Questions With 100% Verified Answers
When should planning discharge process begin?
a. at time of admission
b. 2 days after client is admitted
c. whenever the nurse has the time to do planning
d. when the physician has the discharge order - ANSWERs-A
What is an interdisciplinary team? - ANSWERs-A group of health care professionals
from
different disciplines
Fill in the blank:
1. _______ is used by interdisciplinary team to make health care decisions about
clients with multiple problems. 2. ________, which may take place at team meetings,
allows the achievement of results that the participants would be incapable of
accomplishing if working alone. - ANSWERs-1 & 2 = collaboration
What is the nurse's contribution to an interdisciplinary team? - ANSWERs-- knowledge
of
nursing care & its management
- a holistic understanding of the client, her/his healthcare needs & healthcare systems.
A four-month-old infant is admitted to the pediatric intensive care unit
with a temperature of 105°F (40.5 °C). The infant is irritable, and the
nurse observes nuchal rigidity. Which assessment finding would indicate
an increase in intracranial pressure?
1. Positive Babinski.
2. High-pitched cry.
3. Bulging posterior fontanelle.
4. Pinpoint pupils. - ANSWERs-2
A client is receiving total parenteral nutrition (TPN). To determine the
client's tolerance of this treatment, the nurse should assess for which of the
following?
1. A significant increase in pulse rate.
2. A decrease in diastolic blood pressure.
3. Temperature in excess of 98.6°F (37°C).
4. Urine output of at least 30 cc per hour. - ANSWERs-4
,The client is exhibiting symptoms of myxedema. The nursing
assessment should reveal
1. increased pulse rate.
2. decreased temperature.
3. fine tremors.
4. increased radioactive iodine uptake level. -
ANSWERs-2
A nonstress test is scheduled for a client at 34-weeks gestation who
developed hypertension, periorbital edema, and proteinuria. Which of the
following nursing actions should be included in the care plan in order to
BEST prepare the client for the diagnostic test?
1. Start an intravenous line for an oxytocin infusion.
2. Obtain a signed consent prior to the procedure.
3. Instruct client to push a button when she feels fetal movement.
4. Attach a spiral electrode to the fetal head. - ANSWERs-3
Which of the following nursing interventions is MOST important for a 45-year-
old woman with rheumatoid arthritis?
1. Provide support to flexed joints with pillows and pads.
2. Position her on her abdomen several times a day.
3. Massage the inflamed joints with creams and oils.
4. Assist her with heat application and ROM exercises. - ANSWERs-4
The nurse is caring for a young adult admitted to the hospital with a
severe head injury. The nurse should position the patient
1. with his neck in a midline position and the head of the bed elevated 30°.
2. side-lying with his head extended and the bed flat.
3. in high Fowler's position with his head maintained in a neutral position.
4. in semi-Fowler's position with his head turned to the side. - ANSWERs-1
The nurse is teaching a 40-year-old man diagnosed with a lower motor
neuron disorder to perform intermittent self-catheterization at home. The
nurse should instruct the client to
1. use a new sterile catheter each time he performs a catheterization.
2. perform the Valsalva maneuver(holding breath and bearing down) before doing the
catheterization.
3. perform the catheterization procedure every 8 hours.
4. limit his fluid intake to reduce the number of times a catheterization is needed. -
ANSWERs-2
A client is being discharged with sublingual nitroglycerin (Nitrostat).
The client should be cautioned by the nurse to
,1. take the medication five minutes after the pain has started.
2. stop taking the medication if a stinging sensation is absent.
3. take the medication on an empty stomach.
4. avoid abrupt changes in posture. -
ANSWERs-4
A 38-year-old woman is returned to her room after a subtotal
thyroidectomy for treatment of hyperthyroidism. Which of the following, if
found by the nurse at the patient's bedside, is nonessential?
1. Potassium chloride for IV administration.
2. Calcium gluconate for IV administration.
3. Tracheostomy set-up.
4. Suction equipment. - ANSWERs-1
A nurse recognizes that an initial positive outcome of treatment for
a victim of sexual abuse by one parent would be that the client 1.
acknowledges willing participation in an incestuous relationship.
2. reestablishes a trusting relationship with his/her other parent.
3. verbalizes that s/he is not responsible for the sexual abuse.
4. describes feelings of anxiety when speaking about sexual abuse. - ANSWERs-3
An adolescent client is ordered to take tetracycline HCL (Achromycin)
250 mg PO bid. Which of the following instructions should be given to
this client by the nurse?
1. "Take the medication on a full stomach, or with a glass of milk."
2. "Wear sunscreen and a hat when outdoors."
3. "Continue taking the medication until you feel better."
4. "Avoid the use of soaps or detergents for two weeks." - ANSWERs-2
After a client develops left-sided hemiparesis from a cerebral vascular
accident (CVA), there is a decrease in muscle tone. Which of the following
nursing diagnoses would be a priority to include in his care plan?
1. Alteration in mobility related to paralysis.
2. Alteration in skin integrity related to decrease in tissue oxygenation.
3. Alteration in skin integrity related to immobility.
4. Alteration in communication related to decrease in thought processes - ANSWERs-
2
A client has a history of oliguria, hypertension, and peripheral edema.
Current lab values are: BUN -25, K+ -4.0 mEq/L. Which nutrient should be
restricted in the client's diet?
1. Protein.
2. Fats.
, 3. Carbohydrates.
4. Magnesium. - ANSWERs-1
An extremely agitated client is receiving haloperidol (Haldol) IM every 30
minutes while in the psychiatric emergency room. The MOST important
nursing intervention is to
1. monitor vital signs, especially blood pressure, every 30 minutes.
2. remain at the client's side to provide reassurance.
3. tell the client the name of the medication and its effects.
4. monitor the anticholinergic effects of the medication. - ANSWERs-1
The nurse is caring for clients in the skilled nursing facility. Which of the
following clients require the nurse's IMMEDIATE attention?
1. A client admitted for a cerebral vascular accident (CVA) whose prescription
for warfarin (Coumadin) expired two days ago.
2. A client in pain who was receiving morphine in an acute care institution and
was transferred with a prescription for acetaminophen with codeine. 3. A client who
has dysuria and foul-smelling, cloudy, dark amber urine.
4. An immunosuppressed client who has not received an influenza immunization. -
ANSWERs-1
The nurse is observing care given to a client experiencing severe to
panic levels of anxiety. The nurse would intervene in which of the
following situations?
1. The staff maintains a calm manner when interacting with the client.
2. The staff attends to client's physical needs as necessary.
3. The staff helps the client identify thoughts or feelings that occurred prior to the onset
of the anxiety.
4. The staff assesses the client's need for medication or seclusion if other
interventions have failed to reduce anxiety. - ANSWERs-3
A 69-year-old client is undergoing his second exchange of intermittent
peritoneal dialysis (IPD). Which of the following would require an
intervention by the nurse?
1. The client complains of pain during the inflow of the dialysate.
2. The client complains of constipation.
3. The dialysate outflow is cloudy.
4. There is blood-tinged fluid around the intra-abdominal catheter. - ANSWERs-
3
The clinic nurse is performing diet teaching with a 67-year-old client
with acute gout. The nurse should teach the client to limit his intake of
1. red meat and shellfish.
2. cottage cheese and ice cream.