Review Answers
Question Answer
A nurse is caring for a client who is taking alprazolam. Which of Ceftriaxone
the following prescriptions should the nurse clarify with the
provider?
A nurse is assessing a client who is postoperative following Place the client i
abdominal surgery. The client states “I feel like my incision Fowler’s position
ripped open”, the nurse notes dehiscence of the incision.
Which of the following actions should the nurse take?
A nurse is caring for a client who is receiving radiation therapy Wear a lead apro
through a sealed implant. Which of the following actions should providing care fo
the nurse take? client.
A nurse is inserting an IV catheter for a client who requires fluid Apply the tourniq
replacement. Which of the following actions should the nurse cm above the ins
take? site
A nurse is administering medications to a client who has Administer the
dysphagia and a new prescription for divalproex sodium medication with
extended release tablets. Which of the following actions should applesauce
the nurse take?
A nurse is completing a dietary assessment for a client who is Meat and dairy p
Jewish and observes kosher dietary practices. Which of the are eaten separa
following behaviors would the nurse expect to find?
A nurse is assessing a client who has minor injuries following a Tachycardia
motor-vehicle crash and appears agitated and apprehensive.
The nurse identifies that the client is in the alarm stage of
general adaptation syndrome and should expect which of the
following findings?
A nurse is caring for a client who has a femur fracture and is on Inspect the client
bed rest with Buck’s extension traction. Which of the following under the device
actions should the nurse take? hours
A charge nurse is creating assignments for the next shift for 60-year-old clien
several nurses and one of them is pregnant. Which of the recovering from
, Question Answer
following clients should the charge nurse assign to a nurse who
is not pregnant?
A nurse is caring for a client who has a partial laryngectomy The client is lying
and is receiving continuous internal feeding at 65 ml/hr through supine position
a gastrostomy tube. Which of the following findings requires
immediate intervention by the nurse?
A nurse is teaching a client about smoking cessation. Which of “I will set a speci
the following client statements should the nurse identify as an to stop smoking.
understanding of the teaching?
A nurse has been caring for a female client who has bruises on Help the client to
her arms that are a result of physical abuse by her partner. The recognize the sig
client states “I don’t know how much longer I can take this, but escalation of abu
I’m afraid he’ll really hurt me if I leave”. Which of the following behavior
is an appropriate nursing intervention?
A client who is 8 hr postpartum asks the nurse if she will need “You should rece
to receive Rh immune globulin. The client is gravid 2, para 2, immune globulin
and her blood type is AB negative. The newborn’s blood type is 72 hours of deliv
B Positive. Which of the following statements is appropriate?
A client hospitalized for a bone marrow transplant is in Allow the sibling
protective isolation while undergoing total body radiation and after donning a s
intense chemotherapy. The client’s sibling comes to visit but gown, mask, glov
has obvious manifestations of an upper respiratory infection. prohibit physical
Which of the following nursing actions is appropriate at this
time?
A nurse is planning care for a client who takes haloperidol for Screen the clien
the treatment of schizophrenia. Which of the following should tardive dyskines
the nurse include in the plan of care?
A nurse is performing a vision screening for a client. Which of Increased opaci
the following findings should the nurse identify as an indication lens of the eye
that the client has cataracts?
A nurse is caring for a client who reports difficulty falling asleep Schedule routin
at night. Which of the following actions should the nurse take? tasks during the
when the client
awake
, A nurse is providing discharge teaching to a client who is Calcium
postpartum and plans to breastfeed. Which of the following
should the nurse recommend the client increases in their diet
during lactation?
A nurse is providing nutritional counseling to the parents of a Offer snacks thr
toddler. Which of the following instructions should the nurse the day
include in the teaching?
A nurse is assessing a clients cardiovascular system. Identify Option A
where the nurse should place the diaphragm of the stethoscope
to best hear the closing of the aortic valve.
A nurse is planning to perform wound irrigation for a client who Place the lid of a
has an open secondary wound. When creating a sterile field. sterile solution w
Which of the following actions should the nurse take? the sterile field
A nurse is planning an education session for a client who has Diaphoresis
type 1 diabetes mellitus. Which of the following should the
nurse plan to include when teaching the client to monitor for
hypoglycemia?
A nurse is instructing a group of newly hired nurses about Betamethasone
medication to promote fetal lung maturation. Which of the
following medications should the nurse include in the
instructions?
A nurse is caring for a client who has atypical depression and is Low fat yogurt
taking phenelzine. Which of the following is appropriate for
the nurses to offer as an evening snack?
A nurse is planning care for a newborn who is receiving Assess the infan
phototherapy. Which of the following actions should the nurse for corneal irrita
include the plan of care? every 4 hrs
A nurse is caring for a client who is receiving a blood Infuse 0.9% sod
transfusion at 125 ml/hr and develops a hemolytic reaction. chloride IV
Which of the following actions should the nurse perform?
A nurse is planning care for a client who has schizophrenia and Social worker
is having difficulty expressing their feelings. Which of the
following referrals should the nurse make?
A nurse from the state health department is instructing a group Lyme disease
of nurses regarding infections. Which of the following infections
should the nurse report to the centers for disease control and
prevention?