Question: A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?
Answer Options: Hypokalemia Heart rate 160/min Mottled skin Blood pressure 115/68 mmHg
Answer: Heart rate 160/min
Question: Which of the following is an appropriate nursing intervention for this client at this time?
Answer Options: Wrap the residual limb with an elastic bandage in a figure-eight configuration. Wrap the residual limb with an elastic bandage in a proximal-to-distal direction. Secure the elastic bandage to the lowest joint. Remove the elastic bandage and re-wrap the residual limb once a day.
Answer: Wrap the residual limb with an elastic bandage in a figure-eight configuration.
Question: Which of the following actions should the nurse take? (3 days postoperative following an above-the-knee amputation)
Answer Options: Have the client lie prone several times per day. Elevate the stump on a pillow. Elevate the foot of the bed. Encourage the client to sit up as much as possible.
Answer: Have the client lie prone several times per day.
Question: The nurse should monitor the client for which of the following complications? (Cervical spinal cord injury)
Answer Options: Hypotension Weakened gag reflex Absence of bowel sounds Hyperthermia Polyuria
Answer: Hypotension Weakened gag reflex Absence of bowel sounds Hyperthermia
Question: Which of the following findings should the nurse expect? (HIV infection with dementia, progressed to AIDS)
Answer Options: Increased WBC count Night sweats Weight gain Increased hemoglobin
Answer: Night sweats
Question: Which of the following instructions should the nurse include? (GERD management)
Answer Options: Drink milk to soothe your stomach. Eat four small meals each day. Sleep on your left side. Wait to go to bed for 1 hour after eating.
Answer: Eat four small meals each day.
Question: Which of the following findings indicated that the client is ready for discharge? (IV conscious sedation for colonoscopy)
Answer Options: The client is restless. The client shows a sluggish response to stimulus. The client is cooperative and oriented. The client shows a brisk response to stimulus.
Answer: The client is cooperative and oriented.
Question: Which of the following laboratory findings should the nurse identify as an indication of postoperative infection?
Answer Options: Elevated erythrocyte sedimentation rate Negative leukocyte esterase in urine Absence of ketones in urine Increased band neutrophils Increased hemoglobin
Answer: Elevated erythrocyte sedimentation rate Increased band neutrophils
Question: The nurse anticipates which of the following orders from the provider based on the suspected diagnosis?
Answer Options: Urinalysis Airborne precautions IV antibiotics Chest x-ray Draw an STI lab panel Chest tube placement Admit to inpatient Complete blood count
Answer: IV antibiotics Chest x-ray Complete blood count
Question: Which of the following information should the nurse confirm about AMI (antibody-mediated immunity)?
Answer Options: AMI defends only against viral infections. Humoral immune response is mediated by T-lymphocytes. AMI is mediated by antibodies produced by B-lymphocytes. AMI involves phagocytic natural killer cells.
Answer: AMI is mediated by antibodies produced by B-lymphocytes.
Question: Which of the following instructions should the nurse include in the teaching? (Seizure precautions)
Answer Options: Insert a padded tongue blade into the client’s mouth. Move objects away from the client. Place the client on his back. Restrain the client.
Answer: Move objects away from the client.
Question: Which of the following actions should the nurse take? (Clostridium difficile infection)
Answer Options: Disinfect equipment in the client’s room daily. Have the client wear a mask when out of the room. Use alcohol hand sanitizer after completing tasks for the client. Place the client in a protective environment.
Answer: Disinfect equipment in the client’s room daily.
Question: Which of the following is an appropriate conclusion based on this data? (Glasgow Coma Scale: Eye opening 3, Verbal 5, Motor 5)
Answer Options: The client can follow simple motor commands. The client is unconscious. The client is unable to make vocal sounds. The client opens his eyes when spoken to.
Answer: The client opens his eyes when spoken to.
Question: Which of the following actions should the nurse include in the client’s plan of care? (T4 spinal cord injury, risk of UTI)
Answer Options: Offer the client the bedpan every 2 hr. Obtain a prescription for an indwelling urinary catheter. Cleanse the perineum from back to front. Encourage fluid intake at and between meals.
Answer: Encourage fluid intake at and between meals.
Question: Which of the following actions should the nurse take? (Postoperative after total hip arthroplasty, nausea and vomiting)
Answer Options: Insert a nasogastric tube. Administer an antiemetic. Auscultate bowel sounds. Encourage use of the incentive spirometer.
Answer: Administer an antiemetic.
Question: A nurse is teaching discharge instructions to a client who has a right above-the-knee amputation. Which of the following information should the nurse include to prevent complications?
Answer Options: Place a pillow between your legs. Keep your leg at a 30° elevation while in bed. Lie on your abdomen every 4 hours for 30 minutes. Use a soft mattress at home.
Answer: Lie on your abdomen every 4 hours for 30 minutes.
Question: A nurse is providing education about treatment options for a client who has genital herpes simplex virus 2 (HSV-2). Which of the following information should the nurse include?
Answer Options: Treatment of outbreaks can include oral and topical medications. Use oil-based lubricants during outbreaks to treat pain with intercourse. Cryotherapy can decrease the likelihood that the vesicles will cause cancer. Antiviral medications taken daily will prevent transmission.
Answer: Treatment of outbreaks can include oral and topical medications.
Question: A nurse is teaching a client who is scheduled for a surgical procedure with moderate (conscious) sedation. Which of the following client statements indicates an understanding of the teaching?
Answer Options: I might be able to hear my surgeon speaking to me during the surgery. I will be alert during the surgery. I will need a breathing tube inserted before the surgery. I might be able to drive home after the surgery.
Answer: I might be able to hear my surgeon speaking to me during the surgery.
Question: A nurse is caring for a client who develops diabetic ketoacidosis. Which of the following actions should the nurse take first?
Answer Options: Monitor blood glucose levels. Initiate an IV infusion of 0.9% sodium chloride. Administer regular insulin IV. Check the client’s level of consciousness.
Answer: Initiate an IV infusion of 0.9% sodium chloride.
Question: A nurse in the emergency department is assessing a client who has a head injury. Which of the following assessments should the nurse complete first?
Answer Options: Test the client’s pupil reactivity. Measure the client’s oxygen saturation level. Determine the client’s pulse pressure. Obtain the client’s Glasgow Coma Scale score.
Answer: Obtain the client’s Glasgow Coma Scale score.