NSG 321 V3 EXAM QUESTIONS AND ANSWERS

NSG 321 V3 EXAM QUESTIONS AND ANSWERS 1. A male client develops oral candidiasis. He has MRSA-positive sputum, is dyspneic, and is receiving oxygen per facemask and linezolid (Zyvox) 600 mg BID IV. In planning care for this client, the nurse identifies which factor as the probable cause of the stomatitis? A. Antibiotic therapy. 2. A 38-year-old male client collapsed at his outside construction job in Texas in July. His admitting vital signs to ICU are: BP 82/70, heart rate 140 beats/minute, urine output 10 ml/hr, skin cool to the touch. Pulmonary artery (PA) pressures are: PAWP 1, PAP 8/2, RAP -1, SVR 1600. What nursing action has the highest priority? A. Increase the client’s IV fluid rate to 200 ml/hr. 3. A one-year-old child with neuroblastoma is crying continuously and is curled into a fetal position. What action is most important for the nurse to implement? A. Give a prescribed analgesic. 4. 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? A. Involve the client in usual at-home activities. 5. The nurse is evaluating an asthmatic client’s response to an inhaled corticosteroid medication. What assessment finding indicates that the medication has been effective in controlling the asthma symptoms? The client has increased A. Peak flow meter rates. 6. In reviewing the goals of “Healthy People”, the nurse determines that the community has a significant problem in preventing dental caries among children. To bring about change that addresses this identified community health problem, where is the best place to initiate a prevention program? A. WIC program intake offices. 7. A client with a permanent pacemaker develops loss of capture resulting in symptomatic sinus bradycardia at a rate of 38/minute. Which intravenous medication should the nurse prepare to administer immediately? A. Atropine sulfate (Atropine). 8. A 25-year-old female client reports to the nurse that she has a throbbing headache over her left eye that began early yesterday right after experiencing dark spots in her vision. Movement makes her nauseous, but lying still in a dark room does provide some relief. Over-the-counter pain medications have not helped. This client is describing which type of headache? A. Classic migraine. 9. A client with acute renal failure has a daily urine output of 1000 mL per day and is experiencing nausea, vomiting, diarrhea, and weakness. Which action would help the client at this time? A. Remove potassium from intravenous fluids. 10. A client is being evaluated for sciatica. What will the nurse most likely assess in this client? A. Pain in the buttock that radiates down the leg. 11. When instructing an elderly client on insulin self-administration the client says “my daughter is going to give me the shots every day.” Which action would the nurse take at this time? A. Continue teaching the client. 12. A client complains of feeling tired and not sleeping well during the night. What will the nurse include when assessing the effectiveness of this client’s sleep pattern? A. Number of hours of sleep each night. 13. Thirty-six hours after a cesarean delivery, a client complains of nausea and bloating. Assessment reveals a distended abdomen and no bowel movement since delivery. What intervention should the nurse implement first A. Auscultate the abdomen 14. The nurse who is performing blood sugar and cholesterol screenings at a community health fair determines that a female client’s blood sugar is 59 mg/dl at 10:00 a.m. Which nursing intervention is most important for the nurse to implement A. Ask the client how she is feeling 15. The nurse is responding to telephone messages at a psychiatric day clinic. Which client situation requires immediate intervention by the nurse A. The wife of a client with post-traumatic stress syndrome reports that her husband is threatening to kill her 16. Following vaginal delivery of a 10 lb infant, nurse assesses new mother’s vaginal bleeding and finds that she has 2 pads in 30 min and boggy uterus. What action? A. Perform fundal massage until firm 17. Angina experiences chest pain after morning care. First? A. Administer a nitro tab 18. Gravida 3, Para 2 at 31 wks gestation admitted to hosp with suspected HELLP syndrome. CC- N/V malaise, epigastric pain, BP 116/74. What assessment? A. Evaluate for thrombocytopenia 19. 60 yr old male admitted complaining of R knee pain for past week; knee and calf are warm and edematous, history of diabetes and arthritis. What info obtain? 20. Neurovascular status of lower extremities 21. A male client with hepatitis A is admitted with elevated hepatic enzymes and jaundice. Which intervention should the nurse implement A. Meticulous hand washing after each client contact 22. The nurse observes that a client with COPD is exhibiting fingernail clubbing. What action should the nurse take A. Document the assessment finding in the nurses’ notes 23. The nurse is assessing a 4-year-old girl with eczema. Her skin is dry and scaly, and the mother reports that she frequently scratches her skin to the point of causing bleeding. Which guideline is indicated for care of this child A. Keep her nails trim and short 24. A female client who had a total thyroidectomy several weeks ago is admitted with myxedema coma. Which finding indicates that the client has been noncompliant with her postoperative treatment plan A. Serum T3 and T4 levels are below normal 25. The nurse is assessing a 9-year-old boy who is experiencing an acute asthma attack. When auscultating this child’s breath sounds, which finding is the nurse most likely to obtain A. Musical sounds upon expiration 26. Diagnosed with severe acute diverticulitis and being admitted to med unit. Priority Q? A. Bisacodyl (Dulcolax) rectally PRN for constipation 27. Nurse notes that a depressed adolescent fluoxetine (Prozac) cannot be given because the mother refuses to sign consent. Do? A. Wait for the mother to sign the medication consent 28. Child injured at sporting event and a nurse attending the event evaluates the child. What is the most accurate method to determine fracture? A. Send child for radiological exam 29. Nurse working in health clinic assessing need for Hep A vaccine. Which client has greatest risk of contracting? A. Female who regularly consumes raw oysters 30. Client with depression remains in bed most of day, declines activities, refuses meals. Dx? A. Feeding Self-care deficit 31. A. Which intervention would nurse expect to decrease discomfort and muscle spasms in elderly pt with fractured left hip? A. Prepare the client for application of Buck’s traction 32. In performing the admission assessment for pt experiencing complications of long-term PD, which Q provides best info about progression? A. “Have you ever been frozen to a spot and unable to move?” 33. 18 yr old female with primary dysmenorrheal does not want to take meds for symptoms, asks nurse which herbals likely to help alleviate the pain. What supplement? A. Chamomile 34. Assessment intervention should the psych nurse implement when performing mental status exam? A. Ask pt to interpret the proverb, “A stitch in time saves nine” 35. Nurse is conducting routine assess of 24 hr old AA infant delivered vaginally. At birth weight was 5 lbs 5oz, HR 150 bpm, R 88bpm, temp 97.7. Which needs further assess? A. Weight loss of 10oz since birth 36. When evaluating the preoperative teaching of a client scheduled for arthroscopic anterior cruciate ligament repair, which statement by the client indicates that the teaching was effective? A. “I will use my crutches to keep my weight off my knee” 37. When lactulose (Cephulac) 30ml QID is prescribed for a male client with advanced cirrhosis, he complains that it is causes diarrhea. What action should the nurse take in response to the client’s statement? A. Explain that diarrhea is expected, but the drug reduces ammonia levels 38. The nurse teaches the mother of a 6 year old anemic boy to give iron supplements. Which statement indicates that the mother understands the proper administration of iron? A.“The iron tablets will be best absorbed between meals, on an n empty stomach” 39. “Oxygen at 5 liters/min per nasal cannula PRN difficult breathing” is prescribed for a client with pneumonia. Which nursing intervention is effective in preventing oxygen toxicity? A. Avoiding the administration of oxygen at high levels for extended periods 40. 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. Maintain a quiet environment 41. A child with leukemia is admitted for chemotherapy, and the nursing diagnosis, “Altered nutrition, less than body requirements related to anorexia, nausea, and vomiting” is identified. Which intervention should the nurse include in this child’s plan of care? A. Allow the child to eat any foods desired and tolerated 42. The nurse believes that a client who frequently requests pain medication may have a substance abuse problem. Which intervention reflects the nurse’s value of client autonomy over veracity? A. Administer the prescribed analgesic when requested 43. A client is leaving the hospital against medical advice (AMA) and voluntarily signs the AMA forms. Which nursing action is essential prior to the client leaving? A. Remove the client’s peripheral IV access 44. The nurse observes a client in a wheelchair with a vest restraint in place. What nursing intervention is most important for the nurse to implement? A. Assess the need for continued restraint 45. A client whose finger stick glucose is 210mg/dl is receiving a sliding scale dose of short-acting insulin before breakfast. In what sequence should the nurse prepare the dose of insulin? A. Determine the number of units to be administered Cleanse the top of the vial with an alcohol swab Use an insulin syringe to withdraw the amount of units to be given Verify the units of insulin in the syringe with another nurse 46. The nurse is preparing to administer an IM injection to a 6 month old child. Which injection site is best for the nurse to use? A. Vastus lateralis 47. The nurse is caring for a laboring 22-year old primigravida following administration of regional anesthesia. In planning care for this client, what nursing intervention has the highest priority? A. Raising the side rails and placing the call bell within reach 48. A client with myelogenous leukemia is receiving an autologous bone marrow transplantation (BMT). What is the priority intervention that the nurse should implement when the bone marrow is repopulating? A. Maintain a protective isolation environment. 49. A woman is transferred to the intensive care unit after hemorrhaging during childbirth, and a pulmonary artery catheter is inserted. Her PCWP is 3, PAP is 10/2, RAP is -4, and he blood pressure is 80/60. What is the highest priority intervention? A. Increase preload with volume replacement. 50. A 78-year-old client in a wheelchair wants to return to bed after eating breakfast. What assessment is most important for the nurse to consider before assisting this client? A. Blood pressure of 86/54. 51. A client who began a series of tests for infertility last month cries when telling the nurse, “I feel like such a failure. I don’t know if I can go through with all these tests.” Which response is best for the nurse to make at this time? A. “Go ahead and cry. I’m sure this must be very difficult for you.” 52. A child with diarrhea and dehydration is receiving an IV solution of half-strength saline at 100 ml/hour and is eating ice chips continuously throughout the day. Which laboratory finding is most important for the nurse to monitor? A. Sodium. 53. An elderly male client is experiencing urinary incontinence. What is the best initial nursing action? A. Apply an external condom catheter. 54. A client who is 30 weeks pregnant is experiencing abdominal pain and vaginal bleeding. For which health problem will the nurse focus an assessment? A. Abruptio placentae 55. A client who has been taking diazepam (Valium) for anxiety at home is demonstrating reduced respirations and unresponsiveness. On what will the nurse focus when assessing for the possible cause of the client’s manifestations? A. Recent intake of alcohol. 60. A client who is an Orthodox Christian asks that the morning insulin dose and breakfast be delayed until after the parish priest comes to provide communion. What action will the nurse take? A. Provide the insulin and breakfast after the parish priest provides communion. 61. The nurse is preparing to administer medication to a client through a nasogastric tube connected to suction. What would the nurse do first when administering this medication? A. Disconnect the suction from the nasogastric tube. 62. The nurse is preparing an education program for community members on breast cancer. Which information would the nurse include as risk factors for the development of this disease? A. Family history. 63. An adolescent male is transferred from the medical unit to the mental health unit because his condition is stable after taking an assortment of prescription drugs. Based on the admission interview, the nurse determines that the client is still having suicidal ideations. What intervention is most important for the nurse to implement A. Search the client’s belongings for potential weapons 64. About 85 victims of a train derailment are brought to the Emergency Department of a small rural hospital. An older male with extensive crush injuries to his lower extremities and pelvis has a blood pressure of 42/28, a thread pulse of 120 beats/minute, and a respiratory rate of 10 breaths/minute with periods of apnea. Using the disaster triage system, which action should the nurse take A. Assign a black triage color 65. A father brings his pre-school-aged son to the rural urgent care clinic because the child fell from a horse earlier today. Which finding indicates to the nurse that further assessment is required for possible abuse or neglect A. Dry, peeling skin, ridged nails, and significantly underweight 66. While caring for a client with a new onset of diabetes mellitus, which intervention is most important for the nurse to include in the client’s plan of care A. Observe client’s glucose self-monitoring technique 67. A client with Type I diabetes mellitus (DM) is admitted for an emergency cholecystectomy. To prevent diabetic ketoacidosis (DKA), which intervention is most important for the nurse to implement A. Supplement insulin needs using a sliding scale 68. A client with metastatic cancer who was taking hydromorphone (Dilaudid) PO at home is not receiving the medication IV while in the hospital. To evaluate if the client is receiving an equianalgesic dose of the Dilaudid, what assessment should the nurse complete A. Pain scale 69. The nurse observes a newly-employed unlicensed assistive personnel (UAP) taking an elderly client’s blood pressure. The nurse says, “You need to start over. The blood pressure reading you obtained was falsely high for that client.” What is the most likely explanation for the erroneous reading A. The size of the cuff used was too small for this adult client’s arm 70. Which activity is best for the nurse to initiate with a depressed client A. Make cut-out cookies 71. Diagnosed with severe acute diverticulitis and being admitted to med unit. Priority Q? A. Bisacodyl (Dulcolax) rectally PRN for constipation 72. Nurse notes that a depressed adolescent fluoxetine (Prozac) cannot be given because the mother refuses tosign consent. Do? A. Wait for the mother to sign the medication consent 73. Child injured at sporting event and a nurse attending the event evaluates the child. What is the most accurate method to determine fracture? A. Send child for radiological exam 74. Nurse working in health clinic assessing need for Hep A vaccine. Which client has greatest risk of contracting? A. Female who regularly consumes raw oysters 75. Client with depression remains in bed most of day, declines activities, refuses meals. Dx? A. Feeding Self-care deficit 76. Which intervention would nurse expect to decrease discomfort and muscle spasms in elderly pt with fractured left hip? A. Prepare the client for application of Buck’s traction 77. In performing the admission assessment for pt experiencing complications of long-term PD, which Q provides best info about progression? A. “Have you ever been frozen to a spot and unable to move?” 78. A 18 yr old female with primary dysmenorrheal does not want to take meds for symptoms, asks nurse which herbals likely to help alleviate the pain. What supplement? Chamomile 79. Assessment intervention should the psych nurse implement when performing mental status exam? A. Ask pt to interpret the proverb, “A stitch in time saves nine” 80. A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential nursing problem has the highest priority when planning nursing care for this client? A. Ineffective airway clearance 81. When the nurse enters the room to change the dressing of a male client with cancer, he asks, “have you ever been with someone when they died?” Best response? A. “Yes I have. Do you have questions about dying?” 82. A 9 year old client received a short arm cast for a fractured right radius. To relieve itching under the child’s cast, which instruction should the nurse provide to the parents? A. Blow cool air from a hair dryer under the cast 83. The nurse is assessing a client on the first postoperative day following thyroid surgery. Which laboratory value is most important for the nurse to monitor? A. Calcium 84. Several clients on a telemetry unit are scheduled for discharge in the morning, but a telemetry-monitored bed is needed immediately. The charge nurse should make arrangements to transfer which client to another medical unit? A. Learning to self-administer insulin injections after being diagnosed with diabetes mellitus 85. The nurse preceptor is orienting a new graduate nurse to the critical care unit. The preceptor asks the new graduate to state symptoms that most likely indicate the beginning of a shock state in a critically ill client. What findings should the new graduate nurse identify? A. Tachycardia, mental status change, and low urine output 86. 135. During the initial newborn assessment, the nurse finds that a newborn’s heart rate is irregular. Which intervention should the nurse implement? A. Document the finding in the infant’s record. 87. A client is diagnosed with a frontal lobe glioma, which is a benign brain tumor. When teaching the client about the tumor, which information should the nurse consider? A. Personality changes or expressive aphasia are likely. 88. A client who has suffered 3rd degree burns over 60% of the body is admitted to the emergency department. The healthcare provider writes a prescription for “IV Lactated Ringer’s 350 ml/hr”. Which intervention should the nurse implement? A. Obtain an intravenous infusion pump prior to administering the IV. 89. A client just returned to the nursing unit after surgery, and initial assessment findings include a pulse rate of 120 beats/minute, restlessness, cyanosis, and gurgling sounds on inspiration and expiration. What action should the nurse take first? A. Perform oropharyngeal suctioning. 90. A female client comes to the clinic complaining of fatigue and inability to sleep because she is the full-time caretaker for a 22-year-old son who was paralyzed by a motor vehicle collision. She adds that her husband left her because he says he can’t take her behavior anymore since all she does is care for their son. What intervention should the nurse implement? A. Acknowledge the client’s stress and suggest that she consider respite care. 91. The nurse plans to administer a scheduled dose of metoprolol (Toprol SR) at 0900 to a client with hypertension. At 0800, the nurse notes that the client’s telemetry pattern shows a second-degree heart block with a ventricular rate of 50. What action should the nurse take? A. Hold the scheduled dose of Toprol and notify the healthcare provider of the telemetry pattern. 92. In shift report the charge nurse is told of several problems. Which problem should the nurse address first? A. A bucket of water was spilled in the hallway. 93. After receiving report on an inpatient acute care unit, which client should the nurse asses first? A. with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity. 94. A male client diagnosed with gastroesophageal reflux (GERD) often wakes up at night experiencing heartburn. He tells the nurse that he sleeps with the head of the bed on blocks, and always drinks a glass of milk at bedtime to help him fall asleep. How should the nurse respond? A. “Drinking milk before bedtime can increase your symptoms at night.” 95. The home health nurse visits a client with heart failure (HF). Assessment findings include: temperature 97.6oF, pulse 116 beats/minute, respiratory rate 36 breaths/minute, blood pressure 140/70, pulse oximeter 86% on 2 L/min of oxygen, and crackles are heard throughout the lung fields. Which intervention has the highest priority A. Call 911 and prepare the client for transport 96. Following a devastating hurricane, a client is admitted for dehydration as the result of vomiting and diarrhea that occurred after ingesting contaminated water. The client expresses feelings of fear and anger about the destruction of homes, the loss of property due to the storm, and the looting that occurred following the storm. According to Maslow’s hierarchy of needs, what priority need should be addressed first A. Physiological needs 97. What diet modification is most important for the nurse to recommend to a client with high cholesterol A. Replace beef with fish or poultry 98. The nurse is managing four clients who are mechanically ventilated. The client with which assessment finding requires the most immediate intervention by the nurse A. Restrained and restless with a low volume alarm 99. A client with chronic kidney disease is being discharged with continuous ambulatory peritoneal dialysis (CAPD). What is the priority nursing diagnosis the nurse should use when developing a discharge teaching plan for this client A. Risk for sepsis 100. The nurse is preparing to administer 1.6 ml of medication IM to a 4-month-old infant. Which intervention should the nurse implement A. Divide the medication into two injections with volumes under 1 ml 101. The nurse is giving medications to an older client who has a percutaneous esophageal gastrostomy (PEG) tube in place. Which medication drug form should the nurse question A. Enteric-coated aspirin (Ecotrin) 102. Assessment of the fetal heart rate is an important finding when caring for a laboring client. Decelerations in fetal heart rate that are of most concern occur at what time during the contraction cycle A. After the contraction 103. Sodium nitroprusside (Nipride) at 0.8 mcg/kg/minute is prescribed for a client who weighs 65kg. The available IV solution is labeled Nipride 50 mg in 500 ml D5W. The nurse should program the infusion pump to deliver how many ml/hour A. 31 104. Nurse calculating 1 minute Apgar score for newborn male infant. HR 150 bpm, vigorous cry, muscle tone good with total flexion, quick reflexes, irritability, and color is dusky and cyanotic. Score? A. 8 105. Administering IV med through central venous catheter with hep lock. Which sequence? A. Saline, med, saline, hep 106. After change of shift report on psych unit of general hosp, which client see first? A. Client with depression who states she is leaving because she feels better 107. Nurse caring for Pt being treated for fever. Intervention to prevent chills? A. Give Rx antipyretics around the clock 108. To assess with meningitis for meningeal irritation, how to position head? A. Head and neck are flexed toward the chest 109. Female pt just completed full chemo cycle for CA, lost 15 lbs from anorexia, N/V. BMI is 19. Nurse reinforces nutrition during DC. What dinner selection? A. Fried chicken breast, sweet potato, spinach, roll and butter, protein milk 110. Nurse caring for dyspneic pt whose O2 sat of 90%. What position? A. Fowler’s with both legs supported 111. Obtaining a health history, male client tells nurse become impotent. What part of info is likely to be significant to the dysfunction? A. Dx with DM 10 years ago 112. Mother of hospitalized 2 yr old boy asks the nurse if her child is ready to pottytrain. Response? A. “Does he let you know just before or after he soils his diaper?” 113. Nurse agrees to work double because of shortage, but requests another nurse be assigned to care for demanding client. Response? A. “I’ll assign the client to another nurse, but your help may be needed” 114. Nurse evaluating teaching about short-acting insulin coverage to newly diagnosed with type 1. Which statement indicates understanding? A. “After taking my regular insulin, I need to eat a meal soon to prevent hypoglycemia episode.” 115. Pt admitted to inpatient psych unit and antipsychotic drug clozapine is Rx. Which intervention? A. Report findings from the client’s weekly WBC counts to the HCP 116. Nurse assessing Pt 8 hrs postparathyroidectomy. Assessment findings include a negative trousseaus sign. Action? A. Document the finding 117. Nurse preparing a native-American for surgery In 1 hr. client says “I want to have my med man called before surgery.” Response? A. “I will be happy to assist you in contacting your medicine man right away.” 118. The community health nurse is planning a nutritional program that targets older adults who live alone and who may be in need of additional community services. Which intervention should the nurse implement first? A. Gather information about the makeup of the population using a windshield survey. 119. A family member contacts the nurse at the community mental health center and wishes to share concerns and ask questions about a client’s medications. What action is best for the nurse to take? A. Obtain written consent from the client to talk to the family member about treatment. 120. The nurse provided discharge teaching to a male client who was recently diagnosed with diabetes mellitus (DM). After receiving the instructions, the client states he understands when, how, and why to take his prescribed medications at home. Which intervention is most important or the nurse to implement? A. Provide the client with a printed list of medicines and a schedule for administration. 121. A male client who has a serum potassium level of 5.9 mEq tells the nurse that he has decided to leave the hospital, even though his healthcare provider has not discharged him. He also states that he does not care if he is discharged, he is refusing all treatments. It is most important for the nurse to ensure that the client understands which fact prior to leaving the facility? A. He must understand that his condition is extremely serious and that he could die as a result of his decision. 122. 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? A. Have the parent take the child for emergency help. 123. What is the rationale for the nurse to teach a client to compress the lacrimal duct after eye drop instillation? A. To prevent systemic absorption of the medication. 124. Three days after surgery, a male client who had a laryngectomy has an elevated pulse and respiratory rates. His skin is dry to touch and he is beginning to thrash about in the bed. What intervention should the nurse implement first? A. Suction the client’s tracheostomy. 125. A client with chronic kidney disease (CKD) is scheduled for hemodialysis Monday and Wednesday mornings. Based on findings reported in the client’s medical record, which action should the nurse implement on Wednesday morning? A. Withhold the morning dose of lisinopril (Zestril). 126. A male client with chronic alcohol use is admitted with signs of early cirrhosis. Which nursing action should the nurse delegate to the unlicensed assistive personnel (UAP) A. Gather oral hygiene products for client’s use 127. Which instruction regarding immediate postoperative care should the nurse plan to include in the preoperative teaching for a client scheduled for an incisional rotator cuff repair A. It will be necessary to wear a sling to keep the joint still 128. 12A client who is experiencing panic attacks receives a prescription for the benzodiazepine alprazolam (Xanax). Which instruction should the nurse provide this client A. Instruct the client of safety issues since this medication causes drowsiness 129. The nurse is assessing an infant on admission to the newborn nursery and finds that both brachial pulses are bounding, but bilateral femoral pulses are only slightly palpable. Which assessment should the nurse implement next A. Obtain blood pressures in all extremities 130. HCP prescribes etanercept (enbrel) 50mg Sub-Q weekly for rheumatoid arthritis. Nurse should evaluate effectiveness of med within what time frame? A. 2-4 weeks 131. Male pt with history of generalized tonic-clonic seizures tells nurse he feels like about to have seizure. What do? A. Stay with the client and call for assistance 132. Nurse gives pt daily dose of Rx for captopril 12.5mg PO Q AM. Shortly after, med the HCP instructs nurse to give another dose to reach the newly Rx dose of 50mg PO daily. Med is avail in 12.5 mg tabs. How many additional tabs should nurse give? A. 3 133. Pt receiving intermittent infusion of erythromycin lactobionate inj, USP 1 gram in 250ml of NS over 2 hrs. Nurse programs infusion pump ml/hr? A. 125 134. 1 day old neonate awaiting surgical correction of myelomeningocele. During preop what is priority? A. Observe for CNS infection R/T sac trauma 136. The triage nurse in an emergency center must prioritize the admission of four clients from the waiting area to a treatment room. Which client should the nurse identify as the first to receive care? A. A female teenager who states she took 9 of her mother’s amitrptyline hydrochloride (Elavil) pills an hour ago 137. A client who had an intraosseous (IO) cannula placed by the HCP for an emergent fluid resuscitation is complaining of severe pain and numbness below the IO site. The skin around the site is pale and edematous. ACTION? A. Discontinue the IO infusion 138. The nurse working in an emergency center collects physical evidence 6 hours following a reported sexual assault. After placing the samples in sealed containers, which action is most important for the nurse to implement? A. Maintain possession of the evidence collection kit at all times until submitted to law enforcement 139. The nurse is caring for a 10-year old who is diagnosed with acute glomerulonephritis. Which outcome is the priority for this child? A. Activity tolerance as evidenced by performing appropriate age-level activities 140. A 20 year old male client is diagnosed with Ewing’s sarcoma following examination for a knee injury. Which instruction is most important for the nurse to provide the client? A. Take analgesics regularly to reduce the pain 141. A client with gestational diabetes, at 39-weeks gestation, is in the second stage of labor. After delivery of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first? A. Assist the client to sharply flex her thighs up against the abdomen. 142. The nurse should observe most closely for drug toxicity when a client receives a medication that has which characteristic? A. Narrow therapeutic index. 143. Following insertion of a LeVeen shunt in a client with cirrhosis of the liver, which assessment finding indicates to the nurse that the shunt is effective? A. Decreased abdominal girth. 144. A female client with Type 1 diabetes mellitus is trying to lose weight, and recently started an exercise program. Which information is most important for the nurse to provide this client? A. Increase carbohydrate intake before exercising. 145. During the second treatment with IV antibiotic, the client develops a rash on the upper torso. What intervention should the nurse implement first? A. Observe the client’s breathing pattern. 146. A male client with moderate Alzheimer’s disease had abdominal surgery yesterday. Today, when the nurse begins to perform a dressing change, the client states, “I don’t want you to change my dressing.” What is the best initial action for the nurse to take? A. Leave the room and re-approach the client in about 30 minutes. 147. The nurse is preparing a teaching plan for a 23-year-old female client who has had a kidney transplant. What should be the nurse’s focus in conducting this teaching? A. Stressing the importance of life-long medical follow-up care after the kidney transplant. 148. What instruction should the nurse include in the discharge-teaching plan of a client with ulcerative colitis who has had a traditional ileostomy? A. Tell the client to notify the healthcare provider if the stoma becomes purple. 149. A male admitted to the mental health unit for somatoform disorder, become angry because he cannot have his pain medication. He demands that the nurse call the HCP and threatens to leave the hospital. Action? A. Ask what other methods he uses to deal with pain 150. While flushing the proximal port of a triple lumen central venous catheter with heparin solution, the nurse meets resistance. Action? A. Cover the cap with tape and label the port as being obstructed 151. A client is admitted to the hospital with a serum sodium level of 128 mEq/L, distended neck veins, and lung crackles. Intervention? A. Restrict oral fluid intake 152. A female client presents to the ED in the early evening complaining of abdominal cramping, watery diarrhea, and vomiting. She tells the nurse that she was at a picnic and ate BBQ that afternoon. What question is important to ask? A. “is anyone else sick who was also at the picnic?” 153. A client with active tuberculosis (TB) is receiving isoniazid (INH) and rifampin (RMP) daily, so direct observation therapy (DOT) is initiated while the client is hospitalized. Instructions? A. Take medication in the presence of the nurse 154. The nurse should explain to a client with lung CA that pleurodesis is performed to achieve which expected outcome? A. Prevent the formation of effusion fluid 155. Following a thyroidectomy, a client experiences tetany. The nurse should expect to administer what intravenous medication A. Calcium gluconate 156. What nursing intervention is most important to implement after a client has completed a myelogram? A. Neurovascular assessment of lower extremities 157. Two weeks following a Biliroth II (gatrojejunostomy), a client develops nausea, diarrhea and diaphoresis after every meal. When the nurse develops a teaching plan, which expected outcome statement is the most relevant? A. Selects a pattern of small meals alternating with fluid intake 158. A client has produced the first of a series of sputum samples for cytology. Action? A. Transport the sputum container to the laboratory in a biohazard bag 159. An elderly client at an adult daycare center with type 2 DM becomes unresponsive verbally with the other daycare participants and tells the nurse, “I just don’t feel right.” Action? A. Give 4 ounces of apple juice 160. A client with an electrical burn is admitted to the Emergency Department on a backboard with a cervical collar. Which intervention should the nurse implement A. Place the client on cardiac telemetry