A nurse is showing a student nurse how to care for Tonisha Bennete, a 32-
year-old female who has pneumonia. The student nurse asks the nurse to
explain why Ms. Bennete is placed in Fowler position. What is the nurse's
best response to the student nurse?
"It is an intervention for activity intolerance."
"It is an intervention for ineffective airway clearance."
"It is the position in which the client will be most comfortable."
"It is an intervention for ineffective breathing pattern."
"It is an intervention for ineffective airway clearance."
Rationale
Placing Ms. Bennete in Fowler position is an intervention for ineffective airway
clearance. It is not an intervention for activity intolerance or ineffective breathing
pattern. Ms. Bennete's comfort level is not the reason to place her in Fowler
position.
1. What instruction should the nurse include in the discharge teaching
plan of a client who had a cataract extraction today?
a. Sexual activities may be resumed upon return home
b. Light housekeeping is permitted but avoid heavy lifting
c. Use a metal eye shield on operative eye during the day
d. Administer eye ointment before applying eye drops
b. Light housekeeping is permitted but avoid heavy lifting
2. A male adult comes to the urgent care clinic 5 days after being diagnose
with influenza. He is short of breath, febrile, and coughing green colored
sputum. Which intervention should the nurse implement first?
a. Obtain a sputum sample for culture
b. Check his oxygen saturation level
c. Administer an oral antipyretic
d. Auscultate bilateral lung sound
a. Obtain a sputum sample for culture
3. An elder male client tells the nurse that he is loosing sleep because he
has to get up several times at night to go to the bathroom that he has
trouble starting his urinary stream and that he does not feel like his
bladder is ever completely empty. Which intervention should the nurse
implement?
a. collect a urine specimen for culture analysis
b. obtain a fingerstick blood glucose level
c. palpate the bladder above the symphysis pubis
d. review the client fluid intake
c. palpate the bladder above the symphysis pubis
4. An adult client is admitted with diabetic ketoacidosis (DKA) and a
urinary tract infection (UTI) Prescriptions for intravenous antibiotics and
insulin infusion are initiated. Which serum laboratory value warrants the
,most immediate intervention by the nurse?
a. blood ph of 7.30
b. glucose of 350 mg /dl
c. white blood cell count of 15000mm
d. potassium of 2.5 meq/l
d. potassium of 2.5 meq/l
5. A client with sickle cell anemia develops a fever during the last hour of
administration of a unit of packed red blood cell. When notifying the
healthcare provider what information should the nurse provide first using
the SBAR communication process?
a. explain specific reason for urgent notification
b. preface the report by stating the clients name and admitting diagnosis
c. communicate the pre-transfusion temperatures
d. optain prn prescription for acetaminophen for fever 101f
a. explain specific reason for urgent notification
6. An adult male client is admitted for pneumocystis carinil pneumonia
(PCP) secondary to aids. While hospitalize he receives IV pentamidine
isethionate therapy. In preparing this client for discharge what important
aspect regarding his medication therapy should the nurse explain?
a. AZT therapy must be stopped when IV aerosol pentamine is being used.
b. IV pentamine will be given until oral pentamine can be tolerated
c. It will be necessary to continue prophylactic doses of IV or aerosol
pentamine every month
d. Iv pentamine may offer protection to others aids related conditions such
as kaposis sarcoma
c. It will be necessary to continue prophylactic doses of IV or aerosol pentamine
every month
7. A client subjective data includes dysuria, urgency, and urinary
frequency. What action should the nurse implement next?
a. collect a clean catch specimen
b. palpate the suprapubic region
c. instruct to wipe from front to back
d. inquire about recent sexual activity
a. collect a clean catch specimen
8. A client tells the nurse that her biopsy results indicate that the cancer
cells are well differentiated How should the nurse respond?
a. offer the client reassurance that this information indicates that the
clients cancer cells are benign
b. explain that these tissue cells often respond more effectively to
radiation than to chemotherapy
c. ask the client in the healthcare provider has giving her any information
about the classification of her cancer
, d. help the client make plans to begin inmediate treatment since her
cancer is likely to spread quickly
c. ask the client in the healthcare provider has giving her any information about the
classification of her cancer
9. A client with a chronic kidney disease is treated on hemodialysis.
During the 1 treatment clients blood pressure drops from 150/90 to 80/30
Which action should the nurse take first?
a. monitor bp q45 minutes
b. lower the head of the chair and elevate feet
c. stop dialysis treatment
d. administer 5%albumin IV
c. stop dialysis treatment
10.A client with deep vain thrombosis (DVT) is receiving a continues
infusion of heparin sodium 25,000 unit in 5% dextrose injection 250ml.
The prescription indicates the dosage should be increase 900 units/hr. The
nurse should program the infusion pump to deliver how many ml/hr?
=9ml/hr
11.The nurse is obtaining the admission history for a client with suspected
peptic ulcer disease (PUD). Which subjective data reported by the client
supports this diagnosis?
a. upper mid abdominal gnawing and burning pain
b. severe abdominal cramps and diarrhea after eating spicy foods
c. marked loss of weight and appetite over the last few months
d. use of chewable and liquid antacids for indigestion
a. upper mid abdominal gnawing and burning pain
12.The nurse is providing preoperative education for a jewish client
schedule to receive a xenograft graft to promote burn healing. Which
information should the nurse provide this client?
a. the xenograft is taken from nonhuman sources
b. grafting increases the risk for bacterial infection
c. as the burn heals the graft permanently attaches
d. grafts are later removed by debriding procedure
a. the xenograft is taken from nonhuman sources
13.A client who took a camping vacation two weeks ago in a country with
a tropical climate comes to the clinic describing vague symptoms and
diarrhea for the past week. Which finding is most important for the nurse
to report?
a. jaundice sclera
b. intestinal cramping
c. weakness and fatigue
d. weight loss
year-old female who has pneumonia. The student nurse asks the nurse to
explain why Ms. Bennete is placed in Fowler position. What is the nurse's
best response to the student nurse?
"It is an intervention for activity intolerance."
"It is an intervention for ineffective airway clearance."
"It is the position in which the client will be most comfortable."
"It is an intervention for ineffective breathing pattern."
"It is an intervention for ineffective airway clearance."
Rationale
Placing Ms. Bennete in Fowler position is an intervention for ineffective airway
clearance. It is not an intervention for activity intolerance or ineffective breathing
pattern. Ms. Bennete's comfort level is not the reason to place her in Fowler
position.
1. What instruction should the nurse include in the discharge teaching
plan of a client who had a cataract extraction today?
a. Sexual activities may be resumed upon return home
b. Light housekeeping is permitted but avoid heavy lifting
c. Use a metal eye shield on operative eye during the day
d. Administer eye ointment before applying eye drops
b. Light housekeeping is permitted but avoid heavy lifting
2. A male adult comes to the urgent care clinic 5 days after being diagnose
with influenza. He is short of breath, febrile, and coughing green colored
sputum. Which intervention should the nurse implement first?
a. Obtain a sputum sample for culture
b. Check his oxygen saturation level
c. Administer an oral antipyretic
d. Auscultate bilateral lung sound
a. Obtain a sputum sample for culture
3. An elder male client tells the nurse that he is loosing sleep because he
has to get up several times at night to go to the bathroom that he has
trouble starting his urinary stream and that he does not feel like his
bladder is ever completely empty. Which intervention should the nurse
implement?
a. collect a urine specimen for culture analysis
b. obtain a fingerstick blood glucose level
c. palpate the bladder above the symphysis pubis
d. review the client fluid intake
c. palpate the bladder above the symphysis pubis
4. An adult client is admitted with diabetic ketoacidosis (DKA) and a
urinary tract infection (UTI) Prescriptions for intravenous antibiotics and
insulin infusion are initiated. Which serum laboratory value warrants the
,most immediate intervention by the nurse?
a. blood ph of 7.30
b. glucose of 350 mg /dl
c. white blood cell count of 15000mm
d. potassium of 2.5 meq/l
d. potassium of 2.5 meq/l
5. A client with sickle cell anemia develops a fever during the last hour of
administration of a unit of packed red blood cell. When notifying the
healthcare provider what information should the nurse provide first using
the SBAR communication process?
a. explain specific reason for urgent notification
b. preface the report by stating the clients name and admitting diagnosis
c. communicate the pre-transfusion temperatures
d. optain prn prescription for acetaminophen for fever 101f
a. explain specific reason for urgent notification
6. An adult male client is admitted for pneumocystis carinil pneumonia
(PCP) secondary to aids. While hospitalize he receives IV pentamidine
isethionate therapy. In preparing this client for discharge what important
aspect regarding his medication therapy should the nurse explain?
a. AZT therapy must be stopped when IV aerosol pentamine is being used.
b. IV pentamine will be given until oral pentamine can be tolerated
c. It will be necessary to continue prophylactic doses of IV or aerosol
pentamine every month
d. Iv pentamine may offer protection to others aids related conditions such
as kaposis sarcoma
c. It will be necessary to continue prophylactic doses of IV or aerosol pentamine
every month
7. A client subjective data includes dysuria, urgency, and urinary
frequency. What action should the nurse implement next?
a. collect a clean catch specimen
b. palpate the suprapubic region
c. instruct to wipe from front to back
d. inquire about recent sexual activity
a. collect a clean catch specimen
8. A client tells the nurse that her biopsy results indicate that the cancer
cells are well differentiated How should the nurse respond?
a. offer the client reassurance that this information indicates that the
clients cancer cells are benign
b. explain that these tissue cells often respond more effectively to
radiation than to chemotherapy
c. ask the client in the healthcare provider has giving her any information
about the classification of her cancer
, d. help the client make plans to begin inmediate treatment since her
cancer is likely to spread quickly
c. ask the client in the healthcare provider has giving her any information about the
classification of her cancer
9. A client with a chronic kidney disease is treated on hemodialysis.
During the 1 treatment clients blood pressure drops from 150/90 to 80/30
Which action should the nurse take first?
a. monitor bp q45 minutes
b. lower the head of the chair and elevate feet
c. stop dialysis treatment
d. administer 5%albumin IV
c. stop dialysis treatment
10.A client with deep vain thrombosis (DVT) is receiving a continues
infusion of heparin sodium 25,000 unit in 5% dextrose injection 250ml.
The prescription indicates the dosage should be increase 900 units/hr. The
nurse should program the infusion pump to deliver how many ml/hr?
=9ml/hr
11.The nurse is obtaining the admission history for a client with suspected
peptic ulcer disease (PUD). Which subjective data reported by the client
supports this diagnosis?
a. upper mid abdominal gnawing and burning pain
b. severe abdominal cramps and diarrhea after eating spicy foods
c. marked loss of weight and appetite over the last few months
d. use of chewable and liquid antacids for indigestion
a. upper mid abdominal gnawing and burning pain
12.The nurse is providing preoperative education for a jewish client
schedule to receive a xenograft graft to promote burn healing. Which
information should the nurse provide this client?
a. the xenograft is taken from nonhuman sources
b. grafting increases the risk for bacterial infection
c. as the burn heals the graft permanently attaches
d. grafts are later removed by debriding procedure
a. the xenograft is taken from nonhuman sources
13.A client who took a camping vacation two weeks ago in a country with
a tropical climate comes to the clinic describing vague symptoms and
diarrhea for the past week. Which finding is most important for the nurse
to report?
a. jaundice sclera
b. intestinal cramping
c. weakness and fatigue
d. weight loss
