Question: A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and palpitations. Which finding is most important for the nurse to monitor?
Answer Options: A) Dark yellow urine, B) Excessive perspiration, C) Myalgia in wrists and hands, D) Cold hands and feet.
Answer: B) Excessive perspiration.
Question: While assisting a client to the toilet, the client begins to have a seizure and the nurse eases the client to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?
Answer Options: A) Evaluate for evidence of incontinence. B) Observe for prolonged periods of apnea. C) Observe for lacerations to the tongue. D) Document details of the seizure activity.
Answer: D) Document details of the seizure activity.
Question: A 19-year-old female college student has had type 1 diabetes mellitus for 14 years. She is concerned about her feet, reporting that they itch so much that she gets distracted in school. Upon assessment, scaliness and cracking skin between the toes on the left foot are noted. Hemoglobin A1C (today) is 8.2% and Hemoglobin A1C (3 months ago) was 7.5%. Which condition is she most likely experiencing and what actions should the nurse take?
Answer Options: Tinea pedis, Plan for cryotherapy, Request an order for griseofulvin, Instruct the client to change to clean, dry socks, etc.
Answer: Condition: Tinea pedis. Actions: Request an order for griseofulvin and instruct the client to change to clean, dry socks. Parameters to monitor: Spread to other areas of the body and nail growth and color.
Question: A client with chronic kidney disease on peritoneal dialysis exhibits redness, tenderness, and drainage around the catheter site on the abdominal wall. While planning care, the nurse is most concerned about preventing which complication related to these findings?
Answer Options: A) Outflow obstruction. B) Peritonitis. C) Atelectasis. D) Exit site infection.
Answer: B) Peritonitis.
Question: A client with metastatic cancer reports a pain level of 10 on a scale of 0 to 10. Twenty minutes after the nurse administers an IV analgesic, the client reports no pain relief. Which intervention is most important for the nurse to include in this client’s plan of care?
Answer Options: A) Administer analgesics on a fixed and continuous schedule. B) Frequently evaluate the client’s pain. C) Replace transdermal analgesic patches every 72 hours. D) Monitor client for breakthrough pain.
Answer: B) Frequently evaluate the client’s pain.
Question: A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?
Answer Options: A) Indication of the onset of joint degeneration. B) Evidence of spread of the disease to the kidneys. C) Confirmation of the autoimmune disease process. D) Representative of a decline in the client’s condition.
Answer: C) Confirmation of the autoimmune disease process.
Question: The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this disease process?
Answer Options: A) Marked loss of weight and appetite over the last 3 or 4 months. B) Frequent use of chewable and liquid antacids for indigestion. C) Upper mid abdominal pain described as gnawing and burning. D) Severe abdominal cramps and diarrhea after eating spicy foods.
Answer: C) Upper mid abdominal pain described as gnawing and burning.
Question: An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rales and wheezing. When assessing this client, which additional finding is the nurse likely to obtain?
Answer Options: A) Lower extremity edema. B) Jugular vein distension. C) Hepatomegaly. D) Fatigue.
Answer: A) Lower extremity edema.
Question: A client with draining skin lesions of the lower extremity is admitted with possible methicillin resistant Staphylococcus aureus (MRSA). What nursing intervention(s) should the nurse include in the plan of care?
Answer Options: A) Monitor the client’s white blood cell count. B) Institute contact precautions for staff and visitors. C) Send wound drainage for culture and sensitivity. D) Explain the purpose of a low bacteria diet. E) Use standard precautions and wear a mask.
Answer: B) Institute contact precautions for staff and visitors and C) Send wound drainage for culture and sensitivity.
Question: Following a motor vehicle accident, a client with chest trauma receives a chest tube to relieve a hemothorax. Two hours following the chest tube insertion, the nurse observes the water level in the water-seal chamber is rising during inspiration and falling during expiration. Which action should the nurse implement?
Answer Options: A) Continue to monitor the drainage system. B) Inspect the tube insertion site for leaking. C) Lift and clear drainage from the chest tube. D) Auscultate lungs for unequal breath sounds.
Answer: A) Continue to monitor the drainage system.
Question: A client with a right ulnar fracture and cast placement reports an increase in arm pain. Which action should the nurse take next?
Answer Options: A) Administer a PRN analgesic. B) Measure the blood pressure. C) Implement distraction techniques. D) Assess right radial pulse volume.
Answer: D) Assess right radial pulse volume.
Question: The healthcare provider prescribes regular insulin 10 units/hr IV. The IV solution contains 100 units of regular insulin in 100 mL of 0.9% normal saline. How many mL/hr should the nurse program the infusion pump?
Answer Options: (Requires numerical input)
Answer: 10 mL/hr.
Question: A 48-year-old male with gangrene of the right lower leg which has not been responsive to treatment. A below-the-knee amputation (BKA) of the right lower leg has been performed. The client has a history of peripheral vascular disease, high blood pressure, and has a pacemaker for 2nd degree heart block.
Answer Options: Various patient activities and whether they indicate positive or negative health promotion post-amputation.
Answer: Activities like “Executes pull-ups on trapeze bar” indicate positive health promotion, whereas “Avoids looking at residual limb” could be seen as negative.
Question: The nurse practitioner prescribes diazepam 8 mg IM every 4 hours PRN muscle spasms for a client with a fractured femur. The available vial is labeled, “Diazepam Injection, USP 10 mg/2 mL.” How many mL should the nurse administer to the client?
Answer Options: (Requires numerical input)
Answer: 1.6 mL.
Question: The nurse calls the healthcare provider because a client diagnosed with an abdominal aortic aneurysm (AAA) is reporting low back pain. Which additional information about the client would be important for the nurse to tell the healthcare provider?
Answer Options: A) Calcium level and skin condition. B) Hematocrit and blood pressure. C) White blood cell count and pulse rate. D) Serum amylase and level of consciousness.
Answer: B) Hematocrit and blood pressure.
Question: A client has an absolute neutrophil count (ANC) of 500/mm^3 (0.5 x 10^9/L) after completing chemotherapy. Which intervention is most important for the nurse to implement?
Answer Options: A) Review need for pneumococcal vaccine. B) Assess vital signs every 4 hours. C) Place the client in protective isolation. D) Implement bleeding precautions.
Answer: C) Place the client in protective isolation.
Question: The nurse is preparing an older adult client for a magnetic resonance imaging (MRI) with contrast. Which laboratory value should the nurse report to the healthcare provider before the scan is performed?
Answer Options: A) Blood urea nitrogen of 22 mg/dL. B) Glycosylated hemoglobin of 8%. C) Serum creatinine of 1.9 mg/dL. D) Fasting blood sugar of 200 mg/dL.
Answer: C) Serum creatinine of 1.9 mg/dL.
Question: The nurse is evaluating a client’s understanding of diet teaching about the DASH (Dietary Approaches to Stop Hypertension) eating plan. Which behavior indicates that the client is adhering to the eating plan?
Answer Options: A) Enjoys fat-free yogurt as an occasional snack food. B) Carefully cleans and peels all fresh fruit and vegetables. C) Uses only lactose-free dairy products. D) No longer includes grains in the daily diet.
Answer: A) Enjoys fat-free yogurt as an occasional snack food.
Question: A client who fractured the right femur from a fall at home is placed in traction while awaiting surgery. When the client informs the nurse of the need to urinate, which intervention should the nurse implement?
Answer Options: A) Maintain traction while the client uses a urinal. B) Log roll the client and place adult disposable briefs beneath the client. C) Release the traction so the client can use a bedpan. D) Insert an indwelling urinary catheter preoperatively.
Answer: A) Maintain traction while the client uses a urinal.