Question: A nurse is caring for a client who has a prescription for potassium chloride (KCl) 20 mEq PO daily. The nurse reviews the client’s most recent laboratory results and finds the client’s potassium level is 5.2 mEq/L. Which of the following actions should the nurse take?
Answer Options: Omit the KCl dose and document it was not given. Call the lab to verify the client’s results. Call the prescribing physician and inform her of the client’s serum potassium level results. Give the ordered KCl as prescribed.
Answer: Call the prescribing physician and inform her of the client’s serum potassium level results.
Question: A nurse is providing nutritional teaching to a client who has dumping syndrome following a hemi-colectomy. Which of the following foods should the nurse instruct the client to avoid?
Answer Options: Fresh apples Rice Poached eggs White bread
Answer: White bread.
Question: A nurse is caring for a client who is postoperative following a laminectomy. Select the 3 findings that require immediate follow-up.
Answer Options: Pain level Incision site Lung sounds Pedal pulse Blood pressure
Answer: Incision site, Lung sounds, Pain level.
Question: A nurse is caring for a client who has a Jackson-Pratt (JP) drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which of the following purposes?
Answer Options: To prevent fluid from accumulating in the wound To eliminate the need for wound irrigations To provide a means for medication administration To limit the amount of bleeding from the surgical site
Answer: To prevent fluid from accumulating in the wound.
Question: A nurse is providing teaching to a client who has nephrotic syndrome. The nurse should recognize that which of the following client statements indicates a need for further teaching?
Answer Options: I can expect to have swelling in my face. I should expect my provider to prescribe a kidney biopsy. I will lose protein in my urine. I should increase my sodium intake.
Answer: I should increase my sodium intake.
Question: A nurse is assessing a preschooler. Which of the following findings should indicate to the nurse a need for speech therapy? (Select all that apply.)
Answer Options: The preschooler talks to himself when reading. The preschooler stutters when speaking. The preschooler mispronounces words. The preschooler speaks in three-word sentences. The preschooler speaks in a nasally tone.
Answer: The preschooler stutters when speaking, The preschooler mispronounces words, The preschooler speaks in three-word sentences, The preschooler speaks in a nasally tone.
Question: A nurse is admitting a client who is about to undergo surgery for benign prostatic hypertrophy. The client states, “I don’t know what I will do if they find I have cancer.” Which of the following responses should the nurse make?
Answer Options: Why do you think you might have cancer when your diagnosis is a benign condition? I think that’s something you need to discuss with your provider. I’m hearing that you are concerned that it might turn out that you have cancer. I’m looking at your chart here and I don’t see any reason for you to worry about that.
Answer: I’m hearing that you are concerned that it might turn out that you have cancer.
Question: A nurse is caring for a child who is allergic to penicillin. The nurse should clarify which of the following prescriptions with the provider?
Answer Options: Gentamicin Erythromycin Amoxicillin-clavulanate Amphotericin B
Answer: Amoxicillin-clavulanate
Question: A nurse is caring for a 9-year-old boy who has a new diagnosis of diabetes mellitus and is eager to return to school. The mother tells the nurse she is afraid to let him take part in physical activities. Which of the following responses should the nurse make?
Answer Options: “I agree. His well-being is the most important.” “You might want to use tutors to home-school him.” “Tell me more about how you are feeling about your son’s activities.” “You sound overprotective. Let’s talk about this some more.”
Answer: Tell me more about how you are feeling about your son’s activities.
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 of the following actions should the nurse take?
Answer Options: Place a black tag on the client’s upper body and attempt to help the next client in need. Place a red tag on the client’s upper body and obtain immediate help from other personnel. Reposition the client’s upper airway a second time before assessing his respirations. Start CPR.
Answer: Start CPR
Question: A nurse is caring for a client who has just been diagnosed with cancer of the colon. The client asks the nurse several questions about what the provider might be planning to do. Which of the following nursing responses should the nurse make?
Answer Options: Assure the client that the provider will explain what has been planned. Provide the client with articles from the Internet that explain colon cancer stages. Explain the various options available for treatment based on the cancer stage. Encourage the client to write down questions to ask the provider.
Answer: Encourage the client to write down questions to ask the provider.
Question: A nurse is performing a cardiac assessment. Identify where the nurse should place the stethoscope to auscultate the client’s apical pulse.
Answer Options:
Answer: Fifth intercostal space at the midclavicular line on the left side of the chest.
Question: A nurse is caring for a client who has a new diagnosis of urolithiasis. Which of the following should the nurse identify as an associated risk factor?
Answer Options: Family history Diuretic use BMI less than 25 Hypocalcemia
Answer: Family history
Question: A volunteer assigned to the pediatric unit reports to the charge nurse for an assignment. Which of the following assignments is unsafe for the volunteer?
Answer Options: Transporting a school-age client who is in traction to another department Playing a computer video game with an adolescent who has sickle cell disease Rocking an infant who was admitted for croup Reading a book to a preschool client who has AIDS
Answer: Rocking an infant who was admitted for croup
Question: A nurse is caring for a client who has schizophrenia. Which of the following statements by the client indicates concrete thinking?
Answer Options: “I am a prophet of the most high king.” “The voices tell me that I must avoid large crowds.” “I am aware that each problem has only one solution.” “I know that you and the other nurses are trying to poison me.”
Answer: I am aware that each problem has only one solution.