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An older adult client recently transferred to a rehabilitation facility after aortic valve replacement
surgery is experiencing anxiety and difficulty adjusting to the transition to healthcare provider
prescribes an antidepressant and a mild sedative for sleep. Which intervention is most important
for the nurse to include in the clients plan of pet care?
A) Measure and record the clients urinary output every day.
B) Provide the client with teaching regarding a cardiac diet.
C) Obtain a blood pressure reading before client gets out of bed.
D) Obtain client vital signs every four hours one week. - Answer>>> C) Obtain a blood pressure
reading before client gets out of bed.
When preparing to administer a prescribed medication to a homeless male at a community
psychiatric clinic, the client tells the nurse that he usually takes a different dosage. Which action
should the nurse take?
A) Explain to the client that the dosage has been changed.
B) Tell him to take the medication and then verify the dosage at the next healthcare team
meeting.
C) Withhold the medication until the dosage can be confirmed.
D) Inform him that he may refuse the medication and document whether or not he takes it. -
Answer>>> C) Withhold the medication until the dosage can be confirmed.
A preschool age child who is being treated for streptococcal pharyngitis returns to the clinic for
signs of scarlet fever. Which assessment finding provides the earliest indication to the nurse that
the child is experiencing a reaction to the toxins that are created by the Streptococcus bacteria?
,A) Red bumps across chest.
B) White coating on tongue.
C) High, protracted fever.
D) Flaky, peeling skin. - Answer>>> B) White coating on tongue.
Client is being urgently transported to radiology for computerized tomograph he after a sudden
decreased level of consciousness. The client is orally intubated and has a left lateral chest tube to
20 cm section. What action is most important for the nurse to take?
A) Secure chest tube to the stretcher for transport.
B) Administer PRN medication prior to transport.
C) Keep chest tube container below the site of insertion.
D) Mark the amount of chest drainage on the container. - Answer>>> C) Keep chest tube
container below the site of insertion.
The nurse recognizes that the infant of a diabetic mother is at risk for _________ ,
_____________ , and _________________ - Answer>>> Hyperbilirubinemia , Resppiratory
Distress Syndrome , and Cardiomyopathy
NGN: Orders
Breast-feed immediately once stable then on demand. If unstable, may feed breastmilk via
orogastric tube. If two feeding attempts failed to increase the glucose levels or if symptoms of
hypoglycemia develop, apply dextrose gel inside the babies cheek. If the above are ineffective,
IV glucose should be administered to maintain glucose levels above 45. Bolus of 2mL/kg
glucose 10% IV, hello by a continuous glucose perfusion of 6 to 8mg/kg/min, maintain glycemic
levels over 40.
,A female client with fibromyalgia asked the nurse to arrange for hospice care to help her manage
the severe, chronic pain. Which intervention should the nurse provide to address the clients
problem?
A) Contact a hospice nurse for an evaluation.
B) Arrange an appointment with a pain specialist.
C) Form an interdisciplinary team for evaluation.
D) Ask for a consultation with a psychologist. - Answer>>> B) Arrange an appointment with a
pain specialist.
Three hours after birth, a newborn becomes jittery and tacky piña. What should the nurse do
first?
A) Obtain a capillary glucose level.
B) Feed 30 mL of 10% dextrose in water.
C) Wrapped tightly in a warm blanket.
D) Encourage the mother to breast-feed. - Answer>>> A) Obtain a capillary glucose level.
Nurse receives a shift report about a male client with obsessive-compulsive disorder. The nurse
completes morning rounds and approaches the client while he is repeatedly washing the top of
the same table. Which intervention should the nurse implement?
A) Allow time for the behavior and then redirect the client to other activities.
B) Teach the client thought stopping techniques and ways to refocus behavior.
C) Assist the client to identify stimuli that precipitate the activity.
D_ Encourage the client to be calm and relax for a little while. - Answer>>> A) Allow time for
the behavior and then redirect the client to other activities.
, Which 6 orders take priority?
A) Feed Immediately
B) Monitor for respiratory distress
C) Apply dextrose gell inside the baby's cheek
D) Keep in warmer with bilirubin lights
E) Monitor temp every 30 min
F) Bolus 2 mL/kg glucose 10% IV
G) Contact RT for ABG and oxygen therapy
H) Echo
I) Transfer to NICU
J) Blood glucose level - Answer>>> A) Feed Immedicately
B) Monitor for Respiratory Distress
D) Keep in warmer with bili lights
E) Monitor temp q30min
G) Contact RT for ABG and O2 therapy
J) Blood glucose level
NGN Laboratory Results (same case of patient who just gave birth)
Which actions are appropriate for the nurse to take at this time? SATA
A) Keep infant in warmer with bili lights to maintain temp of 97.6F
B) Monitor Temp
C) Continue to monitor glucose level
D) Tell the mother that she will need to discuss this with the neonatologist