Vati Green Ligth Comprehensive form A,B,C

A nurse is admitting a client who has antisocial personality disorder. Which of the following client behaviors should the nurse identify as consistent with this disorder? A. Compulsive attention to details B. Avoids interacting with others C. Uses others for personal gain D. Socially awkward in group situations - answer-C. Uses others for personal gain A nurse is interpreting the cardiac rhythm strip of a client who was admitted with syncope. Which of the following images indicates that the client has atrial fibrillation? - answer- A client who has a diagnosis of complete placenta previa is admitted to the labor and delivery suite at 36 weeks gestation with contractions 5 min in frequency and 1 min in duration. Which of the following actions should the nurse take? A. Rupture the amniotic sac B. Medicate the client for pain C. Prepare the client for a cesarean section D. Perform a vaginal exam - answer-C. Prepare the client for a cesarean section A charge nurse on a pediatric unit is making assignments for a float nurse from the medical unit. Which of the following clients is appropriate to assign to the float nurse? A. A 10-year-old client who has pneumonia and is receiving respiratory treatments B. A 4-year-old client who has a Wilms tumor and is receiving chemotherapy C. An 8-month-old client who is scheduled for a surgical repair of a ventricular septal defect tomorrow D. A 14-year-old client who is scheduled for discharge today following placement of a Harrington rod - answer-A. A 10-year-old client who has pneumonia and is receiving respiratory treatments A nurse notices smoke coming from a client's room and discovers a fire in the wastebasket. After moving the client to safety, which of the following is the priority action? A. Notify the facility operator. B. Close the fire doors on the unit. C. Turn off oxygen sources. D. Put out the fire with the appropriate extinguisher. - answer-A. Notify the facility operator. A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect? A. Generalized edema B. Elevated urine specific gravity C. Thready pulse D. Increased hematocrit - answer-A. Generalized edema A nurse is discussing the z-track administration of hydroxyzine with a newly licensed nurse. Which of the following statements indicates the newly licensed nurse understands the purpose of the technique? A. This technique prevents injury to the sciatic nerve B. This technique decreases the risk of subcutaneous infiltration C. This technique allows a larger amount of medication to be injected D. This technique increases the absorption rate of the drug - answer-This technique decreases the risk of subcutaneous infiltration A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan? A. Encourage the client to gain 2.3 kg per week B. Weigh the client once per week throughout hospitalization C. Monitor the client for 1 hr after meals D. Allow the client to choose mealtimes - answer-C. Monitor the client for 1 hr after meals A nurse is planning care for a child who has increased intracranial pressure with a decrease in level of consciousness. Which of the following interventions should the nurse include in the plan of care? A. Perform active range-of-motion exercises B. Maintain the head at a midline position C. Suction the airway frequently D. Perform neurological checks every 4 hrs - answer-B. Maintain the head at a midline position 10. A nurse is assessing a client who has delirium due to a febrile illness. Which of the following findings should the nurse expect? A. Hallucinations B. Agnosia C. Bradycardia D. Aphasia - answer-A. Hallucinations A nurse is assessing a client who is receiving enteral feedings via a gastrostomy tube. The nurse should identify that which of the following findings indicates fluid overload? A. Diminished bowel sounds B. Bradycardia C. Hypotension D. Bounding pulses - answer-D. Bounding pulses A nurse is caring for a client following an open colectomy. Which of the following findings places the client at risk for delayed wound healing? A. INR 1.1 B. Hyperemesis C. Hba1c 5.6% D. Uncontrolled pain - answer-B. Hyperemesis A home health nurse is reviewing treatment goals with a client who has diabetes mellitus. The nurse should evaluate which of the following laboratory tests to determine effective long-term management of blood glucose levels? A. 3-hr oral glucose tolerance test B. Hba1c C. Fasting blood glucose test D. Urinalysis for ketones - answer-B. Hba1c A nurse is caring for a client who has neutropenia due to HIV. Which of the following precautions should the nurse take while caring for this client? A. Wear an N95 respirator B. Insert an indwelling urinary catheter to monitor urinary output C. Monitor the client's vital signs every 8 hr D. Use a dedicated stethoscope - answer-D. Use a dedicated stethoscope A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions should the nurse take? A. Encourage the client to ambulate in the hallway 1 hr before bedtime B. Tell the client to avoid drinking fluids 1 hr before bedtime C. Schedule routine care tasks during hours when the client is awake D. Advise the client to leave the television in the room on when trying to fall asleep - answer-C. Schedule routine care tasks during hours when the client is awake A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy. Which of the following interventions should the nurse include? A. Clothe the newborn in light cotton B. Check the newborn's temperature every 8 hrs. (every 4) C. Administer 120 ml of water between feedings D. Place the newborn 45 cm from the light source - answer-D. Place the newborn 45 cm from the light source A nurse is planning care for a client who has schizophrenia and is having difficulty expressing their feelings. Which of the following referrals should the nurse make? A. Art therapist B. Speech-language pathologist C. Social worker D. Recreational therapist - answer-A. Art therapist A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the following findings indicates the client is experiencing an adverse effect of the medication? A. Decreased reflexes B. Weight gain of 1.4 kg C. Increased urinary output D. Jugular vein distention - answer-A. Decreased reflexes At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first? A. Constipation B. Indigestion C. Swollen ankles D. Urinary frequency - answer-B. Indigestion . A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following actions by the assistive personnel requires the nurse to intervene? A. Encourages the client to use the incentive spirometer B. Elevates the head of the client's bed C. Offers oral fluids to the client D. Checks the client's pulse oximetry - answer-C. Offers oral fluids to the client . A nurse in a mental health facility is interviewing a newly admitted client. Which of the following actions should the nurse take when conducting the interview? A. Insist the client use direct eye contact during the interview B. Seat the client at least 3.7m from the nurse C. Position the client's chair between the nurse's chair and the door D. Lean in slightly when speaking to the client - answer-D. Lean in slightly when speaking to the client A nurse on a medical unit has just received change-of-shift report. Which of the following clients should the nurse assess first? A. A 68-year-old client who had a myocardial infarction 2 days ago and reports chest pain 4 on a scale of 0 to 10 B. A 48-year-old client who has AIDS, pneumocystis pneumonia, and a temperature of 38.3 C (101F) C. A 60-year-old client who has COPD, is receiving 2 L/min O2 via a nasal cannula, and has an oxygen saturation of 89% D. A 26-year-old female client who has pelvic inflammatory disease and is unable to void - answer-A 68-year-old client who had a myocardial infarction 2 days ago and reports chest pain 4 on a scale of 0 to 10 A nurse is assessing a client prior to performing a blood draw. The nurse should identify that an allergy to which of the following food can indicate that the client has an allergy to latex? A. Peanuts B. Shellfish C. Avocados D. Eggs - answer-C. Avocados A nurse is preparing to witness a client's signature on an informed consent for a total knee arthroplasty. Which of the following client statements indicates the nurse should contact the surgeon? A. I wonder if the metal in my knee will show up in airport screenings B. The physical therapy has not been working, so I will need to have the surgery C. I look forward to being able to bend my knee again when I sit in a chair D. I am thankful there are no serious complications from this type of surgery - answer-D. I am thankful there are no serious complications from this type of surgery A nurse is teaching the parent of a school-age child who has scabies about the application of permethrin 5% cream. The nurse should include which of the following as a potential adverse effect of the medication? A. Burning B. Discoloration C. Photosensitivity D. Alopecia - answer-A. Burning A nurse is teaching a client who has a new prescription for digoxin. Which of the following statements should the nurse include in the teaching? A. "Notify your provider if you experience muscle weakness." B. "Reports a weight gain of one-half pound per day." C. "Expect this medication to increase your blood pressure." D. "You will need to take a diuretic while taking this medication." - answer-A. "Notify your provider if you experience muscle weakness." A nurse is planning teaching for a client who is at 10 weeks of gestation and has a history of urinary tract infections. Which of the following information should the nurse plan to include in the teaching about UTI prevention? A. Decrease intake of citrus foods and beverages B. Wear nylon underwear C. Empty the bladder before and after intercourse D. Increase the time between voiding - answer-C. Empty the bladder before and after intercourse A nurse is providing discharge teaching to a client who is postpartum and plans to breastfeed. Which of the following should the nurse recommend the client increase in their diet during lactation? A. Vitamin D B. Iron C. Vitamin A D. Calcium - answer-D. Calcium A nurse is providing teaching about preventing mastitis to a client who is postpartum and breastfeeding her newborn. Which of the following instructions should the nurse include? A. "Wear an underwire bra between feedings." B. "Cover your breasts immediately after feedings." C. "Apply cold compresses to your breasts before feedings." D. "Try to have your baby empty your breasts with each feeding." - answer-D. "Try to have your baby empty your breasts with each feeding." A nurse is caring for a client who reports chest pain. Which of the following findings indicates myocardial damage? A. Aptt 80 seconds B. Troponin I 1.8 ng/ml C. Erythrocyte sedimentation rate 17 mm/hr D. Human B-type natriuretic peptide 88 pg/ml - answer-B. Troponin I 1.8 ng/ml A nurse is providing teaching about car seat safety to the parent of a term newborn. Which of the following statements by the parent indicates an understanding of the teaching? A. "I should place a rolled blanket along each side of my baby's head in the car seat." B. "I should place my baby's car seat rear-facing until 6 months of age." C. "I should put the car seat retainer clip at the level of my baby's belly button." D. "I should position my baby's car seat at a 90-degree angle in the car." - answer-A. "I should place a rolled blanket along each side of my baby's head in the car seat." A nurse is performing high-frequency chest compressions using a mechanical chest compression device for a child who has cystic fibrosis. Which of the following findings indicates the treatment has been effective? A. The child develops a dry, hacking cough B. The child has increased nasal secretions C. The child has increased sputum production D. The child develops diminished breath sounds - answer-C. The child has increased sputum production A nurse is caring for a client following a possible exposure to anthrax. Which of the following actions should the nurse take? A. Administer an antitoxin B. Quarantine the client C. Monitor the client for a productive cough D. Begin prophylactic treatment with ciprofloxacin - answer-D. Begin prophylactic treatment with ciprofloxacin A nurse is caring for a client who has a newly implanted sealed internal radiation device to treat cervical cancer. Which of the following is an appropriate action for the nurse to take? A. Prohibit visitors for the first 24 hrs B. Keep a 3-foot distance from the radiation implant C. Maintain the client on bed rest for 72 hr D. Require the client wear a dosimeter badge - answer-C. Maintain the client on bed rest for 72 hr A nurse is admitting a client to the medical-surgical unit. Which of the following actions should the nurse take first? A. Place the client's valuables in the facility's safe B. Observe the client's level of mobility C. Administer prescribed medications D. Electronically enter the prescriptions from the provider - answer-B. Observe the client's level of mobility A nurse at a public health clinic is caring for a group of clients. Which of the following should the nurse identify as a reportable diagnosis to the CDC? A. Herpes simplex virus (HSV) type 1 B. Hepatitis A C. Human papillomavirus (HPV) D. Pediculosis capitis - answer-B. Hepatitis A A charge nurse is evaluating the time management skills of a newly licensed nurse. Which of the following actions should the charge nurse identify as an effective time management skill? A. Delegates creation of a client's teaching plan to a licensed practical nurse B. Completes activities for one client before moving to the next client C. Focuses on activities rather than objectives D. Skips break times to catch up on charting - answer-B. Completes activities for one client before moving to the next client A nurse delegates tasks to a licensed practical nurse and an assistive personnel. When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN? A. Insert an indwelling catheter if the client has not voided in 3 hr B. Obtain the abdominal girth now and every 4 hr C. Assess and document the level of consciousness every hour D. Measure the amount of gastric drainage every 2 hr - answer-A. Insert an indwelling catheter if the client has not voided in 3 hr