NURS404 HEALTHCARE
A client is receiving a continuous half strength tube feeding at 50ml/hour. To
prepare enough of the solution for eight hours, how many ml of full strength
feeding will the nurse need? (Enter numeric value only.) Correct answer-
200ml. 25 ml of full strength feeding mixed with 25ml of water provided
50ml of half strength. 25ml × 8 hours= 200ml
An elderly male client is experiencing urinary incontinence. What is the best
initial nursing action? Correct answer- Apply an external condom catheter
3. A male Muslim 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. What action should the nurse implement? Correct answer-
Reschedule administration of the antibiotic until after he completes his
prayers
UAP using a hand sanitizers that is alcohol for 2 minutes Correct answer- tell
that hand sanitizer use is less > 2min
5. A child is to receive vancomycin (Vancocin) 40 mg/kg IV one hour before a
scheduled procedure. The child weighs 44 pounds. How many mg of the
medication should the nurse administer correct answer- Answer: 800
Rationale: First, convert the child's weight to kg: 44 pounds divided by
2.2pound/kg = 20 kg. Next calculate the mg/kg/dose, 40 mg x 20 kg =
800mg
6. While assisting a postpartum client with perineal care, the nurse notes
that her vaginal bleeding spurts rather than trickles from the vagina. The
uterine fundus is firm and the client's vital signs are pulse 88 beats/minute;
respiratory rate, 21 breaths/minute; and blood pressure, 104/68 mmHg.
What action should the nurse take next? Correct answer- Compare current
vital signs with previous vital signs
A 6-year old boy was hit with a bat while playing at school. He has a splinter
of wood imbedded in his eye. Which action should the school nurse take?
Correct answer- Have the parent take the child for emergency help
Within four weeks of childbirth, a client is admitted to the hospital for
disorganized speech bizarre behavior, and strange thoughts about her infant
being possessed by demons. The nurse identifies a nursing diagnosis of
"Altered thought processes, secondary to" what condition? Correct answer-
Postpartum psychosis
,The nurse identifies a priority diagnosis of, "Altered comfort related to
menstrual cramps" for a 25-year-old female client. Which self-care activity
should the nurse emphasize in the client's teaching plan? Correct answer-
Regular aerobic exercise.
Psych/Alcohol/Tylenol overdose antidote Correct answer- Give Mucomyst
Medical Surgical/Laxative abuses Correct answer- Patient -taking Milk of
Magnesium
Spiritual/Documentation Correct answer- Native American - Allow pt's family
to stay in the room
Leadership- Interpreter informed consent Correct answer- Pt should sign the
consent
Geriatrics/Emergency Rib fractures fall Correct answer- Pulmonary embolism
A client diagnosed with major depression is being allowed a weekend pass
from the psychiatric unit. Which instruction should the nurse provide to the
client's family? Correct answer- Involve the client in usual at home activities
Upon assessment, the nurse discovers that a postpartum client has
persistent red lochia.
Which of the following does this assessment finding suggest to the nurse?
Correct answer- Coagulation disorders
The healthcare provider performs peritoneal dialysis on a client, after which
2 liters of fluid is drained. What action should the nurse complete first?
Correct answer- Assess vital signs.
After administering a medication through a nasogastric tube connected to
suction, what action should the nurse take first? Correct answer- Clamp the
tube
The nurse is caring for four clients: Client A 94% o2 saturation, Client B,
hemoglobin of 8.;
Client C, potassium level of 3.8 and Client D appendectomy who has a white
blood cell count of 15,000. What
should the nurse implement? Correct answer- Determine if Client B has two
units of packed cells available in the blood bank.
Triage question with a train wreck The psychiatric nurse is called to a train
derailment that was likely caused by a terrorist bomb. In triaging those in
need of immediate care, what is the priority ranking for these cases?
,(arrange these cases in order or priority with the top item requiring the most
immediate care and the bottom item requiring the least priority care) Correct
answer- A mother and father have just arrived on the .
A crying child being held by another passenger. A woman sitting on the
ground with a blanket.
A middle-aged man who is wandering around
(arrange in order) = middle age woman bleeding- woman w/ blanket- child
crying- mother and father. (Mine didn't have a middle age woman bleeding,
instead it had an old man wandering and Correct answer- correct order is:
wandering old man, woman w/blanket, man holding baby, and mother &
father)
The nurse in the emergency department is using the simple triage and rapid
transport (START) system to assess victims of a hurricane. Which statement
correctly describes a yellow disaster tag? Correct answer- A yellow disaster
tag means critical injuries and require immediate intervention.
What makes a baby frontal bulge or rises Correct answer- crying
Which of the following is a nursing intervention for a 3-year-old client who is
going in for sugery in 8 hours
that has an order for fluid restriction? Correct answer- Do not allow the child
to drink fluids
The ear, where do u pull to give a ear drop Correct answer- it a picture so
look it up online (KNOW CHILD & ADULT) (pull the pinnae top side of ear; u
can look at a picture to see exactly where pinnae is) (Mine had a picture of
ear and put it on the lobule of the pinnae it is the ear lobe). The eye picture
asked to find the macula or the fovea centralis (there are 2 prominent spots
on the eye - choose the DARK spot to the left not the spot where the light is)
Know your serum levels? Correct answer- K- 3.5-5.1,
Na - 135-145,
Ca 9-11,
BUN - 10-20
When to use drug for motion sickness drug question Correct answer- Take
Zofran 4 hours before going on trip via sea.
Pt with DM Correct answer- she states that she has to eat lunch rite after the
gets her insulin to prevent going to hypoglycemia
Electrical burn pt Correct answer- put him in a cardiac telemetry monitor
, Which discharge instruction has the greatest priority for the mother of a 6-
year-old who was diagnosed with
Type 1 diabetes mellitus one week ago? Correct answer- "Always carry a
quick source of sugar
A nurse working on a mental health unit where a diagnosis of bulimia
nervosa is being admitted. Which of the following symptoms would the nurse
most likely NOT expect to find with this client? Correct answer- severe over-
or under-weight
The charge nurse is developing the nursing guidelines for a coronary care
unit. Which references is likely to be the most useful in developing these
guidelines? Correct answer- The Scope of Standards of Practice from the
American Nurses Association
Which assessment finding indicates a client's readiness to leave the nursing
unit for a Bronchoscopy? Correct answer- On-call sedation administered.
A nurse-manager is preparing an annual budget for the unit. Nursing salaries
should be included in which component of the budget? Correct answer-
Operating budget
The nurse has not finished administering routine oral medication because on
e client experienced chest pain and another rectal bleeding. It is now dinner
time and two clients must be fed. The unlicensed assistive personnel (UAP) is
filling water pitchers and the practical nurse (PN) is charting vital signs.
Which change in assignments is best for the team leader to make? Correct
answer- UAP feed the two clients, PN finish oral medications and RN monitor
clients with chest pain and rectal bleeding
What is manntiol drug used for? Correct answer- To promote diuresis in
prevention and treatment of oliguric phase of renal failure, ICP, IOP, edema
in CHF.
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? Correct answer- Edema
A 40-year-old client with type 1 diabetes developed chronic kidney (CKD)
disease 6 months ago. Because of secondary complications often associated
with this illness the nurse plans to carefully assess for signs of what
condition? Correct answer- Anemia
A pt on a trachea/endotrach with gurgling sound Correct answer- always pick
suctioning
A client is receiving a continuous half strength tube feeding at 50ml/hour. To
prepare enough of the solution for eight hours, how many ml of full strength
feeding will the nurse need? (Enter numeric value only.) Correct answer-
200ml. 25 ml of full strength feeding mixed with 25ml of water provided
50ml of half strength. 25ml × 8 hours= 200ml
An elderly male client is experiencing urinary incontinence. What is the best
initial nursing action? Correct answer- Apply an external condom catheter
3. A male Muslim 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. What action should the nurse implement? Correct answer-
Reschedule administration of the antibiotic until after he completes his
prayers
UAP using a hand sanitizers that is alcohol for 2 minutes Correct answer- tell
that hand sanitizer use is less > 2min
5. A child is to receive vancomycin (Vancocin) 40 mg/kg IV one hour before a
scheduled procedure. The child weighs 44 pounds. How many mg of the
medication should the nurse administer correct answer- Answer: 800
Rationale: First, convert the child's weight to kg: 44 pounds divided by
2.2pound/kg = 20 kg. Next calculate the mg/kg/dose, 40 mg x 20 kg =
800mg
6. While assisting a postpartum client with perineal care, the nurse notes
that her vaginal bleeding spurts rather than trickles from the vagina. The
uterine fundus is firm and the client's vital signs are pulse 88 beats/minute;
respiratory rate, 21 breaths/minute; and blood pressure, 104/68 mmHg.
What action should the nurse take next? Correct answer- Compare current
vital signs with previous vital signs
A 6-year old boy was hit with a bat while playing at school. He has a splinter
of wood imbedded in his eye. Which action should the school nurse take?
Correct answer- Have the parent take the child for emergency help
Within four weeks of childbirth, a client is admitted to the hospital for
disorganized speech bizarre behavior, and strange thoughts about her infant
being possessed by demons. The nurse identifies a nursing diagnosis of
"Altered thought processes, secondary to" what condition? Correct answer-
Postpartum psychosis
,The nurse identifies a priority diagnosis of, "Altered comfort related to
menstrual cramps" for a 25-year-old female client. Which self-care activity
should the nurse emphasize in the client's teaching plan? Correct answer-
Regular aerobic exercise.
Psych/Alcohol/Tylenol overdose antidote Correct answer- Give Mucomyst
Medical Surgical/Laxative abuses Correct answer- Patient -taking Milk of
Magnesium
Spiritual/Documentation Correct answer- Native American - Allow pt's family
to stay in the room
Leadership- Interpreter informed consent Correct answer- Pt should sign the
consent
Geriatrics/Emergency Rib fractures fall Correct answer- Pulmonary embolism
A client diagnosed with major depression is being allowed a weekend pass
from the psychiatric unit. Which instruction should the nurse provide to the
client's family? Correct answer- Involve the client in usual at home activities
Upon assessment, the nurse discovers that a postpartum client has
persistent red lochia.
Which of the following does this assessment finding suggest to the nurse?
Correct answer- Coagulation disorders
The healthcare provider performs peritoneal dialysis on a client, after which
2 liters of fluid is drained. What action should the nurse complete first?
Correct answer- Assess vital signs.
After administering a medication through a nasogastric tube connected to
suction, what action should the nurse take first? Correct answer- Clamp the
tube
The nurse is caring for four clients: Client A 94% o2 saturation, Client B,
hemoglobin of 8.;
Client C, potassium level of 3.8 and Client D appendectomy who has a white
blood cell count of 15,000. What
should the nurse implement? Correct answer- Determine if Client B has two
units of packed cells available in the blood bank.
Triage question with a train wreck The psychiatric nurse is called to a train
derailment that was likely caused by a terrorist bomb. In triaging those in
need of immediate care, what is the priority ranking for these cases?
,(arrange these cases in order or priority with the top item requiring the most
immediate care and the bottom item requiring the least priority care) Correct
answer- A mother and father have just arrived on the .
A crying child being held by another passenger. A woman sitting on the
ground with a blanket.
A middle-aged man who is wandering around
(arrange in order) = middle age woman bleeding- woman w/ blanket- child
crying- mother and father. (Mine didn't have a middle age woman bleeding,
instead it had an old man wandering and Correct answer- correct order is:
wandering old man, woman w/blanket, man holding baby, and mother &
father)
The nurse in the emergency department is using the simple triage and rapid
transport (START) system to assess victims of a hurricane. Which statement
correctly describes a yellow disaster tag? Correct answer- A yellow disaster
tag means critical injuries and require immediate intervention.
What makes a baby frontal bulge or rises Correct answer- crying
Which of the following is a nursing intervention for a 3-year-old client who is
going in for sugery in 8 hours
that has an order for fluid restriction? Correct answer- Do not allow the child
to drink fluids
The ear, where do u pull to give a ear drop Correct answer- it a picture so
look it up online (KNOW CHILD & ADULT) (pull the pinnae top side of ear; u
can look at a picture to see exactly where pinnae is) (Mine had a picture of
ear and put it on the lobule of the pinnae it is the ear lobe). The eye picture
asked to find the macula or the fovea centralis (there are 2 prominent spots
on the eye - choose the DARK spot to the left not the spot where the light is)
Know your serum levels? Correct answer- K- 3.5-5.1,
Na - 135-145,
Ca 9-11,
BUN - 10-20
When to use drug for motion sickness drug question Correct answer- Take
Zofran 4 hours before going on trip via sea.
Pt with DM Correct answer- she states that she has to eat lunch rite after the
gets her insulin to prevent going to hypoglycemia
Electrical burn pt Correct answer- put him in a cardiac telemetry monitor
, Which discharge instruction has the greatest priority for the mother of a 6-
year-old who was diagnosed with
Type 1 diabetes mellitus one week ago? Correct answer- "Always carry a
quick source of sugar
A nurse working on a mental health unit where a diagnosis of bulimia
nervosa is being admitted. Which of the following symptoms would the nurse
most likely NOT expect to find with this client? Correct answer- severe over-
or under-weight
The charge nurse is developing the nursing guidelines for a coronary care
unit. Which references is likely to be the most useful in developing these
guidelines? Correct answer- The Scope of Standards of Practice from the
American Nurses Association
Which assessment finding indicates a client's readiness to leave the nursing
unit for a Bronchoscopy? Correct answer- On-call sedation administered.
A nurse-manager is preparing an annual budget for the unit. Nursing salaries
should be included in which component of the budget? Correct answer-
Operating budget
The nurse has not finished administering routine oral medication because on
e client experienced chest pain and another rectal bleeding. It is now dinner
time and two clients must be fed. The unlicensed assistive personnel (UAP) is
filling water pitchers and the practical nurse (PN) is charting vital signs.
Which change in assignments is best for the team leader to make? Correct
answer- UAP feed the two clients, PN finish oral medications and RN monitor
clients with chest pain and rectal bleeding
What is manntiol drug used for? Correct answer- To promote diuresis in
prevention and treatment of oliguric phase of renal failure, ICP, IOP, edema
in CHF.
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? Correct answer- Edema
A 40-year-old client with type 1 diabetes developed chronic kidney (CKD)
disease 6 months ago. Because of secondary complications often associated
with this illness the nurse plans to carefully assess for signs of what
condition? Correct answer- Anemia
A pt on a trachea/endotrach with gurgling sound Correct answer- always pick
suctioning
