Question: A nurse and an assistive personnel (AP) are providing care for four clients. The nurse should delegate meal assistance for which of the following clients to the AP?
Answer Choices:
– A client who has a lumbosacral spinal tumor
\n- A client who has systemic sclerosis
\n- A client who has Guillain-Barre syndrome
\n- A client who has amyotrophic lateral sclerosis (ALS)
Answer: A client who has a lumbosacral spinal tumor
Question: A nurse is reviewing the medical record of a client who reports drinking three to four glasses of wine each night and taking 3,000 mg of acetaminophen daily. Which laboratory value is priority?
Answer Choices:
– Aspartate aminotransferase (AST)
\n- Antidiuretic hormone (ADH)
\n- Creatinine
\n- Amylase
Answer: Aspartate aminotransferase (AST)
Question: A nurse on the psychiatric unit is assessing a client who has moderate anxiety disorder. Which of the following findings should the nurse expect?
Answer Choices:
– Rapid speech
\n- Chills
\n- Urinary frequency
\n- Distorted perceptual field
Answer: Rapid speech
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\nQuestion 67 [There appears to be a gap – this question wasn’t shown in our conversation]
Question: [Case study about client with potential bacterial meningitis]
Answer Choices:
[Diagram completion question]
Answer: Potential Condition: Bacterial Meningitis
\nActions to Take:
\n1. Prepare to administer IV antibiotics
\n2. Ensure oxygen and suctioning equipment are readily available
\nParameters to Monitor:
\n1. Level of consciousness
\n2. WBC count
Question: A nurse is teaching a client who has a new prescription for pancrelipase to aid in digestion. The nurse should inform the client to expect which of the following gastrointestinal changes?
Answer Choices:
– Decreased fat in stools
\n- Decreased watery stools
\n- Decreased black tarry stools
\n- Decreased mucus in stools
Answer: Decreased fat in stools
Question: A nurse is caring for a client who is 2 hr postoperative after having a total abdominal hysterectomy. The client is at risk for developing what? Answer Options (to fill in blanks): – Pressure injuries – Diarrhea – Pneumonia – Urinary retention – Deep vein thrombosis – Endometritis
Answer Choices:
Answer: Pneumonia, Deep vein thrombosis, and Urinary retention
Question: A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?
Answer Choices:
– Edema
\n- Hair loss
\n- Dependent rubor
\n- Thick, deformed toenails
Answer: Edema
Question: A nurse is caring for a client who is participating in a research study for an experimental chemotherapy medication. After three treatments, the experimental medication is discontinued due to evidence of rapidly advancing kidney failure. The nurse should understand discontinuing this medication demonstrates which of the following ethical principles?
Answer Choices:
– Fidelity
\n- Autonomy
\n- Nonmaleficence
\n- Veracity
Answer: Nonmaleficence
Question: A nurse is teaching a client about carbon monoxide poisoning. Which of the following statements should the nurse identify as an indication that the client needs further instruction?
Answer Choices:
– “Breathing in carbon monoxide can cause headaches and nausea”
\n- “I can detect the presence of carbon monoxide by a metallic odor”
\n- “I should purchase a carbon monoxide detector for my home”
\n- “A high concentration of carbon monoxide can cause death”
Answer: “I can detect the presence of carbon monoxide by a metallic odor”
Question: A nurse is preparing to remove an NG tube from a client. Which of the following actions should the nurse take first?
Answer Choices:
– Verify the provider’s prescription to discontinue the tube
\n- Provide mouth care to the client
\n- Perform hand hygiene
\n- Disconnect the tube from the wall suction
Answer: Verify the provider’s prescription to discontinue the tube
Question: A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?
Answer Choices:
– Oriented to person, place, and year
\n- Severe headache
\n- Bradycardia
\n- Blurred vision
Answer: Severe headache
Question: A nurse is triaging victims of a multiple motor-vehicle crash. The nurse assesses a client trapped under a car who is apneic and has a weak pulse at 120/min. After repositioning his upper airway, the client remains apneic. Which action should the nurse take?
Answer Choices:
– Place a red tag on the client’s upper body and obtain immediate help
\n- Start CPR
\n- Reposition the client’s upper airway a second time
\n- Place a black tag on the client’s upper body
Answer: Place a red tag on the client’s upper body and obtain immediate help
Question: A nurse is caring for a client who suspects recent exposure to inhalation anthrax. Which of the following findings indicate possible exposure?
Answer Choices:
– Respiratory failure
\n- Vesicles on the skin
\n- Flu-like symptoms
\n- Sloughing of skin
Answer: Flu-like symptoms
Question: A nurse is instructing a female client on obtaining a midstream urine specimen. Which of the following statements by the client indicates an understanding of the teaching?
Answer Choices:
– “I should not collect a urine sample when I am menstruating”
\n- “I need to urinate a small amount in the toilet before collecting the sample”
\n- “I should let the urine cool to room temperature before sending it to the lab”
\n- “I will wipe from the back to front with the cleansing cloth”
Answer: “I need to urinate a small amount in the toilet before collecting the sample”