Comprehensive practice B 2020
A nurse at a long-term care facility is caring for a client who requires oral
suctioning. Which of the following supplies should the nurse plan to use for this
task? - CORRECT ANSWER-yankeurs catheter
Rationale:
A Yankauer catheter is a clean suction catheter used when performing oral and
oropharyngeal suctioning to remove secretions from the client's mouth to
facilitate breathing or obtain a sample for diagnostic evaluation.
A nurse is caring for a client following a bronchoscopy. Which of the following
actions should the nurse take first? - CORRECT ANSWER-check for gag reflex
Rationale:
The greatest risk to this client is injury from aspiration. Therefore, the first action
the nurse should take is to check for a gag reflex.
A nurse is collecting data from a client who is in severe pain. Which of the
following questions should the nurse ask first? - CORRECT ANSWER-where is
your pain located
A nurse is collecting data from a postpartum client who had a vaginal birth 2 days
ago. Which Of the following findings is the nurse's priority to report to the
provider? - CORRECT ANSWER-client reports burning with urination.
Rationale:
When using the urgent vs. non-urgent approach to client care, the nurse should
determine that dysuria is a manifestation of a urinary tract infection. Therefore,
the nurse should identify this as the priority finding to report to the provider.
A nurse is reinforcing teaching about stress management techniques with a client
who has moderate anxiety disorder. Which of the following responses by the
client indicates an understanding of the teaching? - CORRECT ANSWER-i will
imagine myself in a calm place when i cant concentrate
,A charge nurse in a long-term care facility notices an assistive personnel's (AP)
repeated failure to provide oral care for clients. Which of the following actions
should the charge nurse take? - CORRECT ANSWER-Discuss this behavior with
the AP while reinforcing expectations.
Rationale:
The charge nurse should discuss this behavior with the AP and reinforce
expectations moving forward. Evaluation of the AP's performance is a part of the
nurse's delegation process. Teaching and counseling the AP about behaviors
and expectations is an important component of leadership.
A nurse is reinforcing discharge instructions with the parent of an infant who has
rotavirus. Which of the following statements by the parent indicates an
understanding of the teaching? - CORRECT ANSWER-i will apply diaper cream
to my baby skin during each diaper change
rationale: The nurse should reinforce to the parent that applying a skin barrier,
such as zinc oxide, during diaper changes will minimize skin irritation from
frequent stools.
A nurse is reinforcing teaching with a client regarding prescribed asthma
medications. The nurse should instruct the client to use which of the following
medications for treatment of an acute asthma attack? - CORRECT
ANSWER-albuterol
Rationale:
The nurse should instruct the client to use albuterol, a bronchodilator, to relieve
the bronchospasms of an acute asthma attack.
A nurse is collecting data from a client who has multiple fractures following a
motor-vehicle crash. For which of the following client statements should the
nurse recommend a referral to an occupational therapist? - CORRECT
ANSWER-i am so frustrated i cannot even open my milk carton for breakfast
A nurse is caring for a client who has an altered mental status and has become
aggressive. Which of the following prescriptions should the nurse clarify with the
provider prior to administration? - CORRECT ANSWER-Zolipedem
,A nurse is reinforcing teaching with a client who has hypothyroidism and a
prescription for levothyroxine. Which of the following instructions should the
nurse include in the teaching? - CORRECT ANSWER-you will need to take the
medication for the rest of your life
Rationale:
Hypothyroidism is a chronic disorder that requires lifelong thyroid hormone
replacement therapy.
Needs to be taken 30-60 min before breakfast bc food affects the absorption
level.
Needs to be taken in morning bc can result in insomnia
A nurse is collecting data from a client who has myasthenia gravis (MG). Which
of the following images should the nurse identify as an indication that the client is
experiencing ptosis? - CORRECT ANSWER-C. the guy with one drooping eye
and has a unibrow
Rationale:
This is an example of ptosis, in which there is abnormal drooping of the upper
eyelid. Ptosis, along with diplopia, are early manifestations of MG.
A nurse is preparing to administer a client's morning medications. Which of the
following actions should the nurse take to verify the client's identity? - CORRECT
ANSWER-scan the client facility identification band.
A nurse is reinforcing teaching with a newborn's parents about umbilical cord
care. Which Of the following statements by a parent indicates an understanding
Of the instructions? - CORRECT ANSWER-i will give our baby sponge baths
until the cord falls off.
A nurse at a long-term care facility is part of a team preparing a report on the
quality of care at the facility. Which of the following information should the nurse
recommend including in the report to demonstrate improvement in care quality? -
CORRECT ANSWER-the facility has 12% fewer urinary tract infection over the
past 6 months.
, A nurse in a provider's office is collecting data from a preschooler. Which of the
following findings should the nurse report to the provider? - CORRECT
ANSWER-heart rate 146/min
A nurse is performing vision testing for a client following a head injury. Which of
the following findings should the nurse identify as a problem with pupil
accommodation? - CORRECT ANSWER-lack of change in the pupil size when
the client looks form a far to near object.
A nurse is contributing to the plan of care for a client who is at risk of developing
pressure injuries. Which of the following interventions should the nurse include? -
CORRECT ANSWER-place the client in a 30 lateral position
A nurse is transferring a client from a bed to a wheelchair. The client has
right-sided weakness following a recent stroke. Which of the following actions
should the nurse take? - CORRECT ANSWER-Place the wheelchair on the
clients left side.
Rationale:
The nurse should place the wheelchair on the client's stronger side to reduce the
risk of falling.
A nurse is contributing to the plan of care for a client who is newly diagnosed with
iron deficiency anemia. Which of the following foods should the nurse include in
the plan as having the highest amount of iron? - CORRECT ANSWER-boiled
spinach
A nurse is preparing to administer insulin to a client who has type 1 diabetes
mellitus. After drawing up the medication, the nurse accidentally brushes the
needle on the counter's surface. Which of the following actions should the nurse
take? - CORRECT ANSWER-prepare a new dose of insulin injection
A nurse is contributing to the plan of care for a client who has a chest tube
connected to a closed drainage system. Which of the following interventions
should the nurse include? - CORRECT ANSWER-maintain the drainage below
the level of the clients chest.
A nurse at a long-term care facility is caring for a client who requires oral
suctioning. Which of the following supplies should the nurse plan to use for this
task? - CORRECT ANSWER-yankeurs catheter
Rationale:
A Yankauer catheter is a clean suction catheter used when performing oral and
oropharyngeal suctioning to remove secretions from the client's mouth to
facilitate breathing or obtain a sample for diagnostic evaluation.
A nurse is caring for a client following a bronchoscopy. Which of the following
actions should the nurse take first? - CORRECT ANSWER-check for gag reflex
Rationale:
The greatest risk to this client is injury from aspiration. Therefore, the first action
the nurse should take is to check for a gag reflex.
A nurse is collecting data from a client who is in severe pain. Which of the
following questions should the nurse ask first? - CORRECT ANSWER-where is
your pain located
A nurse is collecting data from a postpartum client who had a vaginal birth 2 days
ago. Which Of the following findings is the nurse's priority to report to the
provider? - CORRECT ANSWER-client reports burning with urination.
Rationale:
When using the urgent vs. non-urgent approach to client care, the nurse should
determine that dysuria is a manifestation of a urinary tract infection. Therefore,
the nurse should identify this as the priority finding to report to the provider.
A nurse is reinforcing teaching about stress management techniques with a client
who has moderate anxiety disorder. Which of the following responses by the
client indicates an understanding of the teaching? - CORRECT ANSWER-i will
imagine myself in a calm place when i cant concentrate
,A charge nurse in a long-term care facility notices an assistive personnel's (AP)
repeated failure to provide oral care for clients. Which of the following actions
should the charge nurse take? - CORRECT ANSWER-Discuss this behavior with
the AP while reinforcing expectations.
Rationale:
The charge nurse should discuss this behavior with the AP and reinforce
expectations moving forward. Evaluation of the AP's performance is a part of the
nurse's delegation process. Teaching and counseling the AP about behaviors
and expectations is an important component of leadership.
A nurse is reinforcing discharge instructions with the parent of an infant who has
rotavirus. Which of the following statements by the parent indicates an
understanding of the teaching? - CORRECT ANSWER-i will apply diaper cream
to my baby skin during each diaper change
rationale: The nurse should reinforce to the parent that applying a skin barrier,
such as zinc oxide, during diaper changes will minimize skin irritation from
frequent stools.
A nurse is reinforcing teaching with a client regarding prescribed asthma
medications. The nurse should instruct the client to use which of the following
medications for treatment of an acute asthma attack? - CORRECT
ANSWER-albuterol
Rationale:
The nurse should instruct the client to use albuterol, a bronchodilator, to relieve
the bronchospasms of an acute asthma attack.
A nurse is collecting data from a client who has multiple fractures following a
motor-vehicle crash. For which of the following client statements should the
nurse recommend a referral to an occupational therapist? - CORRECT
ANSWER-i am so frustrated i cannot even open my milk carton for breakfast
A nurse is caring for a client who has an altered mental status and has become
aggressive. Which of the following prescriptions should the nurse clarify with the
provider prior to administration? - CORRECT ANSWER-Zolipedem
,A nurse is reinforcing teaching with a client who has hypothyroidism and a
prescription for levothyroxine. Which of the following instructions should the
nurse include in the teaching? - CORRECT ANSWER-you will need to take the
medication for the rest of your life
Rationale:
Hypothyroidism is a chronic disorder that requires lifelong thyroid hormone
replacement therapy.
Needs to be taken 30-60 min before breakfast bc food affects the absorption
level.
Needs to be taken in morning bc can result in insomnia
A nurse is collecting data from a client who has myasthenia gravis (MG). Which
of the following images should the nurse identify as an indication that the client is
experiencing ptosis? - CORRECT ANSWER-C. the guy with one drooping eye
and has a unibrow
Rationale:
This is an example of ptosis, in which there is abnormal drooping of the upper
eyelid. Ptosis, along with diplopia, are early manifestations of MG.
A nurse is preparing to administer a client's morning medications. Which of the
following actions should the nurse take to verify the client's identity? - CORRECT
ANSWER-scan the client facility identification band.
A nurse is reinforcing teaching with a newborn's parents about umbilical cord
care. Which Of the following statements by a parent indicates an understanding
Of the instructions? - CORRECT ANSWER-i will give our baby sponge baths
until the cord falls off.
A nurse at a long-term care facility is part of a team preparing a report on the
quality of care at the facility. Which of the following information should the nurse
recommend including in the report to demonstrate improvement in care quality? -
CORRECT ANSWER-the facility has 12% fewer urinary tract infection over the
past 6 months.
, A nurse in a provider's office is collecting data from a preschooler. Which of the
following findings should the nurse report to the provider? - CORRECT
ANSWER-heart rate 146/min
A nurse is performing vision testing for a client following a head injury. Which of
the following findings should the nurse identify as a problem with pupil
accommodation? - CORRECT ANSWER-lack of change in the pupil size when
the client looks form a far to near object.
A nurse is contributing to the plan of care for a client who is at risk of developing
pressure injuries. Which of the following interventions should the nurse include? -
CORRECT ANSWER-place the client in a 30 lateral position
A nurse is transferring a client from a bed to a wheelchair. The client has
right-sided weakness following a recent stroke. Which of the following actions
should the nurse take? - CORRECT ANSWER-Place the wheelchair on the
clients left side.
Rationale:
The nurse should place the wheelchair on the client's stronger side to reduce the
risk of falling.
A nurse is contributing to the plan of care for a client who is newly diagnosed with
iron deficiency anemia. Which of the following foods should the nurse include in
the plan as having the highest amount of iron? - CORRECT ANSWER-boiled
spinach
A nurse is preparing to administer insulin to a client who has type 1 diabetes
mellitus. After drawing up the medication, the nurse accidentally brushes the
needle on the counter's surface. Which of the following actions should the nurse
take? - CORRECT ANSWER-prepare a new dose of insulin injection
A nurse is contributing to the plan of care for a client who has a chest tube
connected to a closed drainage system. Which of the following interventions
should the nurse include? - CORRECT ANSWER-maintain the drainage below
the level of the clients chest.
