Question: A nurse is assessing a client who is receiving a unit of packed red blood cells. Which of the following findings is a manifestation of an acute hemolytic reaction?
Answer Options:
Distended neck veins
Client report of tinnitus
Client report of low back pain
A productive cough
Answer: Client report of low back pain
Question: A nurse is caring for a client who has autism spectrum disorder. Which of the following findings should the nurse expect? (Select all that apply.)
Answer Options:
Spinning a toy repetitively
Delayed language development
Speaking with direct eye contact
Long attention span
Ritualistic behavior
Answer: Spinning a toy repetitively
Delayed language development
Ritualistic behavior
Question: A nurse is assessing a client prior to administering atenolol. Which of the following findings should prompt the nurse to withhold the medication?
Answer Options:
Respiratory rate 18/min
Blood pressure 160/94 mm Hg
Heart rate 46/min
Oxygen saturation 95%
Answer: Heart rate 46/min
Question: A nurse manager has recently become aware of a conflict between the pharmacy and the staff nurses regarding sending and receiving medications. Which of the following actions should the nurse take first to resolve the conflict?
Answer Options:
Brainstorm solutions.
Evaluate the results.
Implement a resolution.
Identify the problem.
Answer: Identify the problem.
Question: A nurse is teaching a client about preventing osteoporosis. Which of the following statements by the client indicates a need for further teaching?
Answer Options:
“I will decrease my intake of caffeine.”
“I will limit my intake of soft drinks.”
“I will reduce my intake of vitamin K-rich foods.”
“I will reduce my intake of sodium.”
Answer: “I will reduce my intake of vitamin K-rich foods.”
Question: A community health nurse is reviewing the levels of disease prevention. Which of the following activities is an example of tertiary prevention?
Answer Options:
Performing screening for sexually transmitted infections
Administering influenza immunizations at a local health fair
Testing new nurses for exposure to tuberculosis
Providing treatment for clients who have chronic obstructive pulmonary disease
Answer: Providing treatment for clients who have chronic obstructive pulmonary disease
Question: A nurse is working with an emergency response team in caring for a group of people who may have been exposed to anthrax while doing farm work. Which of the following is the appropriate action for the nurse to take?
Answer Options:
Administer antibiotic therapy.
Treat clients with an antitoxin.
Place the clients in isolation.
Initiate client decontamination.
Answer: Administer antibiotic therapy.
Question: A nurse is teaching a client about car seat use for their newborn. Which of the following information should the nurse include?
Answer Options:
Place the retainer clip across the newborn’s abdomen.
Keep the car seat rear-facing until the newborn can sit unsupported.
Position the newborn at a 45-degree angle in the car seat.
Place the shoulder harness straps below the level of the newborn’s armpits.
Answer: Position the newborn at a 45-degree angle in the car seat.
Question: A nurse is caring for an adolescent client with a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take?
Answer Options:
Apply an ice pack to the casted leg.
Perform a neurovascular assessment.
Explain the discharge instructions to the client and parents.
Provide reassurance to the client and parents.
Answer: Perform a neurovascular assessment.
Question: A nurse is assessing a client 15 minutes after administering morphine sulfate 2 mg via IV push. Which of the following findings should the nurse identify as an adverse effect of the medication?
Answer Options:
SaO₂ 94%
Respiratory rate 8/min
Pain level of 6 on a scale from 0 to 10
Sleepy, but arousing when her name is called
Answer: Respiratory rate 8/min
Question: A nurse is caring for a client with acute pancreatitis. After treating the client’s pain, which of the following interventions should the nurse address as the priority?
Answer Options:
Assist the client to a side-lying position.
Withhold oral fluids and food.
Auscultate the client’s lungs.
Provide oral hygiene.
Answer: Auscultate the client’s lungs.
Question: A nurse is providing care for a client who has bipolar disorder and is in the manic phase. Which of the following room assignments should the nurse give the client?
Answer Options:
A semi-private room across from the day room
A private room in a quiet location on the unit
A semi-private room across from the snack area
A private room across from the exercise room
Answer: A private room in a quiet location on the unit
Question: A nurse is teaching a group of nurses about smallpox. Which of the following statements by one of the nurses indicates an understanding of the teaching?
Answer Options:
Smallpox lesions appear in various stages of healing.
There are rare, occasional occurrences of smallpox.
Unlike chickenpox, the vesicles of smallpox are more abundant on the face.
Vaccination against smallpox provides lifelong immunity.
Answer: Unlike chickenpox, the vesicles of smallpox are more abundant on the face.
Question: A nurse is preparing to administer vancomycin 500 mg PO daily, divided into four equal doses. The amount available is vancomycin 125 mg capsules. How many capsules should the nurse administer with each dose?
Answer Options:
Answer: 1 capsule per dose
Question: A nurse is caring for a client who has a chest tube in place connected to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client’s lung has re-expanded?
Answer Options:
Occasional bubbling in the water-seal chamber
No reports of pleuritic chest pain
No fluctuations in the water-seal chamber
Oxygen saturation of 95%
Answer: No fluctuations in the water-seal chamber
Question: A nurse is preparing to administer lansoprazole 30 mg PO daily to a client. The amount available is lansoprazole 10 mg/tablet. How many tablets should the nurse administer per dose?
Answer Options:
Answer: 3 tablets per dose