Question: A nurse is caring for an infant who has congenital heart disease. Which of the following actions should the nurse plan to take? (Select all that apply.)
Answer Choices:
Perform nasopharyngeal suctioning for a maximum of 5 seconds.
Provide 100% oxygen by face mask.
Place the infant in a knee-chest position.
Answer: Perform nasopharyngeal suctioning for a maximum of 5 seconds.
Place the infant in a knee-chest position.
Question: A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. Which of the following is the priority nursing intervention?
Answer Choices:
Assess for indications of pulmonary embolism
Answer: Assess for indications of pulmonary embolism
Question: A nurse is assessing a client who had left femoral cardiac angiography. Where should the nurse palpate to assess the most distal pulse on the affected side?
Answer Choices:
Left foot
Answer: Left foot
Question: A nurse is caring for an adolescent who presents to the emergency department. Which of the following actions should the nurse take to assess the adolescent’s condition after reassessment? Assessment Findings: Oral intake, Dyspnea, Heart rate, Blood pressure, Respiratory rate, Lung sounds, Oxygen saturation
Answer Choices:
Improved
No Change
Declined
Answer: This requires specific updates on each parameter based on the reassessment details provided.
Question: A nurse is planning nutritional teaching for a client who is experiencing fatigue due to iron deficiency anemia. Which of the following foods should the nurse recommend to the client?
Answer Choices:
1.5 oz raisins
1 cup canned black beans
8 oz black tea
8 oz whole milk
Answer: 1 cup canned black beans
Question: A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?
Answer Choices:
“DIC is a genetic disorder involving a vitamin K deficiency.”
“DIC is controllable with lifelong heparin usage.”
“DIC is caused by abnormal coagulation involving fibrinogen.”
“DIC is characterized by an elevated platelet count.”
Answer: “DIC is caused by abnormal coagulation involving fibrinogen.”
Question: A nurse is educating clients about breast cancer at a community health event. Which of the following statements should the nurse include in the training?
Answer Choices:
“Breastfeeding increases the risk of breast cancer in women over 40 years of age.”
“Clients should begin screening mammography annually by the age of 30 years old.”
“Breast cancer can occur in any part of the breast, but ductal breast cancer is most common.”
“Clients who have BRCA1 or BRCA2 gene changes have a decreased risk of breast cancer.”
Answer: “Breast cancer can occur in any part of the breast, but ductal breast cancer is most common.”
Question: A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?
Answer Choices:
Progressive increase in platelet production
Excessive thrombosis and bleeding
Immediate sodium and fluid retention
Increased clotting factors
Answer: Excessive thrombosis and bleeding
Question: A nurse is caring for a client. Which of the following actions should the nurse take?
Answer Choices:
Encourage the client to increase fluid intake.
Wear a mask when caring for the client.
Place the client in a private room.
Prepare to administer an antibiotic to the client.
Answer: Wear a mask when caring for the client.
Question: A nurse is providing education to a client who has a newly diagnosed abdominal aortic aneurysm (AAA). Which of the following statements should the nurse include in the teaching?
Answer Choices:
“An abdominal aortic aneurysm is commonly found in the suprarenal aorta.”
“An abdominal aortic aneurysm is a dilation of the abdominal aorta greater than 30 mm in diameter.”
“An abdominal aortic aneurysm occurs as a result of a thickened wall of the abdominal artery.”
“Abdominal aortic aneurysms might rupture if blood pressure is too low.”
Answer: “An abdominal aortic aneurysm is a dilation of the abdominal aorta greater than 30 mm in diameter.”
Question: A nurse in the post-anesthesia care unit is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give highest priority to?
Answer Choices:
Urinary output
Arterial blood gases
Pain level
Chest tube drainage
Answer: Chest tube drainage
Question: A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). Which of the following actions should the nurse take to help this client with tenacious bronchial secretions?
Answer Choices:
Encouraging the client to drink 2 to 3 L of water daily
Helping the client select a low-salt diet
Maintaining a semi-Fowler’s position as often as possible
Administering oxygen via nasal cannula at 2 L/min
Answer: Encouraging the client to drink 2 to 3 L of water daily