Question: A nurse is teaching a group of newly licensed nurses about preventing acute kidney injury in clients who have trauma. Which of the following interventions should the nurse include in the teaching?
Answer Options: Monitor the client’s bilirubin level. Increase fluid intake. Report the client’s systolic blood pressure greater than 130 mm Hg. Initiate a high-potassium diet.
Answer: Increase fluid intake.
Question: A nurse is providing discharge teaching to a client who has a new diagnosis of multiple sclerosis. Which of the following instructions should the nurse include?
Answer Options: Participate in an aerobics class 3 times per week. Take a hot bath every day. Limit your fluid intake to 1 liter per day to prevent incontinence. Avoid people who have an infection.
Answer: Avoid people who have an infection.
Question: A nurse is providing postoperative teaching for a client following a kidney transplant. Which of the following client statements indicates an understanding of the teaching?
Answer Options: I will notify my doctor if my output is greater than my intake in 1 day. I will taper off my antirejection medications after 6 months. I will no longer be a candidate for hemodialysis. I am at a decreased risk of infection with my new kidney.
Answer: I will notify my doctor if my output is greater than my intake in 1 day.
Question: A nurse is caring for a client who weighs 190 lb and is receiving total parenteral nutrition. If the RDA of protein is 0.8 g/kg of body weight, how many grams of protein should the client receive daily?
Answer Options: (Fill in the blank)
Answer: 69 grams.
Question: A nurse is assessing a client who is receiving morphine for pain and has a respiratory rate of 8/min and a blood pressure of 80/40 mm Hg. Which of the following medications should the nurse administer?
Answer Options: Flumazenil Acetylcysteine Protamine sulfate Naloxone
Answer: Naloxone.
Question: A nurse is assessing the pain status of a group of clients. Which of the following findings indicates a client is experiencing referred pain?
Answer Options: A client who is postoperative reports incisional pain. A client who has pancreatitis reports pain in the left shoulder. A client who has peritonitis reports generalized abdominal pain. A client who has angina reports substernal chest pain.
Answer: A client who has pancreatitis reports pain in the left shoulder.
Question: A nurse is teaching about safe positioning with the caregiver of a client who has right-sided hemiplegia following a stroke. Which of the following statements by the caregiver indicates an understanding of the teaching?
Answer Options: I will use a thick pillow under their head to support the neck. I will ensure their neck is flexed backwards when they’re lying on their stomach. I will support their feet with a rolled pillow when they are lying on their back. I will rest their heels on the mattress when they are sitting up in bed.
Answer: I will support their feet with a rolled pillow when they are lying on their back.
Question: A nurse is caring for an older adult client who reports vaginal dryness and itching. Which of the following responses should the nurse make?
Answer Options: These discomforts should decrease with time. Women your age experience thickening of the vaginal tissue. Your symptoms are likely due to decreasing estrogen levels. You should avoid intercourse to prevent injury to your vagina.
Answer: Your symptoms are likely due to decreasing estrogen levels.
Question: A nurse on the medical-surgical unit is caring for a client who has a seizure disorder. Which of the following interventions should the nurse include in the plan of care?
Answer Options: Maintain peripheral IV access. Teach assistive personnel how to apply restraints. Pad the upper two side rails of the client’s bed. Keep a padded tongue blade at the client’s bedside.
Answer: Pad the upper two side rails of the client’s bed.
Question: A nurse is assessing a client who is taking telmisartan. The nurse should identify that which of the following findings indicates that the medication has been effective?
Answer Options: Respiratory rate of 16/min. Increase in urinary output. Blood glucose of 110 mg/dL. Decrease in blood pressure.
Answer: Decrease in blood pressure.
Question: A nurse is assessing a client who has a urinary catheter. The nurse notes the client’s IV tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse should identify that the client is at risk for which of the following conditions?
Answer Options: Skin breakdown. Neurogenic bladder. Infection. Phlebitis.
Answer: Infection.
Question: A nurse is assessing a client who has a head injury and is experiencing increasing intracranial pressure. Which of the following signs would be an early indication of increased intracranial pressure?
Answer Options: Bradycardia. Increased systolic blood pressure. Decreased level of consciousness. Widened pulse pressure.
Answer: Decreased level of consciousness. You have asked me a total of 5 questions in this chat. Below is the requested information for all the questions answered so far:
Question: A nurse in an acute care mental health facility is preparing to administer morning medication for a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take?
Answer Options: Prepare for gastric lavage due to an extremely elevated lithium level. Administer the morning dose of lithium. Hold the medication and assess for early manifestations of toxicity. Check the client’s medication record to assess whether the client has been refusing her lithium.
Answer: Administer the morning dose of lithium.
Question: A nurse is planning care for a client who has acute glomerulonephritis. Which of the following interventions should the nurse include in the plan?
Answer Options: Obtain weight weekly. Administer antibiotics. Encourage increased fluid intake. Encourage frequent ambulation.
Answer: Obtain weight weekly.
Question: A nurse is caring for a client who has schizophrenia. Select the “3” findings that should indicate to the nurse the client is experiencing negative symptoms related to their schizophrenia.
Answer Options: Blood pressure Lack of motivation Change in behavior Lack of energy Withdrawn
Answer: Lack of motivation, Lack of energy, Withdrawn
Question: A nurse in a mental health facility is caring for a client with borderline personality disorder, alcohol use disorder, and a history of suicidal ideation. The client is taking fluoxetine 20 mg PO daily and has recent stressors including the breakup of a romantic relationship, job loss, and superficial cuts on arms and legs. The nurse is planning care for the client. For each potential nursing action, specify if the action is anticipated, nonessential, or contraindicated for the client.
Answer Options: Encourage the client to talk about feelings prior to maladaptive behavior. Initiate suicide precautions. Maintain same staff members caring for the client. Instruct the client to avoid foods with tyramine. Offer the client opportunities for physical exercise. Explore feelings of abandonment with the client. Apply wrist restraints. Offer sympathy and attention to maladaptive behaviors.
Answer: Encourage the client to talk about feelings prior to maladaptive behavior. – Anticipated Initiate suicide precautions. – Anticipated Maintain same staff members caring for the client. – Anticipated Instruct the client to avoid foods with tyramine. – Nonessential Offer the client opportunities for physical exercise. – Anticipated Explore feelings of abandonment with the client. – Anticipated Apply wrist restraints. – Contraindicated Offer sympathy and attention to maladaptive behaviors. – Contraindicated
Question: A nurse is planning care for a client who has posttraumatic stress disorder and reports increased anxiety about the upcoming anniversary of a traumatic experience. Which of the following resources should the nurse recommend to this client?
Answer Options: Social skills training, Vocational rehabilitation service, Day program, Systematic desensitization
Answer: Systematic desensitization
Question: A nurse is caring for a client in an intensive care unit. The client develops delirium while recovering from surgery. To promote safety, which of the following actions should the nurse take?
Answer Options: Discourage visits from significant others, Provide environmental cues, Promote decision making about care, Apply physical restraints
Answer: Provide environmental cues
Question: A nurse in a primary care provider’s office is caring for a client. The client has laboratory results and symptoms indicating depression. What should the nurse do?
Answer Options: Varies based on provided exhibits
Answer: Provide supportive care and follow up on mental health status
Question: A nurse is planning to lead a support group for clients who have alcohol use disorder. One of the group members is a client who speaks a different language than the nurse. The nurse should ask which of the following individuals to assist with communication?
Answer Options: A unit secretary who speaks the same language as the client, A translator of the same gender as the client, Another client who speaks the same language as the client, A family member of the client
Answer: A translator of the same gender as the client
Question: A nurse is initiating a plan of care for a newly admitted client who has schizoid personality disorder. Which of the following interventions should the nurse include in the plan?
Answer Options: Assist the client in identifying sources of anger, Set limits on the client’s need for constant social contact, Identify when the client engages in splitting behaviors, Give the client a choice of solitary activities
Answer: Give the client a choice of solitary activities
Question: A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take?
Answer Options: Request that security guards restrain the client, Talk to the client using short, simple sentences, Stand directly in front of the client, Identify the client’s stressors, Speak to the client in a loud voice
Answer: Talk to the client using short, simple sentences