Answers
2 hrs post-op following an ileal conduit procedure bladder cancer Correct Ans
- Dusky-colored stoma
Administering an INJ to a client even after the client states, "I don't want that
injection. The last time I got that I was sore for a week." Correct Ans -
Battery
Admitting a client to the medical-surgical unit. Which of the following actions should
the nurse first take? Correct Ans - Observe the client's level of mobility
Adolescent client who has no previous history of a seizure disorder and is admitted
after having a 3-min tonic-clonic seizure 2 wks after sustaining a mild concussion.
EEG Correct Ans - Explain that the client may not have coffee prior to the
EEG
Adolescent who has cystic fibrosis and has a prescription for pancrelipase
Correct Ans - Take w/ meals
After evaluating the morning lab results on several clients, the provider writes
prescriptions for 4 clients assigned to the nurses care? Correct Ans - Infuse
10 meQ/l potassium chloride IV over 1 hr to a client who has potassium of 3.2
After making morning round, the charge nurse on a surgical unit delegates the
follow tasks to the AP. Correct Ans - Set up a room for an expected
postoperative admission
AP reports to the nurse that another ap has spent the entire morning on the phone
and has not completed the morning assignment Correct Ans - Redirect the
AP to discuss the issue with the other AP
Assessing client who systemic lupus erythematous SLE which of the following is an
expected findings Correct Ans - Dry, raised facial rash
At the start of an evening shift on a cardiac unit, a LPN brings the nurse a list of
client reports Correct Ans - Indigestion
Benefit from a three-way indwelling catheter Correct Ans - Prone to
development of blood clots un the urine
Caring for a client who has a new prescription for chlorpromazine by IM injection
Correct Ans - Check orthostatic BP 1 hr after admin
Caring for a client who was involved in a motor-vehicle crash. The client reports
shortness of breath and chest pain and asks the nurse "Am I dying?" Correct
Ans - Admin pain meds
, Charge nurse creating assignments for next shift for several nurses and one of the
nurses is pregnant - which pt the nurse should NOT be assigned to? Correct
Ans - 60 yr old who is recovering from shingles
Charge nurse on pediatric unit is making assignments for a float nurse from the
medical unit. Pt to see first? Correct Ans - 10 yr old who has pneumonia & is
receiving respiratory txs
Child who has pediculosis capitis Correct Ans - store non-washable items in
plastic bags for 14 days
Child who is unresponsive has ICP Correct Ans - Pad the side of the bed
A client ask the nurse if it is safe for him to take glucosamine supplement?
Correct Ans - Shellfish allergy
Client following an open colectomy Correct Ans - Uncontrolled pain
A client has just returned to the nursing unit following cardiac catheterization. In the
immediate postoperative post procedure period which of the following is the priority
nursing actions? Correct Ans - Immobilizing the affect extremity
A client hopitialized for a bone marrow transplant is in protective isolation while
undergoing total body radiation and intense chemotherapy. The clients sibling
comes to visit but has obvious manifestations of an upper respiratory infection.
Correct Ans - Allow the sibling to visit after donning a sterile gown, mask, gloves
but prohibits physical contact
Client recovering from closed head injury assumes a decerbrate posture in response
to stimuli Correct Ans - D lying flat ?? (Extentend extremities) The client
rigidly extends his arm
Client reports chest pain. Which of the following lab findings indicates myocardial
damage Correct Ans - Troponin 1.8
Client who has a left femur fracture and is skeletal traction. The clients reports pain
due to muscle spasms in affected leg Correct Ans - Realign the extremity in
traction
Client who has given birth to a stillborn Correct Ans - Acknowledging the
reality of the newborn's death
Client who is 2 days postoperative following a lumbar laminectomy and is reporting
nausea Correct Ans - Admin an antiemetic (Aprepitant for nausea)
Client who is 8hr postoperative following a right-modified radical mastectomy -
which findings to report to provider? (SATA) Correct Ans - Coughing
Frothy, pink secretions