Question: A nurse on a medical unit is planning care for an older adult client who takes several medications. Which of the following prescribed medications places the client at risk for orthostatic hypotension? (Select all that apply.)
Answer Options: Atorvastatin Diltiazem Clopidogrel Telmisartan Furosemide
Answer: Diltiazem, Telmisartan, Furosemide
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Question: A nurse is preparing to develop a plan of care for a school-aged child who has been hospitalized.
Answer Options: Celiac disease Intussusception Peptic ulcer disease Bacterial pneumonia Acute kidney injury Word Choices for cause: Helicobacter pylori BUN level Platelet level Potassium level Blood pressure
Answer: Peptic ulcer disease due to Helicobacter pylori
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Question: A nurse in a clinic is reviewing the laboratory values of a client who has primary hypothyroidism. The nurse should anticipate an elevation of which of the following laboratory values?
Answer Options: Serum T3 Free T4 Serum T4 Thyroid stimulating hormone (TSH)
Answer: Thyroid stimulating hormone (TSH)
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Question: A nurse is preparing to administer acetaminophen 10 mg/kg/dose to a child who weighs 28 lb. The amount available is acetaminophen 120 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth.)
Answer Options: [Blank space for response]
Answer: 5.3 mL
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Question: A nurse working for a home health agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address?
Answer Options: Swollen gums Dysphagia Urinary hesitancy Pruritus
Answer: Dysphagia
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Question: A nurse is caring for a client who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select all that apply.)
Answer Options: Elevate the head of the bed to at least 30° Apply restraints if the client becomes agitated Verify the prescribed ventilator settings daily Reposition the endotracheal tube to the opposite side of the mouth daily Administer pantoprazole as prescribed
Answer: Elevate the head of the bed to at least 30°, Verify the prescribed ventilator settings daily, Reposition the endotracheal tube to the opposite side of the mouth daily, Administer pantoprazole as prescribed
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Question: A nurse is preparing to administer amoxicillin 500 mg PO four times a day to a client. The amount available is amoxicillin suspension 250 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number.)
Answer Options: [Blank space for response]
Answer: 10 mL
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Question: A nurse is assessing a client who is receiving IV vancomycin. The nurse notes a flushing of the neck and tachycardia. Which of the following actions should the nurse take?
Answer Options: Document that the client experienced an anaphylactic reaction to the medication. Change the IV infusion site. Apply cold compresses to the neck area. Decrease the infusion rate on the IV.
Answer: Decrease the infusion rate on the IV
Question: A nurse is creating home instructions for a client who has immunodeficiency. Which of the following statements by the client indicates an understanding of the teaching?
Answer Options: I will expect to have a mild, occasional fever. I might experience harmless white patches in my mouth. I will limit the use of skin cream to once a week. I will avoid people who have just received a live vaccine.
Answer: I will avoid people who have just received a live vaccine.
Question: A nurse is presenting a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident best indicates an understanding of the teaching?
Answer Options: I should place a throw rug over electrical cords. It is a good idea to use the handrails in the bathroom. I should get a longer cord for my telephone. I should use chairs without armrests.
Answer: It is a good idea to use the handrails in the bathroom.
Question: A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse’s priority?
Answer Options: Blood pressure 80/56 mm Hg Temperature 38.2°C (100.8°F) The client reports some itching. The client reports weakness of the lower extremities.
Answer: The client reports weakness of the lower extremities.
Question: A nurse is teaching self-management to a client who has hepatitis B. Which of the following instructions should the nurse include in the teaching?
Answer Options: Rest frequently throughout the day. Take acetaminophen every 4 hr, as needed, for discomfort. Consume a high-protein diet. You may donate blood 6 months after completing the medication regimen.
Answer: Rest frequently throughout the day.
Question: A nurse is caring for a client who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client?
Answer Options: Approach the client frequently throughout the day for brief interactions. Adopt a neutral attitude when providing care. Disclose some personal information to the client to demonstrate approachability. Wait for the client to initiate interaction.
Answer: Approach the client frequently throughout the day for brief interactions.
Question: A nurse is teaching a newborn’s parent to care for the umbilical cord stump. Which of the following instructions should the nurse include?
Answer Options: Wash the cord daily with mild soap and water. Give a sponge bath until the cord stump falls off. Cover the cord with the diaper. Apply petroleum jelly to the cord stump.
Answer: Give a sponge bath until the cord stump falls off.
Question: A nurse is caring for a newborn who has hydrocephalus. Which of the following manifestations should the nurse expect to find?
Answer Options: Dilated scalp veins Over-riding suture lines A backward sloping appearance of the forehead Hypertension
Answer: Dilated scalp veins.
Question: A nurse is speaking with the mother of a 6-year-old child. Which of the following statements by the mother should concern the nurse?
Answer Options: My child often cheats when we play board games. Sometimes my child acts bossy with his friends. The teacher says my child has to squint to see the board. My child has recently lost both front top teeth.
Answer: The teacher says my child has to squint to see the board.
Question: A nurse is teaching a client who has rheumatoid arthritis about taking methotrexate. Which of the following information should the nurse include?
Answer Options: Take the medication with an NSAID. Take an antiemetic 1 hr following administration. Rinse mouth 2 times per day with an alcohol-based mouthwash. Drink 2 to 3 L of water per day.
Answer: Drink 2 to 3 L of water per day.