answers
A nurse is caring for a client who has given informed consent for
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
ECT. Just before the procedure, the client tells the nurse she is
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
considering not going forward with the treatment. Which of the |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
following statements by the nurse is appropriate? |\ |\ |\ |\ |\ |\ |\
a. "You don't have to go through with the treatment."
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
b. "Most people who have this procedure feel better following the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
treatment."
|\ |\
c. "It's okay to be nervous before this treatment."
|\ |\ |\ |\ |\ |\ |\ |\ |\
d. "Your doctor wouldn't have ordered this treatment unless it
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
was necessary." - CORRECT ANSWERS ✔✔a. "You don't have to go
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
through with the treatment."
|\ |\ |\ |\
While performing a routine assessment, a nurse notices fraying
|\ |\ |\ |\ |\ |\ |\ |\ |\
on the electrical cord of a client's CPM device. Which of the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
following actions should the nurse take first? |\ |\ |\ |\ |\ |\ |\
a. Report the defect to the equipment maintenance staff.
|\ |\ |\ |\ |\ |\ |\ |\ |\
b. Ensure the device inspection sticker is current
|\ |\ |\ |\ |\ |\ |\ |\
c. Remove the device from the room
|\ |\ |\ |\ |\ |\ |\
d. Initiate a requisition for a replacement CPM device - CORRECT
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
ANSWERS ✔✔c. Remove the device from the room |\ |\ |\ |\ |\ |\ |\
,A nurse is caring for a client who is postoperative and has a new
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
prescription for hydromorphone. Which of the following actions |\ |\ |\ |\ |\ |\ |\ |\
should the nurse take? |\ |\ |\ |\
a. Document administration of the medication upon removal from
|\ |\ |\ |\ |\ |\ |\ |\
the medication dispensing system
|\ |\ |\ |\ |\
b. Withhold the medication if the client does not appear to be in
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
pain. |\
c. Count the current number of unit doses available in the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
medication dispensing system |\ |\ |\
d. Withhold the medication if the client has a fever - CORRECT
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
ANSWERS ✔✔c. Count the current number of unit doses available
|\ |\ |\ |\ |\ |\ |\ |\ |\
in the medication dispensing system
|\ |\ |\ |\ |\
A nurse performing a change-of-shift assessment. Which of the
|\ |\ |\ |\ |\ |\ |\ |\ |\
following clients has the priority finding? |\ |\ |\ |\ |\ |\
a. Type 2 DM and a blood glucose of 250 mg/dL
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
b. Pneumonia with a productive cough and a fever of 38.8° C
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
(101.8° F) |\ |\
c. 2 hr. post cast placement and has 2+ pitting edema and pallor
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
|\
d. First-degree heart block and a heart rate of 62/min - CORRECT
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
ANSWERS ✔✔c. 2 hr. post cast placement and has 2+ pitting
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
edema and pallor |\ |\
A nurse in an outpatient mental health facility is providing
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
teaching to a group of adolescents. Which of the following
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
statements by a client indicates an understanding of the |\ |\ |\ |\ |\ |\ |\ |\ |\
teaching? |\
,a. "I will limit my alcohol use to one drink daily while taking
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
disulfiram." |\
b. "I will avoid foods containing tyramine while taking
|\ |\ |\ |\ |\ |\ |\ |\ |\
fluoexetine." |\
c. "I will take the sustained-release methylphenidate every
|\ |\ |\ |\ |\ |\ |\ |\
morning." |\
d. "I will take my lithium on an empty stomach." - CORRECT
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
ANSWERS ✔✔c. "I will take the sustained-release
|\ |\ |\ |\ |\ |\ |\
methylphenidate every morning." |\ |\
A nurse in the emergency department is assessing client who has
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
major depressive disorder. Which of the following actions should
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the nurse take first?
|\ |\ |\ |\
a. Administer Zofran to the client for nausea
|\ |\ |\ |\ |\ |\ |\ |\
b. Implement seizure precautions for the client
|\ |\ |\ |\ |\ |\ |\
c. Encourage the client to verbalize feelings
|\ |\ |\ |\ |\ |\ |\
d. Obtain the client's weight - CORRECT ANSWERS ✔✔b.
|\ |\ |\ |\ |\ |\ |\ |\ |\
Implement seizure precautions for the client |\ |\ |\ |\ |\
A nurse is completing an admission assessment for a client who
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
has narcissistic personality disorder. Which of the following
|\ |\ |\ |\ |\ |\ |\ |\
should the nurse expect? |\ |\ |\ |\
a. Suspicious of others
|\ |\ |\ |\
b. Exhibits separation anxiety
|\ |\ |\ |\
c. Ritualistic behavior
|\ |\ |\
d. Preoccupied with aging - CORRECT ANSWERS ✔✔d.
|\ |\ |\ |\ |\ |\ |\ |\
Preoccupied with aging |\ |\
, A nurse is planning care for a group of clients and is working with
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
one LPN and one AP. Which of the following actions should the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
nurse take first to manage her time effectively?
|\ |\ |\ |\ |\ |\ |\ |\
a. Develop an hourly time frame for tasks
|\ |\ |\ |\ |\ |\ |\ |\
b. Schedule daily activities
|\ |\ |\ |\
c. Determine goals of the day
|\ |\ |\ |\ |\ |\
d. Delegate tasks to the AP - CORRECT ANSWERS ✔✔c.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
Determine goals of the day |\ |\ |\ |\
A nurse is developing a plan of care for a client who has
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
preeclampsia and is to receive magnesium sulfate via continuous |\ |\ |\ |\ |\ |\ |\ |\
IV infusion. Which of the following actions should the nurse
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
include in the plan? |\ |\ |\ |\
a. Restrict the client's total fluid intake to 250 mL/hr.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
b. Measure the client's urine output every hour
|\ |\ |\ |\ |\ |\ |\ |\
c. Give the client protamine if signs of magnesium sulfate toxicity
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
occur
|\ |\
d. Monitor the FHR via Doppler every 30 min - CORRECT
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
ANSWERS ✔✔b. Measure the client's urine output every hour
|\ |\ |\ |\ |\ |\ |\ |\
A nurse is caring for a group of clients. Which of the following
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
wounds should the nurse expect to heal by primary intention?
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
a. Infected laceration
|\ |\ |\
b. Stage II pressure ulcer
|\ |\ |\ |\ |\
c. Approximated surgical incision
|\ |\ |\ |\