271. A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily
at bedtime. What action should the nurse take?
(correct Answer- Administer the medication as prescribed with a glass of water
272. Which client should the nurse assess frequently because of the risk
for overflow incontinence?
A client Who is confused and frequently forgets to go to the bathroom
273. While monitoring a client during a seizure, which interventions should
the nurse implement? (Select all that apply)
(correct Answer-
Move obstacle away from client
Monitor physical movements
Observe for a patent airway
Record the duration of the seizure
274. A male client with a long history of alcoholism is admitted because of
mild confusion and fine motor tremors. He reports that he quit drinking alcohol
and stopped smoking cigarettes one month ago after his brother died of lung
cancer.
,Which intervention is most important for the nurses to include in the client's plan
of care?
(correct Answer- Observe for changes in level of consciousness.
275. An older adult female admitted to the intensive care unit (ICU) with a
possible stroke is intubated with ventilator setting of tidal volume 600, PlO2
40%, and respiratory rate of 12 breaths/minute. The arterial blood gas (ABG)
results after intubation are PH 7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23.
To normalize the client's ABG finding, which action is required?
correct Answer- Increase ventilator rate.
276. The mother of the 12- month-old with cystic fibrosis reports that her child
is experiencing increasing congestion despite the use of chest physical therapy
(CPT) twice a day, and has also experiences a loss of appetite. What instruction
should the nurse provide?
(correct Answer- CPT should be performed more frequently, but at least an hour
before meals.
277. The nurse is evaluating the diet teaching of a client with hypertension.
What dinner selection indicates that the client understands the dietary
recommendationfor hypertension?
(correct Answer- Baked pork chop, applesauce, corn on the cob, 2% milk, and key-
lime pie
278. A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic
episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units
subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h
are prescribed. What action should the nurse include in this client's plan of care?
(correct Answer- Fingerstick glucose assessment q6h with meals
Review with the client proper foot care and prevention of injury
Coordinate carbohydrate controlled meals at consistent times and intervals
Teach subcutaneous injection technique, site rotation and insulin management
279. Which problem reported by a client taking lovastatin requires the
most immediate fallow up by the nurse?
,(correct Answer- Muscle pain
280. While assessing a client's chest tube (CT), the nurse discovers bubbling in
the water seal chamber of the chest tube collection device. The client's vital signs
are: blood pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate
32 breaths/minutes, oxygen saturation 88%. Which interventions should the nurse
implement?
(correct Answer- Provide supplemental oxygen
Auscultate bilateral lung fields
Reinforce occlusive CT dressing
281. Before leaving the room of a confused client, the nurse notes that a half
bow knot was used to attach the client's wrist restraints to the movable portion of
the client's bed frame. What action should the nurse take before leaving the
room?
(correct Answer- Ensure that the knot can be quickly released.
282. Oral antibiotics are prescribed for an 18-month-old toddler with severe
otitis media. An antipyrine and benzocaine-otic also prescribed for pain and
inflammation. What instruction should the nurse emphasize concerning the
installation of the antipyrine/benzocaine otic solution?
(correct Answer- Have the child lie with the ear up for one to two minute after
installation.
283. An older adult male is admitted with complications related to chronic
obstructive pulmonary disease (COPD). He reports progressive dyspnea that
worsens on exertion and his weakness has increased over the past month.
The nurse notes that he has dependent edema in both lower legs. Based on
these assessment findings, which dietary instruction should the nurse
provide?
(correct Answer- Restrict daily fluid intake.
284. The nurse inserts an indwelling urinary catheter as seen in the video
what action should the nurse take next?
(correct Answer- Leave the catheter in place and obtain a sterile catheter.
, 285. A client with coronary artery disease who is experiencing syncopal
episodes is admitted for an electrophysiology study (EPS) and possible cardiac
ablation therapy. Which intervention should the nurse delegate to the unlicensed
assistive personnel (UAP)?
(correct Answer- Prepare the skin for procedure.
286. Fallowing an outbreak of measles involving 5 students in an
elementary school, which action is most important for the school nurse to
take? (correct Answer- Restrict unvaccinated children from attending school
until measles outbreak is resolved.
287. A preeclamptic client who delivered 24h ago remains in the labor and
delivery recovery room. She continues to receive magnesium sulfate at 2 grams
per hour. Her total input is limited to 125 ml per hour, and her urinary output for
the last hour was 850 ml. What intervention should the nurse implement?
(correct Answer- Continue with the plan of care for this client
288. The nurse is planning care for a client who admits having suicidal
thoughts. Which client behavior indicates the highest risk for the client acting
on these suicidal thoughts?
(correct Answer- Begin to show signs of improvement in affect
289. When assessing a multigravida the first postpartum day, the nurse finds
a moderate amount of lochia rubra, with the uterus firm, and three
fingerbreadths above the umbilicus. What action should the nurse implement
first?
(correct Answer- Check for a destined bladder
290. A 12 year old client who had an appendectomy two days ago is receiving
0.9% normal saline at 50 ml/hour. The client's urine specific gravity is 1.035.
What action should the nurse implement?
(correct Answer- Encourage popsicles and fluids of choice
291. An older male client arrives at the clinic complaining that his bladder
always feels full. He complains of weak urine flow, frequent dribbling after
voiding, and
at bedtime. What action should the nurse take?
(correct Answer- Administer the medication as prescribed with a glass of water
272. Which client should the nurse assess frequently because of the risk
for overflow incontinence?
A client Who is confused and frequently forgets to go to the bathroom
273. While monitoring a client during a seizure, which interventions should
the nurse implement? (Select all that apply)
(correct Answer-
Move obstacle away from client
Monitor physical movements
Observe for a patent airway
Record the duration of the seizure
274. A male client with a long history of alcoholism is admitted because of
mild confusion and fine motor tremors. He reports that he quit drinking alcohol
and stopped smoking cigarettes one month ago after his brother died of lung
cancer.
,Which intervention is most important for the nurses to include in the client's plan
of care?
(correct Answer- Observe for changes in level of consciousness.
275. An older adult female admitted to the intensive care unit (ICU) with a
possible stroke is intubated with ventilator setting of tidal volume 600, PlO2
40%, and respiratory rate of 12 breaths/minute. The arterial blood gas (ABG)
results after intubation are PH 7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23.
To normalize the client's ABG finding, which action is required?
correct Answer- Increase ventilator rate.
276. The mother of the 12- month-old with cystic fibrosis reports that her child
is experiencing increasing congestion despite the use of chest physical therapy
(CPT) twice a day, and has also experiences a loss of appetite. What instruction
should the nurse provide?
(correct Answer- CPT should be performed more frequently, but at least an hour
before meals.
277. The nurse is evaluating the diet teaching of a client with hypertension.
What dinner selection indicates that the client understands the dietary
recommendationfor hypertension?
(correct Answer- Baked pork chop, applesauce, corn on the cob, 2% milk, and key-
lime pie
278. A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic
episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units
subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h
are prescribed. What action should the nurse include in this client's plan of care?
(correct Answer- Fingerstick glucose assessment q6h with meals
Review with the client proper foot care and prevention of injury
Coordinate carbohydrate controlled meals at consistent times and intervals
Teach subcutaneous injection technique, site rotation and insulin management
279. Which problem reported by a client taking lovastatin requires the
most immediate fallow up by the nurse?
,(correct Answer- Muscle pain
280. While assessing a client's chest tube (CT), the nurse discovers bubbling in
the water seal chamber of the chest tube collection device. The client's vital signs
are: blood pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate
32 breaths/minutes, oxygen saturation 88%. Which interventions should the nurse
implement?
(correct Answer- Provide supplemental oxygen
Auscultate bilateral lung fields
Reinforce occlusive CT dressing
281. Before leaving the room of a confused client, the nurse notes that a half
bow knot was used to attach the client's wrist restraints to the movable portion of
the client's bed frame. What action should the nurse take before leaving the
room?
(correct Answer- Ensure that the knot can be quickly released.
282. Oral antibiotics are prescribed for an 18-month-old toddler with severe
otitis media. An antipyrine and benzocaine-otic also prescribed for pain and
inflammation. What instruction should the nurse emphasize concerning the
installation of the antipyrine/benzocaine otic solution?
(correct Answer- Have the child lie with the ear up for one to two minute after
installation.
283. An older adult male is admitted with complications related to chronic
obstructive pulmonary disease (COPD). He reports progressive dyspnea that
worsens on exertion and his weakness has increased over the past month.
The nurse notes that he has dependent edema in both lower legs. Based on
these assessment findings, which dietary instruction should the nurse
provide?
(correct Answer- Restrict daily fluid intake.
284. The nurse inserts an indwelling urinary catheter as seen in the video
what action should the nurse take next?
(correct Answer- Leave the catheter in place and obtain a sterile catheter.
, 285. A client with coronary artery disease who is experiencing syncopal
episodes is admitted for an electrophysiology study (EPS) and possible cardiac
ablation therapy. Which intervention should the nurse delegate to the unlicensed
assistive personnel (UAP)?
(correct Answer- Prepare the skin for procedure.
286. Fallowing an outbreak of measles involving 5 students in an
elementary school, which action is most important for the school nurse to
take? (correct Answer- Restrict unvaccinated children from attending school
until measles outbreak is resolved.
287. A preeclamptic client who delivered 24h ago remains in the labor and
delivery recovery room. She continues to receive magnesium sulfate at 2 grams
per hour. Her total input is limited to 125 ml per hour, and her urinary output for
the last hour was 850 ml. What intervention should the nurse implement?
(correct Answer- Continue with the plan of care for this client
288. The nurse is planning care for a client who admits having suicidal
thoughts. Which client behavior indicates the highest risk for the client acting
on these suicidal thoughts?
(correct Answer- Begin to show signs of improvement in affect
289. When assessing a multigravida the first postpartum day, the nurse finds
a moderate amount of lochia rubra, with the uterus firm, and three
fingerbreadths above the umbilicus. What action should the nurse implement
first?
(correct Answer- Check for a destined bladder
290. A 12 year old client who had an appendectomy two days ago is receiving
0.9% normal saline at 50 ml/hour. The client's urine specific gravity is 1.035.
What action should the nurse implement?
(correct Answer- Encourage popsicles and fluids of choice
291. An older male client arrives at the clinic complaining that his bladder
always feels full. He complains of weak urine flow, frequent dribbling after
voiding, and
