grams PO daily, in equally divided doses to be administered every 8 hours. The medication is available in a bottle labeled, “Amoxicillin (Amoxil) suspension 200mg/5ml.” How many ml should nurse administer every 8 hours? A. 12.5 33. 20 year old female client tells nurse her menstrual periods occur about every 28 days, and her breasts are quite tender when her flow is heavy. She also states that she performs her breast self-exam on the first day of every month. Action? A. Encourage the client to perform BSE 2-3 days after her menstrual period ends 34. The nurse is planning care for an assigned group of clients in a small nurse care facility, which client should the nurse see first? A. An older client with Addison’s disease and 20 mmHg decline in systolic pressure. 35. Which self-care measure is most important for the clinic nurse to emphasize when teaching a client who was recently diagnosed with osteoporosis A. Inspect your home for safety hazards 36. A mother brings her 4 month old son to the clinic with a quarter taped over his umbilicus and tells the nurse the quarter is supposed to fix her child’s hernia. Which explanation should the nurse provide? A. The hernia is normal variation that resolves without treatment 37. The nurse begins an oral medication prescription to be given daily to a male client who tells the nurse that he will take his medication later. What action should the nurse implement? A. Agree upon the time to return to the client’s room with the medication 38. Following a left above the knee amputation, the client voiced several complaints. What statement should serve as a warning to the nurse that the client may be experiencing complications? A. I’ve been feeling light headed 39. A child is brought to the clinic complaining of fever and joint pain and is diagnosed with rheumatic fever. When planning care for this child what is the primary goal of nursing care? A. Reduce fever 40. In caring for a 9 month old child following surgical correction of a clubfoot. Which intervention should the nurse implement to determine the child’s need for analgesic administration??? A. Observe feeding and sleeping pattern 41. As a means of relieving a client’s pain associated with osteoarthritis, the nurse plans to provide local rest. To implement this intervention, which action should the nurse take A. Immobilize the affected joint with a splint 42. The healthcare provider prescribes isosorbibide (Isordil) 40 mg every 8 hours for a male client with acute angina pectoris. Which finding should the nurse report to the healthcare provider prior to administering Isordil A. Currently, takes sildenafil (Viagra) 43. A client is admitted with syncopal episodes related to a third degree heart block. After the placement of a transcutaneous pacemaker, the nurse observes several episodes of the pacemaker’s failure to sense. What action should the nurse take A. Increase the sensitivity 44. A 60-year-old male client with cancer of the liver has been in a hepatic coma for the past 24 hours. On admission, the client signed a release of information to his family. His oldest son arrives from out of town and asks the nurse how his father is doing. Which response is best for the nurse to provide A. “Your father has given no response for 24 hours. His condition is extremely critical at this time” 45. The nurse is preparing a client for a scheduled cesarean section. In what order should the nurse perform these actions (place the first action on top and the last action on the bottom) A. Verifying the consent form is signed Inserting an indwelling catheter Prepping the site with iodophor (Betadine) Performing a time-out procedure 46. What nursing action has the highest priority in preventing postoperative bleeding following a submucosal resection for a deviated septum? A. Maintain intact nasal packing. 47. A female client chooses to have a prophylactic mastectomy because she has a positive BRCA1 mutation, her mother died of breast cancer at age 30, and her cousin was diagnosed with breast cancer at age 28. Which intervention is most critical for the nurse to include in this client’s immediate postoperative plan of care? A. Ensure adequate pain control using postoperative analgesics. 48. The industrial health nurse who works in a mobile clinic is developing an exposure control plan for blood-borne pathogens. Which topics should be included in this plan? (Select all that apply.) A. Puncture-resistant containers for needle disposal. Hepatitis B vaccination series. Self-sheathing or needleless medication systems. 49. The nurse is conducting a physical examination of a client with acute laryngitis. Which finding indicates the client’s health status is deteriorating? A. Respiratory rate 26 per minute. 50. A client recovering from surgery to remove a pituitary tumor has an 8- hour urine output of 1500 mL and a specific gravity of 1.001. This finding is consistent with which complication from the surgery? A. Diabetes insipidus. 51. The nurse is reviewing content created for an educational session on cultural diversity when providing client care. Which statement would the nurse question as not being culturally sensitive? A. “All Hispanic clients do not provide personal information to strangers.” 52. A male client awaiting surgery tells the nurse that he has some concerns about the surgical procedure that were never addressed. Which nursing intervention reflects the nurse’s role as a client advocate? A. Notify the surgeon of the client’s concerns. 53. A 2 year old boy who has short bowel syndrome has progressed to receiving enteral feedings only. Today his stools are occurring more frequently and have a more liquid consistency. His temp is 102.2 and he has vomited twice in the past 4 hrs. Which assessment finding indicates that the child is dehydrated? A. Elevated urine specific gravity 54. One hour after delivery the nurse is unable to palpate the uterine fundus of the client and notes a large amount of lochia on the perineal pad. Intervention? A. Perform gentle message at the level of the umbilicus 55. A client with a small bowel obstruction is experiencing frequent vomiting. Which instructions are most important for the nurse to provide to the UAP who is completing morning care for this client? A. Measures all emesis accurately 56. The nurse is teaching a class on child care to new parents. Which instruction should be included about the prevention of rotavirus in infants who are starting to eat foods? A. Wash hands before any food preparation 57. An 18 year old gravid 1, at 41 weeks gestation, is undergoing an oxytocin (Pitocin) induction and has an epidural catheter in place for pain control. With each of the last three contractions, the nurse notes a late deceleration. The client is repositioned and oxygen provided, but the late decelerations continue to occur with each contraction. Action? A. Turn off the oxytocin (Pitocin) infusion 58. In preparing to administer a scheduled dose of intravenous furosemide (Lasix) to a client with heart failure, the nurse notes that the client’s B-type Naturetic peptide (BNP) is elevated. Action? A. Administer the dose of furosemide as scheduled 59. When obtaining a urine specimen from a female infant, which intervention should the nurse implement? A. Secure the pediatric urine collector bag to the true perineum 60. When the charge nurse presents a change in unit procedure to the nursing staff. One of the nurses states “it’s never going to work” Which response by the charge nurse is likely to be most effective. A. Why don’t we try the solution and see if it works 61. MATH Q The healthcare provider prescribes 250mg/hr of magnesium sulfate. The pharmacy delivers 500 ml IV that contains 4 grams of the drug. The nurse should set the IV infusion pump to deliver how many ml per hour. Round to the nearest whole number if needed. A. 16 ml/hr 62. An 8 year old child weighs 60 lbs receives 25mg/kg/day every 8 hrs. The medication is labeled 125mg/5ml. How many ml should the nurse administer? A. Take the 60lbs and divide by 2.2 then multiply that by 25mg then divide by 3 because that is 3 doses per day at 8hr each then take that ordered dose and divide by the available 125mg and multiply by 5ml 63. While assessing the nasogastric tube drainage, the nurse discovers rust colored flecks, which action should the nurse take? A. Manually aspirate the gastric secretions 64. A client receives a prescription for bacitracin 20,000 units every 12 hours IM. The medication is available in a vial that contains 50,000 units and includes reconstitution instructions: “Use 4.8 ml diluent to yield a total volume of 5 ml.” how many ml should the nurse administer A. 2 65. The nurse identifies which recent event as placing a client at high risk for cardiogenic shock A. Myocardial infarction in the right ventricle 66. The unit manager of an acute care unit evaluates the time management skills of the nursing staff and determines that one staff nurse is consistently behind in meeting the needs of assigned clients. What action should the unit manager take A. Schedule a private meeting with the staff nurse as soon as possible 67. The nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client A. Urinate at a specified time, discard this urine, and collect all subsequent urine during the next 24 hours 68. Which assessment finding has the highest priority when planning nursing care for a client with peptic ulcer disease (PUD) A. Dark tarry liquid stools 69. The nurse is obtaining a blood sample via venipuncture from a preschool-aged child. Which intervention should the nurse implement A. Apply a large colored band-aid to the puncture site 70. A 3-year-old boy is brought to the emergency department after the mother found the child in the back yard holding a piece of a toy in his hand and in respiratory distress. The child is dusky with a loud, inspiratory stridor and weak attempts to cough. Which actions should the nurse implement A. Auscultate all pulmonary lung fields and attempt a Heimlich maneuver 71. The nurse plans to obtain a urine specimen for culture from a client’s indwelling catheter. The nurse enters the room with the syringe and notes there is 100ml of urine in the drainage bag, but no urine is in the tubing. What action should the nurse take A. Clamp the tubing until urine is observed in the tubing 72. The scrub nurse places the fenestrated drapes to expose the operative area for a client who is having a hepatic tumor removed. The scrub nurse should assist with applying the sterile impermeable adhesive drape or surgical skin barrier to which area A. Right subcostal 73. An elderly client is experiencing disturbed sleep patterns. Which intervention should the nurse implement to help the client attain maximal sleep function Assess daytime somnolence A. Review medication side effect profiles 74. A 58-year-old male client with chronic kidney disease (CKD) is receiving aluminum hydroxide (Amphojel). He tells the nurse that since he does not have indigestion there is no need for him to take the antacid with his meals. Which response is best for the nurse to provide A. “Your serum phosphate levels are up, and aluminum antacids prevent absorption of phosphates in foods” 75. A client slips and falls while getting out of bed and the charge nurse instructs the nurse who is caring for the client to complete an incident report. What is the main purpose in having the nurse complete the incident report A. To provide computer documentation of the incident as a basis for further investigation 76. A client with pneumonia is admitted with severe shortness of breath and arterial blood gases of pH 7.30, PaO2 60 mm Hg, PaCO2 62 mm Hg, HCO2 35 mEq/liter. Which information should the nurse communicate immediately to the healthcare provider? A. Drowsiness and difficulty in arousing. 77. The nurse is teaching a primigravida, who describes herself as a lacto-vegetarian, about nutrition during pregnancy. Which foods should the nurse encourage this client to include in her diet? A. Cheese, green salads, and fruit. 78. In evaluating the effectiveness of a client’s nocturnal sleep patterns, what information is best for the nurse to obtain? A. Self-evaluation of feeling well rested upon awakening. 79. Four clients present to the Labor and Delivery unit at the same time. The nurse should assess the client with which complaint first? A. Abdominal pain and bright red bleeding. 80. The nurse is conducting discharge teaching about the antianxiety drug diazepam (Valium). Which instruction has the highest priority for inclusion in the teaching plan? A. Evaluate the ingredients of all over-the-counter drugs for alcohol content. 81. A client with an electrical burn on the forearm asks the nurse why there is no feeling of pain from the burn. During dressing change, the nurse determines that the burn is dry, waxy, and white. What information should the nurse provide this client? A. The full thickness burn has destroyed the nerves 82. A 14 yr old girl with asthma complains of feeling nervous and jittery after a respiratory therapy bronchodilator treatment. What explanation is best for the nurse to provide to this adolescent? A. A fast heart rate and jitteriness are side effects of the bronchodilator treatment containing albuterol 83. A client with type 2 DM is admitted for antibiotic treatment of a leg ulcer. Which signs and symptoms, indicative of hyperosmolar hyperglycemic nonketonic syndrome (HHNS), should the nurse report to the HCP? A. Visual disturbances Increased heart rate Decreased mentation 84. A male client sustained a burn injury to more than 25% of this total body area in an industrial fire. Which nursing intervention is most essential to be implemented during the emergency phase? A. Infuse intravenous fluids as prescribed 85. A male client with chronic kidney disease is involved in a motor vehicle collision and is brought to the emergency department with a rapidly hemorrhaging leg fracture. The healthcare provider inserts a central venous catheter (CVC). To promote rapid volume expansion, which equipment should the nurse obtain? A. Lactated ringers 86. To identify a client’s learning needs prior to surgery, what action should the nurse implement? A. Demonstrate cough and deep breathing techniques 87. An older female is admitted for a 24 hour observation after suffering several broken ribs as a result of a fall in her home. Which finding should the nurse report to the healthcare provider immediately? A. widening pulse pressure with an increase in pulse rate 88. A mist tent and intravenous fluids are prescribed to a 6 month old with respiratory syncytial virus (RSV) is a virus that causes respiratory tract infections. It is a major cause of lower respiratory tract infections and hospital visits during infancy and childhood. When the parent inquire why there child is not receiving antibiotics. A. Antibiotics are not effective treatments for viral illnesses such as RSV infection 89. A client with a history of recurrent atrial fibrillation is taking amiodarone (cordarone) and warfarin (Coumadin). Which meal should the nurse provide for the client? A. Seared tuna steak and stewed squash 90. Nurse is preparing to transfer a client who I receiving a primary infusion of normal saline and a secondary infusion of an antibiotic??? Peak and trough levels need to be obtained after transfer. What information is most important for receiving when the client arrives? A. Completion time of the secondary infusion 91. The registered nurse (RN) is observing a newly hired practical nurse (PN) give a newborn a vitamin K (AquaMEPHYTON) injection. The PN uses a filter needle to draw 0.25 mg of AquaMEPHYTON into the syringe, cleanses the thigh with alcohol in a circular motion, and prepares to inject the needle at a 90 degree angle in the left vastus lateralis. What action should the RN take A. Direct the PN to change the filter needle to a ½ inch needle 92. At bedtime, an unlicensed assistive personnel (UAP) is positioning a client with obstructive sleep apnea syndrome (OSAS). The UAP elevates the head of the bed and encourages the client to turn on side. In supervising the UAP, what action should the nurse take A. Confirm that the UAP has placed the call bell within reach of the client 93. Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye. What action should the nurse take A. Report the complaint of eye pain to the surgeon 94. An elderly male client tells the nurse that he often wakes up during the night. What action should the nurse implement first A. Ask the client to describe what happens when he awakens 95. During assessment of a 2-month-old infant, the nurse notices a bluish-black discoloration over the lumbosacral area. Which action should the nurse take A. Document the findings in the record 96. Dinoprostone (Prostin E-2) is prescribed for primigravada who had a missed spontaneous abortion. An increase in which finding should the nurse expect A. Contractions of the uterus 97. Which client should the charge nurse on the oncology unit assign to an RN, rather than a practical nurse (PN) A. An elderly female client with cancer and her children who are trying to decide whether to change to palliative care measures or continue disease control 98. A client taking tamoxifen citrate following a lumpectomy reports several problems to the nurse. It is most important for the nurse to follow-up on which reported problem A. Calf tenderness 99. During morning rounds, the nurse finds a client who has no spontaneous respirations and does not respond to shaking. The nurse activates the “Code-Blue” system. While waiting for the code team to arrive, what action should the nurse implement A. Check the pulse for 10 seconds and begin chest compressions 100. The nurse learns that a client in a semi-private room has a postoperative wound that is colonized with a multi-drug resistant organism. What action should the nurse implement A. Move the client to a private room and implement contact precautions for the client 101. A male Muslin client with pneumonia is scheduled to receive a dose of an intravenous antibiotic but refuses to allow the nurse to begin the medication, stating he cannot allow fluids to enter his body once he is cleansed for prayer. Which action should the nurse implement? A. Reschedule administration of the antibiotic until after he completes his prayers. 102. After administering a medication through a nasogastric tube connected to suction, what action should the nurse take first? A. Re-connect the tube to the suction. 103. Which of these women, all of whom have recently discovered a new breast lump, is at greatest risk for a diagnosis of breast cancer? A. A 51-year-old whose mother had breast cancer and describes the lump as nontender. 104. Which client situation requires the most immediate intervention by the nurse? A. A four-centimeter area of dehiscence is observed on a client’s abdominal incision one day after surgery. 105. On admission, the healthcare provider prescribes a broad-spectrum antibiotic, ticarcillin (Ticar), for a client with a gram-negative infection. Before administering the first dose, it is important for the nurse to implement which prescription? A. Wound and blood specimens for culture and sensitivity. 106. The nurse observes that a client receiving an aminoglycoside for an infection appears dizzy when ambulating. The nurse should consult with the healthcare provider regarding the need for which test? A. Peak and trough. 107. The nurse is administering a continuous IV infusion of dopamine (Intropin) to a client. Which assessment finding indicates that the therapeutic effect has been achieved? A. Increased blood pressure. 108. A client who is being prepared for discharge following a transurethral resection of the prostate (TURP) tells the nurse that he is concerned about becoming constipated. Which instruction should the nurse provide to this client? A. Use oral stool softeners daily. 109. A 3-year-old child visits the clinic with both parents for a well-child check-up. The nurse auscultates bronchovesicular breath sounds in the peripheral lung fields and assesses the child’s respiratory rate of 28 breaths/minute. Which interpretation of this finding is accurate? A. An expected finding. 110. The nurse is providing preoperative teaching to a female client scheduled for surgery tomorrow at an ambulatory surgery center. Which instruction is most important for the nurse to include? A. Advise the client to make arrangements for someone to drive her home. 111. The nurse is caring for a client recovering from a submucosal resection for a deviated nasal septum. What will the nurse explain to the client as the reason for nasal packing? A. Prevent postoperative bleeding. 112. The nurse is preparing discharge instructions for a client recovering from a mastectomy. What will the nurse include to ensure maximum functioning of the client’s upper extremities after the surgery A. Review post-mastectomy arm exercises as prescribed 113. A client is admitted to the emergency room because of an overdose of acetaminophen (Tylenol). Following gastric lavage, the nurse should expect to administer which medication? A. Acetylcysteine (Mucomyst). 114. The nurse is attempting to teach a male client newly diagnosed with diabetes how to administer insulin. When the nurse attempts to answer the client’s questions he becomes angry and tells the nurse that the entire process is just too much to learn. What action is best for the nurse to take? A. Acknowledge the client’s feelings, and tell him that he will eventually be able to do self-administration. 115. The nurse plans to administer an IV heparin bolus of 80 units/kg to a client who weighs 210 pounds. How many units should the nurse administer? A. 7636 116. 40 wks gestation admitted in active labor, labs indicate HIV positive. Action? A. Notify the pediatrician that the mother is HIV positive 117. Toddler with hemophilia discharged from hosp. What teaching? A. Place padding on the corners of all furniture 118. Nurse is preparing a male client for a bilateral adrenalectomy. Which info in preop teaching? A. Replacement therapy with corticosteroids will be needed for the rest of his life 119. Nurse with a history of drug impairment returns from rehab, best initial action by charge nurse? A. Establish a contract with the nurse about role limitations 120. A client is being treated for minor injuries following an automobile accident in which the only other passenger was killed. The client asks the nurse, “Is my friend who was in the car with me ok?” What response is best? A. “I am sorry, but your friend was killed in the accident” 121. To differentiate adventitious lung sounds associated with heart failure from those associated with bacterial pneumonia, what information should the nurse review? A. Sputum culture findings 122. A premature infant weighing 1,200 grams at birth receives a prescription for beractant (Survanta) 120mg endotracheal now and q6 hours for 24 hours. The recommended dose for beractant is 100 mg/kg birth weight per dose. Single use vials of Survanta are labeled, 100 mg/4ml. What action should the nurse take? A. Give 4.8ml q6 hours 123. The nurse is planning care for a family whose children did not receive childhood immunizations. After one of the children contracted mumps, the father is diagnosed with orchitis. Which intervention should be included in the father’s plan of care? . A. Use of bedrest with scrotal support 124. The medical record of a child with Duchenne muscular dystrophy (MD) states that a Gower sign is present. Based on this documentation, the nurse should expect the child to exhibit which behavior? A. Stands from sitting on the floor by using hands to walk up legs 125. The nurse observes that a client who is to avoid any weight-bearing on the left leg is using a 3-point crutch gait for ambulation. What is the best action? A. Encourage use of the 3-point gait by the client 126. The nurse knows the client with a mechanical valve replacement understands the discharge teaching when the client makes which statement? A. “I will need to take antibiotics before any type of invasive dental work” 127. The nurse is caring for six clients on a medical-surgical unit. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP) A. Record vital signs every four hours Assist with ambulation as prescribed Provide oral care after meals 128. An emergency department nurse is giving discharge instructions to the wife of a young adult male client who sustained a concussion after a fall. The nurse should provide the wife with what instruction as part of the discharge teaching plan Tell the wife to bring her husband back to the emergency department if he has projectile vomiting or an A. unsteady gait 129. In monitoring a client receiving propylthiouracil (PTU) for hyperthyroidism, an increase in which finding indicates that the medication is producing the desired effect A. Body weight 130. The nurse is investigating a client injury that occurred when a mechanical lift malfunctioned while moving a client from the bed to an orthopedic-chair. Which question should the nurse ask first A. Was the equipment used according to policy 131. Which menu selection by a male client indicates to the nurse that he understands the dietary management of Crohn’s disease A. Grilled chicken sandwich and pasta 132. An unlicensed assistive personnel (UAP) is teamed with a nurse who is caring for four clients. Client A is admitted to the medical unit for heart failure (HF). Client B has just returned from surgery. Client C, with chronic obstructive pulmonary disease (COPD), needs new oxygen tubing. Client D is waiting to be discharged. Which activity should the nurse delegate to the UAP as having the highest priority A. Take vital signs of the client who has just returned from surgery 133. A client with pneumonia is demonstrating progressive drowsiness and difficulty arousing. Which diagnostic test would be the priority when planning care for this client? A. Arterial blood gases. 134. The nurse is concerned that a client who is 12 weeks pregnant is not ingesting an adequate amount of protein while adhering to a lactovegetarian diet. What can the nurse recommend to this client? D. Use brown rice with legumes as a main course several times a week. 135. A school age client is brought into the emergency department after being rescued from a house fire. The client has singed nasal hairs and is coughing. Which action has the highest priority for this client’s care? A. Ensure an adequate airway is present. 136. The nurse is auscultating a client’s heart sounds. Which description should the nurse use to document this sound (listen to the audio file to select the option that applies) A. S1, S2, S3 137. A mother reports to the nurse that the thick-honey-colored crusts on her child’s legs began as flat red spots. This is highly indicative of what condition A. Impetigo 138. A young woman is preparing to leave for a 7-day boat trip. She requests a prescription for motion sickness so the healthcare provider prescribes meclizine (Antivert). Which instruction should the nurse include in this client’s teaching A. Suck on hard candy for a dry mouth while taking this drug 139. A female client who has been taking diclofenac (Zipsor) for the past month is admitted with right upper quadrant tenderness, jaundice, and flu-like symptoms. She is also complaining of fatigue, diarrhea, and pruritis. Which intervention is most important to include in this client’s plan of care? A. Monitor serum bilirubin levels 140. What intervention should the nurse implement to prevent edema and promote healing of a client’s incision resulting from an above-the-knee amputation A. Maintain the residual limb in a compression dressing 141. A relative comes into the Emergency Department asking for information about a female adult client who was admitted in stable condition following a motor vehicle collision. What action should the triage nurse take A. Ask the client if she would like to talk with the relative, and then bring the relative to the bedside 142. The nurse observes and unlicensed assistive personnel (UAP) applying an alcohol-based hand rub while leaving a client’s room after taking vital signs. What action should the nurse take A. Remind the UAP to continue rubbing the hands together until they dry 143. The nurse administers the opioid antagonist naloxone HCI (Narcan) to a young adult client who overdosed on hydromorphone (Dilaudid). Which assessment data indicates that the naloxone is effective A. Respirations increase from 8/minute to 12/minute 144. Nurse observes client standing with use of crutches and notes that arms are fully extended and tops of crutches are securely pressed into axillae. What intervention? A. Reduce the length of the crutches 145. Parents of a child with CF ask about their chances of having another CF child? A. There is a 1-4 chance that any child of heterozygous parents will be affected 146. 12 yr old male diagnosed with idiopathic hypopituitarism based on plasma growth hormone studies. Sub-Q injection of the hormone somatotropin (HGH), are Rx TID. When to promote the most natural physiological release? A. Before going to sleep at night 147. Planning care for a group of pts on a med unit; which task delegate to UAP? A. Use a mechanical lift to transfer a client to the chair 148. To administer saline enema, nurse inserts the enema tubing 3 inches into rectum, elevates saline container 6 inches above body. After nurse opens clamp, saline does not infuse. What action? A. Raise the saline container 6 more inches above the body 149. Client receiving chemo for lung CA with brain Metastasis scheduled for cranial radiation therapy today. Provide what info? A. Skin markings and head positioning devices are used to ensure that only the tumor site is radiated 150. Inserting an indwelling catheter for female and notes catheter in vagina. Steps? A. Leave in vagina Obtain new catheter kit Use forceps and cotton ball to cleanse Insert the catheter and observe for flow Inflate the indwelling balloon Remove the wrongly placed one 151. Assessing both lower extremities with chronic venous insufficiency; identifies bilateral stasis dermatitis and an ulcer n the medial surface of left ankle. To promote effective self-care what teaching? A. Apply compression stockings before ambulation 152. A 70-year old client is admitted to the hospital after 24 hours of acute diarrhea. To determine fluid status, which initial data is most important for the nurse to obtain? A. Usual and current weight 153. A client with a BMI of 60.2 kg/m2 is admitted to the intensive care unit 3 weeks after gastric bypass with gastric rupture and impending multiple organ dysfunction syndrome (MODS). What should the nurse prepare to implement first? A. Mechanical ventilation 154. After implementing a new fall prevention protocol on the nursing unit, which action by the nurse-manager best evaluates the protocol’s effectiveness? A. Compare the number of falls that occurred before and after protocol implementation 155. A client with endometrial carcinoma is receiving bradytherapy and has radioactive Cesium loaded in a vaginal applicator. Action? A. Wear a dosimeter film badge when in the client’s room 156. A client has a history of vasovagal attacks resulting in brady-dysrhythmias. Which instruction is most important to include in the teaching plan? A. Use stool softeners regularly 157. Which action should the nurse implement when assessing a client’s blood pressure and determining that there is an auscultatory gap? A.Compare the palpated systolic blood pressure with the auscultated pressure 158. A 14 year old male client with a spinal cord injury (SCI) at T-10 is admitted for rehabilitation. During the morning assessment, the nurse determines that the adolescent’s face is flushed, his forehead is sweating, his heart rate us 54 beats/min, and his blood pressure is 198/118. What action? A. Determine if the urinary bladder is distended 159. The mother of a teenager is told that her son has recently been found stealing from other students at school. The mother’s response is, “I cannot think about that today.” The nurse determines that this mother is using what defense mechanism? A. Suppression 160. A 10 month old girl is admitted with a diagnosis of possible cystic fibrosis. What question should the nurse ask the parents about their child to assist in the diagnosis of CF? A. “when you kiss her, does she taste salty?”