Question: A nurse is teaching a client about the uses of chamomile. Which of the following information should the nurse include in the teaching?

Answer Options: “Chamomile may act as a calming agent.” “Chamomile decreases cholesterol levels.” “Chamomile can reduce nausea and vomiting.” “Chamomile has anti-inflammatory properties beneficial for treating skin disorders.”

Answer: Chamomile may act as a calming agent.

 

Question: A nurse is assessing a client who reports an increase in anxiety. Which of the following responses should the nurse make?

Answer Options: “Do you think your anxiety is worse than everyone else’s?” “Tell me what has been happening lately.” “I think you should see a therapist.” “It doesn’t appear as though you are feeling anxious.”

Answer: Tell me what has been happening lately.

 

Question: A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan?

Answer Options: Clean the wound with hydrogen peroxide solution. Apply a heat lamp twice a day. Massage reddened areas with dressing changes. Reposition the client at least every 2 hr.

Answer: Reposition the client at least every 2 hr.

 

Question: A nurse is preparing to administer digoxin to a 6-month-old infant. Prior to administering the dose, the nurse measures the apical heart rate. The nurse should withhold the dose if the infant’s apical heart rate is less than what rate?

Answer Options:

Answer: 90 beats per minute

 

Question: A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse plan to take?

Answer Options: Insert the needle at a 45° angle. Aspirate for a blood return before depressing the plunger. The nurse should not expel the air bubble in the prefilled syringe. Administer the medication 2.54 cm (1 in) from the umbilicus.

Answer: The nurse should not expel the air bubble in the prefilled syringe.

 

Question: A nurse who is off duty finds a woman who has collapsed and has right-sided weakness and slurred speech. Which of the following actions should the nurse take?

Answer Options: Obtain the telephone number of the client’s provider. Drive the client to the nearest emergency department. Find a location for the client to sit. Call emergency services.

Answer: Call emergency services.

 

Question: A nurse is teaching a client who has fibromyalgia about self-care strategies for managing the disorder. Which of the following information should the nurse include in the teaching?

Answer Options: Establish a regular sleep pattern. Increase calcium intake. Avoid exercise during flare-ups. Try jogging or running between flare-ups.

Answer: Establish a regular sleep pattern.

 

Question: A nurse is creating a plan of care for an immunosuppressed client. Which of the following precautions should the nurse include in the plan? (Select all that apply.)

Answer Options: Don a mask, gloves, and gown. Limit the client from bathing daily. Instruct the client to eat cooked foods only. Dispose all linen in trash after use. Restrict visitors who have active infections.

Answer: Don a mask, gloves, and gown. Instruct the client to eat cooked foods only. Restrict visitors who have active infections.

 

Question: A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?

Answer Options: Increase in heart rate from 88 to 110/min. Increase in temperature from 37.5°C (99.5°F) to 38.6°C (101.5°F). Decrease in urinary output from 50 mL to 30 mL per hour. Decrease in respiratory rate from 20 to 16/min.

Answer: Decrease in urinary output from 50 mL to 30 mL per hour.

 

Question: A nurse in the emergency department is caring for an older adult client. Which of the following actions should the nurse take to address the client’s most likely condition?

Answer Options: Obtain a urine sample. Restrict fluid intake. Initiate anticoagulant therapy. Obtain a prescription for an antibiotic.

Answer: Obtain a urine sample. Obtain a prescription for an antibiotic.

 

Question: A nurse is teaching the family of a client who has Alzheimer’s disease about donepezil. Which of the following information should the nurse include in the teaching?

Answer Options: Syncope episodes may occur when taking this medication. You will need to monitor for constipation. You should administer the medication each morning. This medication may cause tachycardia.

Answer: You should administer the medication each morning.

 

Question: A nurse is caring for a client on a medical-surgical unit. The client is at highest risk for developing which of the following conditions?

Answer Options: Intracranial hemorrhage Ventricular tachycardia Hypoxia

Answer: Intracranial hemorrhage

 

Question: A nurse in an emergency department is caring for a client with a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?

Answer Options: Raise the foot of the bed to a 90° angle. Prepare to insert a central line. Administer oxygen via nasal cannula. Remove the dressing to inspect the wound.

Answer: Administer oxygen via nasal cannula.

 

Question: A nurse is caring for a client who has HIV. The client is at risk for developing which conditions?

Answer Options: Malnutrition Sepsis Hemorrhage Tuberculosis

Answer: Sepsis and Tuberculosis

 

Question: A nurse is instructing a client newly diagnosed with pulmonary tuberculosis (TB) about the use of antitubercular medications. Which of the following information should the nurse include in the teaching?

Answer Options: Medications will need to be taken for the rest of the client’s life, even if the client feels better. Medications will need to be taken until the Mantoux test is negative. The client’s family will also need to take medications to prevent infection. A typical course of treatment involves 6 to 9 months of consistent medication use.

Answer: A typical course of treatment involves 6 to 9 months of consistent medication use.

 

Question: A nurse is caring for a client immediately following a procedure that required spinal anesthesia. Which of the following findings indicates the client is experiencing a complication of the anesthesia?

Answer Options: Absence of urge to void Numbness in the legs Hiccoughs Headache

Answer: Headache

 

Question: A nurse is caring for a client who has paraplegia following an automobile accident. The client is on an intermittent urinary catheterization program. Which of the following findings indicates the need for catheterization?

Answer Options: Weight gain Dribbling of urine Rectal distention Urge incontinence

Answer: Dribbling of urine

 

Question: A nurse is caring for a client who has full-thickness burns over 75% of his body. The nurse should use which of the following methods to monitor the cardiovascular system?

Answer Options: Monitor the pulmonary artery pressure. Auscultate cuff blood pressure. Palpate pulse pressure. Obtain a central venous pressure.

Answer: Obtain a central venous pressure.

 

Question: A nurse is preparing to start an IV infusion of lactated Ringer’s for a client who sustained a burn injury. The client is prescribed 5,200 mL of fluid over the first 24 hr. How many mL/hr should the nurse set the pump to infuse for the first 8 hr?

Answer: 325 mL/hr

 

Question: A nurse is teaching the partner of a client who had a stroke about dysphagia. Which of the following statements by the client’s partner should indicate to the nurse that the teaching was effective?

Answer Options: “My partner should place their food on the weaker side of their mouth when eating.” “My partner should tilt their head forward when swallowing.” “My partner should cough while swallowing food.” “My partner should sit at a 30° angle while eating their meals.”

Answer: “My partner should tilt their head forward when swallowing.”

 

Question: A nurse is preparing a presentation at a community center about osteoarthritis. The nurse should plan to include which of the following information? (Select All that Apply.)

Answer Options: Causes joint stiffness Affects weight-bearing joints Causes joint pain Affects bilateral symmetrical joints Crepitus can occur in affected joints

Answer: Causes joint stiffness Affects weight-bearing joints Causes joint pain Crepitus can occur in affected joints

 

Question: A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?

Answer Options: Inability to recognize his family members Aphasia Difficulty reading Right hemiparesis

Answer: Right hemiparesis

 

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 Options: “DIC is controllable with lifelong heparin usage.” “DIC is caused by abnormal coagulation involving fibrinogen.” “DIC is characterized by an elevated platelet count.” “DIC is a genetic disorder involving a vitamin K deficiency.”

Answer: “DIC is caused by abnormal coagulation involving fibrinogen.”

 

Question: A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock?

Answer Options: Pulse oximetry 96% Widening pulse pressure Increased deep tendon reflexes Increased heart rate

Answer: Increased heart rate

 

Question: A nurse is caring for a client in the emergency department (ED). Select the 4 assessment findings on day 2 that require immediate follow-up.

Answer Options: Heart rate Oxygen saturation Edema Temperature Urine color Pedal pulses

Answer: Heart rate Oxygen saturation Temperature Edema

 

Question: A nurse is caring for an older adult client who has dementia. The client’s family member asks why the provider will not prescribe a medication to calm the client down. Which of the following statements should the nurse make?

Answer Options: “It can increase their risk for infection.” “It increases their risk of experiencing a stroke.” “It can increase their risk for falls.” “It can increase their blood pressure.”

Answer: “It can increase their risk for falls.”

 

Question: A nurse is caring for a client who was involved in a motor-vehicle crash. Complete the following sentence by using the list of options: The nurse should first address the client’s ____ followed by the client’s ____.

Answer Options: Circulatory status Sensory perception Upper body findings Mobility perceptions Oxygen saturation Level of consciousness Temperature WBC count

Answer: Circulatory status followed by Level of consciousness