NURS 4212 MIDTERM EXAM 2023 QUESTIONS AND ANSWERS LATEST UPDATE

NURS 4212 MIDTERM EXAM 2023 QUESTIONS AND ANSWERS LATEST UPDATE 1.The nurse is aware that intimate partner violence (IPV) screening should occur with which situation? A. As soon as the clinician suspects a problem. B. As a routine part of each health care encounter C. Once the clinician confirms a history of abuse D. Only when the client presents with an unexpected injury. 2.A client is admitted with diagnosis of Wernicke’s syndrome. Which assessment finding should the nurse….? A. Confusion B. Right lower abdominal pain C. Peripheral neuropathy D. Depression 3. A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure? A. Measure urine output B. Assess body temperature. C. Monitor skin elasticity. D. Observe the aspiration site. 4. A client who had a small bowel resection acquired methicillin resistant staphylococcus aureus (MRSA) while hospitalized. He was treated and released but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention. A. Instruct visitors to gown and wash hands. B. Maintain contact transmission precaution. C. Review WBC count daily. D. Collect serial stool specimens for culture. 5. After an elderly female client receives treatment for drug toxicity, the healthcare provider prescribes a 24 hour creatinine clearance test. Prior to starting the urine collection, the nurse notes that the client's serum creatinine is 0.3 mg/dl (22.9 micromol/L). What action should the nurse implement? A. Notify HCP of the results. B. Assess the client for signs of hypokalemia. C. Evaluate client’s serum BUN level. D. Initiate the urine collection as prescribed. 6. Prior to insertion of an indwelling urinary catheter, what client information is most important for the nurse to obtain? A. Color, clarity, and odor of urine. B. Client allergies to antiseptic solution. C. Previous history of UTI D. Client’s ability to increase fluid intake. 7. An adult is admitted to the emergency department following ingestion of a bottle of antidepressants secondary to chronic pain. A nasogastric tube and a left subclavian venous catheter are placed. The nurse auscultates audible breath sounds on the right side, faint sounds procedure, and chest movement on the right side of the thorax. Which procedure should the nurse prepare for first: A. Insertion of a left- sided chest tube B. Setup of PCA C. Retraction of the nasogastric tube D. Placement of endotracheal tube 8. The nurse is preparing to mix two medications from two different multidose vials, A and B. In which order should these actions be implemented when drawing the solutions from the vials? 1. Verify the drug and dose with the label on the vial. 2. Inject the volume of air to be aspirated from each vial. 3. Aspirate from vial A 4. Aspirate from vial B 9. In assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the fracture site, and recognizes that hematoma formation at the bone fragment site has occurred. What action should the nurse implement? A. Assign UAP to take vitals every hour. B. Advise the client that anticoagulant therapy may be needed. C. Call the lab to obtain a stat APTT and prothrombin time. D. Document the extent of the bruising in the medical record. 10. The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts? A. Begin to show signs of improvement in affect. B. Lacks interest in the activities of family and friends C. Expresses feelings of sadness and loneliness. D. Neglects personal hygiene and has no appetite. 11. A 3 year-old boy is brought to the emergency department after the mother found the child in the backyard 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. Obtain a pulse oximetry reading and arterial blood gases. B. Determine if the child ingested a toxic substance and if vomiting occurred. C. Request a stat chest x-ray and prepare medications for asthmatic episodes. D. Auscultate all pulmonary lung fields and attempt a Heimlich maneuver. 12. While moving stables from the client's postoperative wound site, the nurse observes that the client's eyes closed and his face and hands are clenched. The client states, "I just hate having staples removed." Acknowledge the client’s anxiety, which action should the nurse implement? A. Attempt to distract the client with general conservation. B. Reassure the client that this is a simple nursing procedure. C. Explain the procedure in detail while removing stables. D. Encourage the client to continue to verbalize anxiety. 13. HCP prescribes cephalexin 125mg/5ml oral suspension. Client weighs 77 lbs. The recommended safe dose 25 mg/kg/24hrs 35 mL 14. What is the primary purpose for initiating nursing interventions that promote good nutrition, rest, exercise, and stress reduction for a client diagnosed with HIV? A. Improve function of the immune system. B. Promote a feeling of general well-being C. Increase ability to carry out activities of daily living D. Prevent spread of infection to others 15. A client with chronic obstructive lung disease who is receiving oxygen at 1.5 liters per minute by nasal cannula is currently short of breath. What should the nurse do? A. Instruct the client in pursed lip breathing B. Increase oxygen to three liters/ per minute C. Ask client to take short rapid breaths D. Have the client breathe into a paper bag 16. The nurse is caring for a child who takes methylphenidate extended release for the treatment of attention deficit hyperactivity disorder (ADHD). Which assessment finding is an expected side effect of this medication? A. Flat affect B. Decrease Focus C. Weight loss of 5lbs in 1 month D. Muscle weakness 17. A client with purulent discharge from a venous ulcer that has been unsuccessfully treated with intravenous vancomycin has just been admitted with a possible vancomycin resistant staph infection. Which nursing interventions should the nurse include in the plan of care? A. Explain purpose of low bacteria diet B. Monitor clients WBC’s C. Institute contact precautions for staff and visitors D. Use standard precautions and wear a mask E. Send wound drainage for culture and sensitivity 18. Which client should the charge nurse on the oncology unit assign to an RN rather than a PN? A. A middle aged male client who has just undergone an excisional biopsy and has been told that his tumor appears to be benign. B. An adult client in remission after a series of chemotherapy treatments who is receiving intramuscular iron injections for anemia C. A young adult experiencing fatigue while undergoing a series of external beam radiation treatments for stage 1 cancer D. An elderly female client with cancer whose children are trying to decide whether to change the palliative care measures. 19. The nurse is assessing a client who is receiving enteral feedings. Which clinical data indicate the client may not be tolerating the tube feedings. A. Nausea and vomiting B. Abdominal tympany C. Absent bowel sounds D. Flatulence E. Abdominal cramping 20. A female client is admitted for the diabetic crisis resulting from inadequate dietary practices. After stabilization the nurse talks to the client about her prescribed diet. What client characteristics are most important ? A. Knows that insulin must be given 30 minutes before eating B. B. Demonstrates a willingness to adhere to the diet consistently. C. Frequently eat fruits and vegetables at meals and between meals D. Has someone available who can prepare and oversee the diet 21. The nurse is triaging several children as they present to the emergency room after a school bus accident. Which child requires the most immediate intervention? A. A 12 year old reporting neck, arm, and lower back discomfort B. An 8 year old with a full leg air splint for a possible broken tibia C. An 11 year old with a headache, nausea, and projectile vomiting D. An 6 year old with multiple superficial lacerations of all extremities. 22. An 18 year old female client is seen at the health department for treatment of condylomata (perineal warts) caused by HPV. Which intervention should the nurse implement? A. Inform the client that wants do not return following cryotherapy B. Tell the client the vaccine for HPV is not indicated C. Reinforce the importance of annual Pap Smear D. Recommend the use of latex condoms to prevent HPV transmission 23. The nurse is working on an infectious disease unit. Which client should be assigned to a room, to use a particulate respirator mask and requiring staff to use standard precautions? A. Twin siblings admitted with scarlet fever that is complicated with pneumonia B. A client with a positive Mantoux and sputum cultures results positive for AFB C. A female adolescent admitted with multiple genital herpes simplex 1 lesions D. An older client with scabies who is admitted from an extended care facility 24. A client who recently underwent a tracheostomy is being prepared for discharge to home. Which instruction is most important for the nurse to include in the teaching plan? A. Teach tracheal suctioning techniques B. Explain how to use communication tools C. Demonstrate how to clean tracheostomy site D. Encourage self-care and independence. 25. While the nurse is conducting an admission assessment of a female client with bipolar disorder, the client suddenly begins to take off her clothes and throw them at the nurse A. State it is unacceptable to undress during the interview B. Ignore the clients inappropriate behavior C. Change to less anxiety promoting questions D. Leave the clients room so she can act out her anxiety 26. A female client with dementia who needs assistance with meals and activities of daily living screams at the staff and threatens to hit those who come near her. Which intervention should the nurse include in the care plan? A. Risk for self directed violence B. Risk for acute confusion C. Impaired verbal communication D. Caregiver role strain 27. A female client with a history of heart failure arrives at the clinic after what she describes as a very…… (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner…… A) Reteach medication regimen. B) Administer the prescribed diuretic. c) Give a potassium supplement. D) Auscultate lung and heart sounds 28. When entering a client’s room to administer an 0900 iv antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor, Which action should the nurse implement? A) Ignore the behavior and hang the iv antibiotic. B) Complete an unusual occurrence report C) Leave the room and close the door quietly. D) Tell the client to stop the inappropriate behavior. 29. The healthcare provider prescribes the antibiotic cefdinir 300mg PO every 12 hrs for a client with a postoperative wound infection. Which foods should the nurse encourage…? A) Green leafy vegetables B) Avocados and cheese C) Yogurt or buttermilk d) Fresh fruits. 30) A client is receiving ophthalmic drops preoperatively for cataract extraction and …. Healthcare providers have prescribed all these medications. Which information a nurse will give to this client? (Select all that apply). A) One of the medications is used to anesthetize the corneal surface. B) These medications assist in obstructing a client's vision during the surgery. C) The iris must be paralyzed during surgery to prevent it from reacting to light. D) A medication is used to induce sleep during the procedure. E) Pupillary dilation is necessary to access the eye chamber for lens removal. 31) The nurse is managing 4 clients in the intensive care units who are mechanically ventilated. After performing a quick visual assessment, the nurse…………….. A) Restrained and restless with a low volume alarm sounding. B) High pressure alarm sounds when a client is coughing. C) An audible voice when a client is trying to communicate. D) Diminished breath sounds in the right posterior base. 32) Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse ………. Prasugrel, a platelet inhibitor, to the client. To monitor for ………….. A) Measure body temperature. B) Assess skin turgor C) Check for pedal edema. D) Observe the color of urine. 33) A client with hyperthyroidism is admitted to the postoperative unit after a successful thyroidectomy. Which of the client’s serum laboratory values requires intervention by the nurse? A) T3 – uptake at 50% B) Thyroxine 12 mcg/dl (154 nmol/L) C) Total calcium 5.0 mg/dL (1.25 mmol/L) D) Glucose 150 mg/dL (8.32 mmol/L) 34) A postpartal client who is bottle feeding develops breast engorgement. What is the best recommendation for the nurse to provide the client? D. place warm packs on both of the breast. 35) The mother of an adolescent female tells the clinic nurse that every meal her daughter goes to the bathroom, locks the door and vomits, which…….????? A) Current height and weight B) Skin of palms of the hand C) Condition of tooth enamel D) Length of the last menses. 36) Following breakfast, the nurse is preparing to administer 0900 medications to clients on a medical floor. Which medications should be held until a later time? A) The mucosal barrier, sucralfate, for a client diagnosed with peptic ulcer disease. B) The antifungal nystatin suspension, for a client who has just brushed his teeth. C) The antiplatelet agent aspirin, for a client who is scheduled to be discharged within the hour. D) The loop-diuretic furosemide, for a client with a serum potassium. 37) While changing a client’s postoperative dressing, the nurse observes purulent wound drainage at the site. Before reporting this finding to the healthcare provider, the nurse……. A) Platelet count B) Neutrophil count C) Serum sodium level D) Hematocrit. 38) A female client receives a prescription for alendronate sodium .. osteoporosis. Which instruction should the nurse include in the client’s teaching plan? A) Eat within 30 minutes of taking the medication B) Consume a light snack with the medication. C) Ingest an antacid 30 minutes prior to taking the tablet D) Take on an empty stomach with a full glass of water. 39) The nurse has determined that a client with no pernicious anemia has developed g…….. this problem? A) Pain when eating B) Nausea C) Altered taste sensation D) Fatigue 40. Based on the information provided in this client’s chart medical record during labor. Which should the nurse implement B.) Apply oxygen via face mask. 41. The nurse working in a critical care unit is assigned two clients being mechanically ventilated and the other who had a thoracotomy… -asses the level of consciousness and vital signs 42. Which instruction should the nurse provide to a client who is preparing to have cystoscopy -report any painful urination, blood in urine, or fever 43. The nurse implements a secondary prevention program for STI in a local health center -more than 50% of at risk clients were diagnosed early 44. An adult client is admitted to psychiatric Unit -phobia 45. Prior to surgery, written consent must be obtained. Which is the nurse’s legal responsibility…. -determine that the surgical consent form has been signed 46. The nurse is assigned to a care for a client diagnosed with psoriasis….? -shaking the client’s hand during an introduction 47. The nurse is preparing an adult with Addison’s disease for self-management…? -events requiring steroid dose adjustments 48. What is the priority nursing action when initiating morphine therapy via an intravenously…? -initiate the dosage lockout mechanism on the PCA pump 49. A nurse who took drugs from the unit for personal use was temporarily released from duty….? -allow the impaired nurse to return to work and monitor med admin 50. While taking vital signs, a critically ill male grabs the nurse’s hand and ask the nurse not to leave…..? -pull up a chair and sit beside the client’s bed 51. Which assessment finding of a postmenopausal woman…..? -cold sensitivity 52. The nurse is taking the blood pressure measurement of client with Parkinson’s (SATA) -flat affect, frequent syncope, blurred vision 53. A client is admitted to the intensive care unit with diabetes insipidus due to pituitary gland tumor…..? -Hypokalemia 54. In evaluating a client at 29 weeks gestation, which finding should the nurse report to the HCP immediately? a. Urinary frequency b. Whitish, odorless, mucoid vaginal discharge c. Temperature at 100 degrees F d. Edema of ankles, face and hands. 55. A client with multiple sclerosis is receiving baclofen 15 mg orally three times a day… .....?*4.5 56. The nurse is assisting the HCP with a wound debridement at the bedside of a client who is mildly confused. The client is draped and a sterile field is created . Which nursing intervention should the nurse implement for client safety? a. Assess the discomfort when procedure is completed b. Instruct the client to keep hands under the sterile field c. Verify that the client has given informed consent d. Pour cleaning solution onto the sterile cloth field. 57. The mother of a child recently diagnosed with asthma asks the nurse how to help protect her child from having asthmatic attacks. To avoid triggers of asmthatic attacks, which instruction should the nurse provide the mother? A. decrease the raw sugars in her diet B. keep away from pets with long hair 58. When admitting a client with a diagnosis of transient ischemic attack (TIA), which intervention is most important for the nurse to include ….? a. Assess bilateral breath sounds b. Review client’s daily medications c. Initiate neurological monitoring every 2 hours. d. Palpate suprapubic region for urinary retention. 59. A client with a history of gouty arthritis is scheduled for a right total knee arthopathy. Which lab test result is most important for the nurse to report to the surgeon prior to th schedules surgery? a. Potassium level of 4 mEq/L (4mmol/L) b. Blood glucose of 90 mg/dL (5mmol/L) c. Serum creatinine of 5 mg/dL ( 442micromol/L) d. Hemoglobin level of 13 g/dL 60. The charge nurse is making assignments for one practical nurse (PN) and three registered nurses who are caring for neurologically compromised clients. Which client with which change of status is best to assign to the PN? a. Viral meningitis whose temperature changed from 101.0 to 102.0 F b. Myxedema coma whose blood pressure changed from 80/50 mmHg to 70/40 mm/Hg c. Diabetic ketoacidosis whose glasgow coma scale score changed from 10 to 7 d. Subdural hematoma whose blood pressure changed from 150/80 to 170.60 mmHg. C. stay indoors when grass is being cut D. avoid sudden changes in temperature E. close car windows and use air conditioner 61. A client with possible acute kidney injury is admitted to the hospital and mannitol is prescribed as a fluid challenge. Prior to carrying out this prescription what intervention should the nurse implement? a. Obtain vital signs and breath sounds b. Instruct the client to empty the bladder c. No specific nursing action is required d. Collect a clean catch urine specimen. 62. An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9 is admitted to the hospital with diabetic ketoacidosis. Which intervention is the most likely cause ….? a. Incorrectly administered too much insulin b. Skipped eating lunch c. Ate an extra peanut butter sandwich before gym class d. Had a cold and ear infection for the past 2 days. 63. The nurse notes that a client with depression has been more withdrawn and noncommunicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this ….? a. Schedule a daily conference with social worker b. Engage the client in non-threatening conversations c. Encourage the client to participate in group activities d. Encourage the clients family to visit more often. 64. The school nurse is called to the soccer field because a child has nose bleed. In which position should the nurse place the child? a. Supine with the legs raised b. Side lying with the head slightly elevated c. Sitting up and leaning forward d. Standing with the head leaning backwards 65. A client who is newly diagnosed with type 2 diabetes mellitus recieved a prescription formetformin 500 mg PO twice daily. What information should the nurse include in this clients teaching plan? a. Recognize signs and symptoms of hypoglycemia b. Use sliding scale insulin for fingerstick glucose elevations c. Report persistent polyuria to the HCP d. Take an additional dose for signs of hyperglycemia e. Take metformin with the morning and evening meal 66. An unlicensed assistive personnel is assigned to provide personal care for a client whose prescribed activity is bed rest with bedside commode use. The UAP reports to the nurse that the client? a. Advise the client to maintain bedrest so that the safety can be ensured. b. Determine the client's level of mobility and need for the assistance c. Assign another UAP to care for the client d. Instruct the UAP that all clients deserve equal care. 67. An older client with osteoarthritis reports increasing pain and stiffness in the right knee and asks how to reduce the symptoms. In responding to the client, the nurse recognizes what.. B. Destruction of joint cartilage. 68. A client in the emergency center demonstrates rapid speech, flight of ideas and reports sleeping only three hours during the past 48 hours. Based on these findings, it is most important for the nurse to review the laboratory result for which medication? C. Fluoxetine 69. A 3 yo boy was successfully toilet trained prior to his admission to the hospital for ... are very concerned that the child has regressed in his toileting . What information should the nurse provide to the parents? A. Children usually resume their toileting behaviors when they leave the hospital. 70. Which intervention should the nurse implement when beginning a physical assessment of a 6 mo infant? A. Allow the child to remain sitting in the caretaker’s lap. 71. A male client with suspected lung cancer tells the nurse that he does not want to have a scheduled biopsy performed and states “they already found the cancer when I had my chest xray.” Which action should the nurse implement? C. Instruct the client that biopsy results are important to determine the best treatment. 72. An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period ... B. Teach clients to use an incentive spirometer every 2 courses while awake. E. Remove urinary catheter as soon as possible and encourage voiding. 73. The nurse applies a blood pressure cuff around the clients left thigh. To measure the client’s blood pressure where does the stethoscope need to be placed? Near the femoral artery 74. A client with diabetes mellitus tells the nurse that she uses cranberry juice to help prevent urinary tract infection. What instructions does the nurse explain? B. Drinking cranberry 75. A preschooler with constipation needs to increase fiber intake. Which snack suggestion should the nurse provide? B. Oatmeal cookies 76. The nurse is preparing to administer a histamine 2-receptor antagonist to a client with peptic ulcer disease. What is the primary purpose of the drug classification? B. Decreases the amount of chi secretion by the parietal cells in the stomach. 77. The nurse who works in labor and delivery is reassigned to the cardiac care unit for the day because of a low ... delivery. Which assignment is best for the charge nurse to give the nurse? C. Monitor the central telemetry 78. After having a pulmonary angiogram, a client is diagnosed with a pulmonary embolism (PE). Which intervention is most important for the nurse to include in the client’s plan of care? A. Monitor for confusion and restlessness. 79. A client with renal calculi is experiencing hematuria and reports severe flank pain. Which intervention should the nurse implant first? A. Administer a prescribed opioid analgesic. 80. The healthcare provider prescribes potassium chloride 25 mEq in 500 mL D5W to infuse over 6 hours. The available 20 mL of potassium chloride is labeled, “10 mEq/5mL.” How many mL of potassium chloride should the nurse add to the iv fluid? 12.5 mL 81. The nurse is planning to teach infant care and preventative measures to SIDS to a group of new parents. Answer: ensure that the infant’s crib mattress is firm juice does not prevent infection. 82. For the second time in four months, an overweight client is seen in the clinic because of vulvovaginitis resulting from a candida infection. Which intervention should the nurse implement first? Answer: Obtain the client’s blood glucose level 83. While assessing a client who is admitted with heart failure and pulmonary edema, the nurse identifies dependent peripheral edema, an irregular heart rate, and a persistent cough that produces pink blood-tinged sputum. Answer: Obtain sputum sample 84. A client on the cardiac telemetry unit unexpectedly begins manifesting ventricular fibrillation and the advanced cardiac life support team defibrillates the client. B. Seek clarification of the type of advance directive the client has 85. A client who is being mechanically ventilated is receiving continuous enteral feedings through a nasogastric feeding tube. To prevent aspiration, which intervention is most important for the nurse to implement? Answer: Maintain head of bed elevated while enteral feeding is infusing. 86. An adult is admitted to the emergency room following an automobile collision in which the client sustained a head injury, What assessment data would provide the earliest indication that the client is experiencing increased intracranial pressure? Answer: Fixed dilated pupils 87: which information is most important for the nurse to obtain when determining a client’s risk for obstructive sleep apnea syndrome? Answer: Body Mass Index 88. A young female adult wanders into the emergency department. She is disheveled and confused and states “My date must have put something in my drink. He took my car, and I think he raped me. I don’t exactly remember but I know he hurt me”.Answer: Yes,i can see.Tell me more about what you remember? 89. An S3 heart sounds is auscultated in a client in her third trimester of pregnancy. Answer: Document in the client’s record 90:The healthcare provider prescribes penicillin V potassium 650,000 units IM. The available vial is labeled, penicillin V potassium 500,000 u/ml. How many ml should the nurse administer? Answer:1.3 91. A male client who was discharged 3 days ago after an exploratory laparoscopic biopsy was admitted to the hospital with a warm, tender, reddened, and swollen left lower leg. Answer: Encourage the client to dangle his legs frequently. 92. A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. Answer: ”When did these voices begin?” 93. A client with heart failure is admitted to the medical surgical unit with pneumonia. To reduce cardiac workload, which intervention should the nurse include in the plan of care? Answer: Provide a bedside commode for toileting. 94. When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority? a. Withhold food and fluid intake b. Evaluate intake and output ratio c. Initiate IV fluid replacement d. Administer antiemetics as needed 95. Which problem reported by a client taking lovastatin requires the most immediate follow up by the nurse? a. Abdominal cramps b. Muscle pain c. Altered taste d. Diarrhea and flatulence 96. In evaluating the effectiveness of a postoperative client’s intermittent pneumatic compression devices, which assessment is most important for the nurse to complete? a. Palpate all peripheral pulse points for volume and strength b. Evaluate the client’s ability to use an incentive spirometer c. Observe both lower extremities for redness and swelling d. Monitor the amount of drainage from the client’s incision 97. The nurse is admitting a client with a history of gout. In assessing the client’s hands, how should the nurse assess for the presence of a. Palpate for hard nodules on the fingers b. Note the appearance of the fingernails c. Observe knuckle joints for erythema d. Listen for grating sound with joint flexion 98. The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. a. Participation of community leaders in planning the program b. Technical assistance to produce a video on breast self-examination c. Morbidity data for breast cancer in women of all races d. A listing of African-American women who live in the community 99. The nurse is providing intermittent gavage feedings for a 33 week gestational age newborn. The nurse positions the newborn in a right side-lying position with the head slightly elevated and… Prior to administering the bolus feeding, it is most important for the nurse to obtain which assessment? a. Gag reflex and vomiting b. Nasal breathing obstruction c. Volume of gastric residual d. Intake and output 100. When washing soiled hands, the nurse first wets the hands and applies soap. The nurseshould complete additional actions in which sequence? ans : Rub hands palm to palm, interlace the fingers, dry hands with paper towel, turn off water 101. An older client is referred to a rehab facility following a cerebrovascular accident…. Is aphasic with left side paresis and is having difficulty swallowing. Which intervention is most? a. Facilitate a consult for speech therapy b. Arrange for daily home care assistance c. Initiate passive range of motion exercises d. Use pictures and gestures to communicate 102. A nurse who works in the nursery is attending the vaginal delivery of a term infant. What action should the nurse complete prior to leaving the delivery room? a. Obtain the infant’s vital signs b. Observe the infant latching onto the breast c. Place the id bands on the infant and mother d. Administer vitamin k injection 103. Which assessment is most important for the nurse to include in the daily plan of care for a client with a burnt extremity? a. Distal pulse extremity b. Presence of exudate c. Range of motion d. Extremity sensation 104. When taking a health history, which information collected by the nurse correlates most directly to a diagnosis of chronic peripheral arterial insufficiency? a. A positive brodie-trendelenburg test b. Ankle ulceration and edema c. History of intermittent claudication d. A serum cholesterol level of 250 mg/dl 105. Which intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an IV site in the client's arm? a. Assess IV site frequently for signs of extravasation b. Apply a topical anesthetic at the infusion site for burning c. Explain that temporary burning at the IV site may occur d. Monitor capillary refill distal to the infusion site 106. When conducting diet teaching for a client who is on a postoperative full liquid diet, which foods should the nurse encourage the client to eat? a. Creamy peanut butter b. Canned fruit cocktail c. Clear beef broth d. Vegetable juice e. Vanilla frozen yogurt 107. The healthcare provider prescribes magnesium sulphate 6 grams intravenously (IV) to be infused over 20 minutes- 150ml 108. A client receiving heparin sodium 25,000 units in 5% dextrose- 109. The nurse administers an oral antiviral to a client with shingles- Elevated Liver function test 110. After administering a proton pump inhibitor ( PPI), which action should the nurse take- Ask the client about gastrointestinal pain 111. The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection. A. Blood Pressure of 122/74 mmHg B. Moderate amount of foul-smelling lochia C. Oral temperature of 100.2F (37.9)C D. White blood count of 19000 mm3( 19x10^9/L) 112. A client presents to the emergency department with a gash on the forehead and appears to be dazed and confused- Increasing confusion of the client 113. A client taking clopidogrel reports the onset of diarrhea. Which nursing action should the nurse implement first- Observe the appearance of the stool 114.The nurse is caring for four clients. Client A, who has emphysema and whose oxygen saturation level is 94%- Verify that client B has two units of packed cells available. 115. In assessing a client 12 hours following transurethral resection of the prostate- Ensure that no dependent loops are present in the tubing. 116. A 6-week-old infant with a pyloric stenosis is scheduled for a pyloromyotomy. Which preoperative nursing action has the highest priority- Monitor amount of intake and infant’s response to feedings. 117.The Home health is assessing an older client who lives alone. The client reports- Daily food and fluid intake, Level of physical activity and exercise, Methods currently used to treat constipation, Current prescribed and over- the counter medications. 118. The nurse is assisting the healthcare provider with a thoracentesis for a client who has emphysema- Intubation tray 119. A client with Alzheimer’s Disease (AD) is receiving trazodone, a recently prescribed atypical- Confirm that the desired effect of the medication has been achieved. 120.The nurse enters a room where the practical (PN) is positioning a client in a lateral sidelying position with -Assume care of the client and assign the PN to the care of a different client. 121. A client is undergoing peritoneal dialysis. After several fluid exchanges the abdomen is distended and blood pressure is elevated and 6500ml were infused while 5500ml were drained, in response to this finding what action should the nurse take? A. Turn the client from side to side B. Irrigate the drainage tube with normal saline C. Lower the head of the bed D. instruct the client to cough 122. when conducting diet teaching for a client who was diagnosed with a myocardial infarction, which snacks foods should the nurse encourage the client to eat (select all that apply) A. fresh vegetable with mayonnaise dip B. Soda crackers and peanut butter C. Fresh turkey slices and berries D. chicken bouillon soup and toast E. Raw unsalted almonds and apples 123 . A middle-aged male client at the outpatient clinic receives a prescription for tetracycline due to folliculitis of the scalp. Which instruction should the clinic nurse provide? A. Wash your bed linens in hot water after starting the medication B. Use a fine toothed comb to remove any nits observed on the scalp C. Keep the infected area covered until the infection is resolved D. Take the medication with a glass of water two hours after meals 124. The nurse is caring for a seated client who is experiencing a tonic clonic seizure. Whih action should the nurse implement (select all that apply) A. Note duration of seizure B. Insert a bite block C. Loosen restrictive clothing D. Ease client to the floor E. Restrain the client 125. An older client who was discharged two weeks ago after hip replacement surgery is brought to the hospital accompanied by his daughter and admitted with a diagnosis of acute onset of delirium, the daughter is very worried about her father and tells the nurse that he has been confused for two days and doesn’t recognize her sometimes. Which information should the nurse provide to the daughter? A. Delirium is a sign of an underlying mental illness and institutionalization may be needed B. confusion that suddenly develops may be due to an infection and is potentially reversible C. Psychiatric evaluation will be needed to determine if the client has developed depression D. The client is demonstrating symptoms of dementia and because of age, it may be permanent 126. The nurse is completing the admission assessment of a 3 year old who is admitted with bacterial meningitis and hydrocephalus. Which assessment finding is evident that the child is experiencing increased intracranial pressure (ICP) A. Tachycardia and tachypnea B. Blood pressure fluctuation and syncope C. Sluggish and unequal pupillary responses D. Increased head circumference and bulging fontanels 126. The nurse observes a client sleeping with the mouth open with oxygen at 2 L per nasal cannula, the nurse assess the client's pulse oximetry at 88%, which measure should the nurse implement to improve the clients oxygenation a. check the oxygen tubing for kinks or loops b. Awaken the client to take deep breaths c. change oxygen delivery to a face mask d. increase oxygen to 4 liter per nasal cannula 127. a client with 6cm thoracic aneurysm is being prepared for surgery, the nurse reports to the healthcare provider that the client's blood pressure is 220/112mmHg in an a............ which finding warrants immediate intervention by the nurse? a. sinus tachycardia with frequent premature ventricular beats (PVC) B, Rose colored urine drains from the urinary catheter c. Blood pressure reading of 200/100mmHg 15 min later D. report a tearing, sharp pain between the shoulder blades 128. in assessing a client's pain, which question or statement is likely to elicit the most information? A. Is the pain sharp or dull? B. Does the pain occur in specific area C. Describe what the pain feels like D. Tell me how you respond when you feel the pain 129. A client is admitted with hepatitis A (HAV) and dehydration. Subjective symptoms include anorexia, fatigue and malaise. What additional assessment should the nurse expect to find during a ….. A. Clay-colored stool B. Pruritus C. Icteric sclera D. Right upper quadrant abdominal pain 130. when developing a teaching a teaching plan for a client with newly diagnosed type 1 diabetes, the nurse should explain that an increase thirst is an early sign of diabetic ketoacidosis, which action a. give a dose of regular insulin as prescribed b. measure urine output over the next 24hrs c. drink electrolyte fluid replacentment d. Resume normal physical activity 131. An older client was discharged from hospital 5 days following surgery for a right total knee arthroplasty. Three days after discharge, the client arrives to the ED reporting sever pain in the right leg and the nurse observe edema and erythema below the knee. The nurse recognizes the client is likely exhibiting symptoms of which condition? a. fat emboli b. pulmonary embolism c. Deep vein thrombosis d. infection There is no 133-136 140. The nurse is completing the admission assessment aid a 3-year old is admitted with bacterial and hydrocephalus. Which assessment finding is evidence…… A.Slaughters us an unequal pupillary response B. Blood pressure fluctuations and syncope C. Tachycardia and tachypnea D. Increase head circumference and bulging fontanels 141. The nurse is caring for a client with chronic bronchitis infection who receives a nebulized bronchodilator treatment which is chest physiotherapy [CPT]. Which finding indicates to the nurse the interventions was effective A.Absence of coarse crackle B. Increase in respiratory rate C. Absence of Coarse crackles D. Increase in breath sounds 142.The nurse prepares to defibrillate a client in ventricular fibrillation. Which intervention should the nurse Implement during distribution. A.apply conductive gel on paddles before placing on clients B. Following the shock, shouts all clear C. Position the interior of paddle over the mid Sternal area D.Set synchronizer to deliver shock during the QRS complex 143. The nurse is planning to implement a tuberculosis screening program at a community health clinic. Which technician did not use to screen clients who are non-Compromised A.purified protein derivative [PPD] skin test B. Stain sputum smears C. Cultural tubercle bacilli D. Anterior view of bilateral chest x-ray 144. While a child is hospitalized with Acute glomerulonephritis the Parent asks why blood pressure reading is taken so often.Which response by the nurse is most accurate? A.sodium intake with meals and snacks affects the blood pressure B.Elevated blood pressure must be anticipated and identified quickly C.hypotension leading to sudden stroke and develop at any time D.blood pressure fluctuations means that the conditions has become chronic 145. A client is admitted with acute pancreatitis. The client admits to drinking a pint of bourbon daily A.Yellowing and itching of the skin B.Abdominal pain and vomiting C.confusion and Tremors D.Anorexia and abdominal 146 The nurse is providing care for a client with Severe peripheral arthritis disease [PAD]. The client reports a history of rest ischemia, with leg pain that occurs during the night. Which action ——- A. elevate the leg to assess for Color changes B. Providing Heating pan for PRN use C.suggest dangling the legs when pain begins D.offer cold packs when the pain occurs 147. What action should the nurse take first when a client is inadvertently given an incorrect dose of the medication A.Document events leading to the error in the nurses notes B. assess the client for any adverse effects C. Notify the healthcare provider D. Complete an incident report documents in the facts 148. Which needle should not used to administer intravenous IV via a client implanted port= 149. The nurse is caring for a client who had a repair of A bleeding gastric ulcer. A.assess skin condition and toggle form breakdown B. Replace fluid intravenously based on intake and outtake C. Turn every two hours around the clock from side to side D. Record the amount of daily wound drainage 150. A 12 year old client who had an appendectomy two days ago is receiving 0.9% normal Saline at 50ml/hour A. encourage Popsicles and fluids of choice B. Upton is specimen for urinalysis C. Evaluate postural blood pressure measurements D.Assess bowel sound in all quadrants 151. A client with eczema is experiencing severe Pruritus. Which PRN prescription should the nose administer select all that apply A.Transdermal analgesic B.Topical scabicide C. Oral antihistamine, D.Topical alcohol rub E. Topical corticosteroid 152. An older adult male who had an abdominal cholecystectomy has become increasingly confused and disoriented over the past 24 hours. He is found wandering into another client room and is returned to his room by the UAP. Which actions should the nurse take?select all that apply A.Apply soft upper limb restraints and raise all four bed rails B.assess the clients breath sounds on oxygen saturation, C.Assign the UAP to re-assess the client's risk for fall D.reports mental status changes to the healthcare provider E.review the cleanse most recent serum electrolyte values 153. The school nurse is screening students for scoliosis and notes that one student has Lordosis. Which finding should the nurse document in the student screening record? A.excessive concave curvature of the lumbar spine B. Posterior curvature that is cortex in the thoracic area C. Rounded spine from head to hips without concave curves D.lateral curvature that creates asymmetry of the shoulders low serum magnesium 154. A 41 week gestation primigravida woman is admitted to labor and delivery for induction of Labor. Which findings should the nurse report to the healthcare provider before initiating the infusion of Oxytocin. A. fetal heart tones located in upper right quadrant B. Sarah vaginal exam refill in 3 cm dilatation C. Well physical profile results showing oligohydramnios D. Regular contractions or current every 10 minutes 155. A client who had a lung biopsy ask the nurse to explain the healthcare provider reports that the lung cancer is staged as T2N0M0 lung cancer. What information should you not provide. A. The staging indicates the treatment option for surgery, radiation, or chemotherapy B. The cancer has spread to other organs which limits the success rate of treatment. C. The client understanding of the cancer prognosis and quality of life D. The cancer is within its primary site which no lymph node or metastasis presents. 156. The nurse assesses a client whose hand begins to spasm when the blood pressure cuff is inflated. The client complains of paresthesia in the fingers and toes. Which cereal laboratory findings should the nurse—- A. Elevated serum potassium B. Elevated serum calcium C. D. Low serum calcium 157. Do nurse is caring for a client which is the paralytic ileus who presents with severe, colicky abdominal pain, nausea, vomiting and abdomen distention. Which pathophysiologic magnesium supports—- A. Ulceration of protective duodenal mucosal lining B. Intestinal Volvulus that occurred during surgery C. Esophagitis due to reflux of gastric contents D. A history of having helicobacter pylori infection 158. The nurse observes an unlicensed assistive personnel [UAP] applying alcohol-based hand rub while leaving a client room after taking vital signs. What action should the nurse take? A.Instruct the UAP to return to the clients room to perform and washing B. Supervise UAP in the next clients room to evaluate hand hygiene C. Advise the UAP to wear gloves when opting vital signs for all clients D.remind the UAP to continue rubbing hands together until they are dry 159. The nurse is assigned to care for surgical clients. After receiving a report which client should the nurse see first? A.An adult one day postoperative laparoscopic cholecystectomy requesting pain medication B.An olderClient who is receiving packed RBCs on the Todd de postoperatively for colon resection C. An older clients with continuous bladder irrigation who is two days postoperatively for bladder surgery D. an adult who is in bucks Traction, and scheduled for hip arthroplasty within the next 12hours 160. An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and ask how she will know that her husband’s death is eminent— A. Reassured his paws that the healthcare provider will notify went to call the children B. Offer to discuss the client’s health status with each of the adult children C. Gather information regarding how long it will take for the children to arrive D.explain that the client will start to lose consciousness and the body system will slow down