Question: A nurse is teaching a client about preventing osteoporosis. Which of the following statements by the client indicates a need for further teaching?
Answer Options:
“I will decrease my intake of caffeine.”
“I will limit my intake of soft drinks.”
“I will reduce my intake of vitamin K-rich foods.”
“I will reduce my intake of sodium.”
Answer: “I will reduce my intake of vitamin K-rich foods.”
Question: A nurse is assessing a client prior to administering atenolol. Which of the following findings should prompt the nurse to withhold the medication?
Answer Options:
Respiratory rate 18/min
Blood pressure 160/94 mm Hg
Heart rate 46/min
Oxygen saturation 95%
Answer: Heart rate 46/min
Question: A nurse is caring for a client who has acute pancreatitis. After treating the client’s pain, which of the following should the nurse address as the priority intervention?
Answer Options:
Assist the client to a side-lying position.
Withhold oral fluids and food.
Auscultate the client’s lungs.
Provide oral hygiene.
Answer: Auscultate the client’s lungs.
Question: A nurse is preparing to administer vancomycin 500 mg PO daily divided into four equal doses. The amount available is vancomycin 125 mg capsules. How many capsules should the nurse administer with each dose?
Answer Options:
Answer: 1 capsule per dose
Question: A nurse is assessing a client who is receiving a unit of packed red blood cells. Which of the following findings is a manifestation of acute hemolytic reaction?
Answer Options:
Distended neck veins
Client report of tinnitus
Client report of low back pain
A productive cough
Answer: Client report of low back pain
Question: A nurse is caring for a client with acute kidney injury (AKI). Which of the following arterial blood gas values would the nurse expect this client to have?
Answer Options:
pH 7.26, HCO₃ 14, PaCO₂ 30
pH 7.49, HCO₃ 30, PaCO₂ 40
pH 7.26, HCO₃ 24, PaCO₂ 46
pH 7.49, HCO₃ 24, PaCO₂ 30
Answer: pH 7.26, HCO₃ 14, PaCO₂ 30
Question: A nurse is assessing a client with a new diagnosis of aplastic anemia. Which of the following information should the nurse include in the teaching?
Answer Options:
Aplastic anemia results in an inability to absorb vitamin B12.
Aplastic anemia results in an increased rate of RBC destruction.
Aplastic anemia results from decreased bone marrow production of RBCs.
Aplastic anemia is associated with a decreased intake of iron.
Answer: Aplastic anemia results from decreased bone marrow production of RBCs.
Question: A nurse is caring for a client who has autism spectrum disorder. Which of the following findings should the nurse expect? (Select all that apply.)
Answer Options:
Spinning a toy repetitively
Delayed language development
Speaking with direct eye contact
Long attention span
Ritualistic behavior
Answer: Spinning a toy repetitively
Delayed language development
Ritualistic behavior
Question: A nurse is working with a limited staff due to a severe storm in the area. The facility incident commander has initiated disaster protocols. Which of the following actions should the nurse take?
Answer Options:
Reinforce discharge teaching to clients.
Focus on providing care that prevents life-threatening emergencies.
Stock additional unit supplies.
Instruct assistive personnel (AP) to focus on clients’ ADLs.
Answer: Focus on providing care that prevents life-threatening emergencies.
Question: A nurse is preparing a community presentation about repetitive motion injuries. Which of the following occupations should the nurse identify as increasing a client’s risk for carpal tunnel syndrome?
Answer Options:
Assembly line worker
Truck driver
Nursing assistant
Elementary school teacher
Answer: Assembly line worker
Question: A nurse is assessing a client 15 minutes after administering morphine sulfate 2 mg via IV push. Which of the following findings should the nurse identify as an adverse effect of the medication?
Answer Options:
SaO₂ 94%
Respiratory rate 8/min
Pain level of 6 on a scale of 0 to 10
Sleepy, but arousing when her name is called
Answer: Respiratory rate 8/min
Question: A home healthcare nurse is visiting an older adult client who tells the nurse that she is feeling tired, is unable to shop for groceries, and would like the nurse to shop for her. Shopping and performing personal errands for the client is prohibited in the nurse’s job description. Which of the following is an appropriate nursing response?
Answer Options:
“Let’s look at some other resources to solve this problem.”
“I won’t be able to shop for you today because I have to get home to my family.”
“I would be happy to do whatever I can to help you.”
“What I think you should do is wait for the days when you feel better and do your grocery shopping then.”
Answer: “Let’s look at some other resources to solve this problem.”
Question: A charge nurse is admitting a client with bipolar disorder who is in the manic phase. Which of the following room assignments should the nurse give the client?
Answer Options:
A semi-private room across from the day room
A private room in a quiet location on the unit
A semi-private room across from the snack area
A private room across from the exercise room
Answer: A private room in a quiet location on the unit
Question: A nurse is preparing to administer lansoprazole 30 mg PO daily to a client. The amount available is lansoprazole 10 mg/tablet. How many tablets should the nurse administer per dose?
Answer Options:
Answer: 3 tablets per dose
Question: A nurse is assessing a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client’s lung has re-expanded?
Answer Options:
Occasional bubbling in the water-seal chamber
No reports of pleuritic chest pain
No fluctuations in the water-seal chamber
Oxygen saturation of 95%
Answer: No fluctuations in the water-seal chamber
Question: A nurse is preparing to administer vancomycin 500 mg PO daily, divided into four equal doses. The amount available is vancomycin 125 mg capsules. How many capsules should the nurse administer with each dose?
Answer Options:
Answer: 1 capsule per dose
Question: A nurse is caring for a client with acute pancreatitis. After treating the client’s pain, which of the following should the nurse address as the priority intervention?
Answer Options:
Assist the client to a side-lying position.
Withhold oral fluids and food.
Auscultate the client’s lungs.
Provide oral hygiene.
Answer: Auscultate the client’s lungs.