Reference no: EM133915006

Questions

1. The nurse is contributing to a staff education program about caring for a client with active pulmonary tuberculosis (TB) which is the following information should the nurse suggest including?

1. It is mandatory to report a client's positive TB test results to the public health department

2. It is necessary to isolate a hospitalized client for 24 hours after initiating antitubercular therapy

3. Antitubercular therapy is continued until the client provides 3 sputum cultures that test negative for TB

4. Droplet precautions must be implemented as soon as the hospitalized client is suspected of active TB.

2. The nurse in a pediatric outpatient care facility has received telephone messages from parents of clients who were previously seen at the facility. The nurse should first telephone the parent of a client who has

1. acute otitis media and reports insomnia after taking prescribed amoxicillin 6 hours ago

2. A fracture of the left tibia and has placed a crayon in the cast

3. A colostomy and reports skin irritation around the stoma

4. epilepsy and has pink frothy sputum

3. The nurse is collecting data from a client with sickle cell anemia. Which of the following statements by the clients would be essential to follow up?

1. I usually drink 4 L of water or juice daily

2. I am scheduled to receive the influenza vaccine

3. I may need to receive a prescribed anti-infective if I develop a fever

4. I have been applying cold packs daily to help relieve the pain in my knees.

4. The nurse has reinforced discharge teaching with the parent of a newborn. Which of the following statements by the parent would require follow-up?

1. I will leave my baby's diaper off when possible if the diaper area starts to become red

2. I will secure my baby in a rear-facing infant seat in the from seat of the car since there is an airbag there

3. I should give my baby a pacifier at bedtime to reduce the risk for sudden infant death syndrome (SIDS)

4. I should squeeze the bulb syringe before inserting it into my baby's mouth when I suction excess secretions.

5. The charge nurse in a long-term care facility has been advised that the following clients will be admitted during the shift. The charge nurse should assign the only available private room to the client with

1. Scabies

2. Salmonellosis

3. Hepatitis B (HBV)

4. Cytomegalovirus (CMV)

6. The nurse is reinforcing teaching with the parents of a child who is scheduled for surgical repair of hypospadias. The nurse should reinforce that intended outcomes of the procedure include:

1. Relief from pain

2. Relief from bladder obstruction

3. The ability to void while standing

4. The ability to achieve an erection

7. The nurse is caring for a client. Which of the following prescriptions should the nurse clarify?

1. 2 g sodium diet

2. implement bed rest

3. furosemide 20 mg, p.o. once daily

4. enalapril 5 mg. p.o. twice daily

8. The nurse has assisted with the orientation of new staff members to the case of postpartum clients. Which of the following statements by a staff member would indicate a correct understanding of the orientation?

1. I should encourage a client to wear gloves when the client applies a prescribed medicated cream to the hemorrhoids

2. I should wear gloves to assist a client who is breast-feeding her newborn

3. I should wear a mask when checking a client's lochia

4. I will offer a client gloves to wear during formula feedings if the client's newborn develops a fine white trash over the nose and chin.

9. The nurse is talking with a client who has borderline personality disorder. Which of the following statements would the nurse expect the client to make?

1. I often feel bored and empty

2. I hear voices others are unable to hear

3. I need to go to my room to wash my hands again

4. I am worried the food on this meal tray has been poisoned

10. The charge nurse in a long-term care facility has made client care assignments for unlicensed assistive personnel (UAP). Which of the following statements by the charge nurse would provide the best direction to a UAP about the assignment?

1. Your clients will need assistance to ambulate once in the morning and once in the afternoon.

2. Obtain vital signs for clients every 4 hours and report any abnormal measurements.

3. Assist clients whoa re on special diets to eat their meals.

4. Turn clients who are on bed rest onto the left side for 2 hours and then onto the right side for 2 hours until lunch is served.

11. The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. Which of the following activities would be appropriate to assign to UAP? Select all that apply.

1. Bathing client who has an altered mental status

2. assisting the client who uses a walker to ambulate

3. Checking the vital signs of the client who has peripheral venous access device (VAD)

4. adjusting the prescribed oxygen flow rate for the client based on oxygen saturation levels

5. measuring the oral intake and urine output for the client who has an indwelling urethral catheter.

12. The nurse is collecting data from a client who has hypovolemic shock. Which is the following findings would be consistent with hypovolemic shock? Select all that apply.

1. Confusion

2. Hypertension

3. decreased urine output

4. elevated respiratory rate

5. Jugular vein distension (JVD)

13. The charge nurse in a long-term care facility has been advised that the following assigned clients will be admitted during the shift. The charge nurse should assign the only available private room to the client with

1. Pneumocystis pneumonia (PCP)

2. a positive varicella zoster titer

3. Hepatitis C (HCV)

4. a positive cytomegalovirus (CMV Titer

14. The nurse is caring for a client who has been told their cancer has metastasized. The nurse enters the room and observes the client cycling. Which of the following responses would be appropriate for the nurse to make first?

1. You seem upset. May I sit with you for a while?

2. I can telephone a family member to come and stay with you

3. Do you have a spiritual advisor that you would like me to notify?

4. I will give you some time alone and will come back soon.

15. The nurse has participated in a staff development conference about caring for clients with various religious beliefs who are terminally ill. Which of the following statements by the nurse would indicate a correct understanding of the teaching?

1. A family member will turn a client who practices Buddhism east to face Mecca prior death

2. After death a member of a burial society will wash the body of a client who practices orthodox Judaism.

3. After death, a family member will cover the mirrors in the room of a client who practices the Greek Orthodox religion

4. A priest will tie a thread around the wrist of a client who practices Roman Catholicism to signify a blessing prior to death.

16. The nurse is caring for an adolescent recently diagnosed with diabetes mellitus (type1) The client states, "You don't understand what it is like to have to give yourself injections every day"! Which of the following responses would be appropriate for the nurse to make?

1. I have cared for many clients who are the same age as you and they have adjusted

2. There are many athletes who have the same diagnosis and are very healthy.

3. I can teach one of your parents how to give you injections

4. it must be difficult to self-administer an injection every day.

17. The nurse is contributing to a staff development conference about client confidentiality. Which of the following information should the nurse suggest including? Select all that apply.

1. The client's medical record is the client's property, and the client may have access to the record at any time

2. Unneeded computer-generated worksheets must be shredded at the end of the shift to ensure client confidentiality.

3. Personal computer passwords may not be shared with anyone, including other members of the client's health care team.

4. Medical information about the client may be shared with a police officer who brought the client into the emergency department (ED)

5. Keep your voice low when speaking with the client because direct interaction with clients must be kept as private as possible.

18. The nurse in a rehabilitation facility is caring for a client who had a right knee arthroplasty 8 days ago and has been diagnosed with pneumonia. The client is being transferred to an acute care facility. It would be essential for the nurse to communicate in the transfer report that

1. The discharge to home is anticipated for the client after 1 more week of physical therapy

2. The client lives in a ranch home that requires climbing 2 stairs to get into the house

3. The most recent focused data collection reveals bilateral crackles (rakes) auscultated in the client's lungs

4. The client's spouse will be visiting the client at the hospital later today leaving work.

19. The nurse is preparing to insert an indwelling urethral catheter for an assigned client. Which of the following statement by the client would be priority to follow?

1. I have had a catheter before and felt pressure when the catheter was placed

2. I developed a rash on my neck when I ate shrimp several months ago.

3. I just urinated so I won't need a catheter placed

4. I haven't been drinking many fluids lately.

20. The nurse is caring for a client wo is receiving long-term glucocorticoid therapy. The nurse should encourage the client to select a diet that is high in

1. calcium

2. magnesium

3. thiamine (vitamin B1)

4. Vitamin K

21. The nurse is contributing to the plan of care for a client who had a stroke 3 days ago and has right-sided hemiplegia and dysphagia. Which of the following nutritional outcomes would be the most appropriate for the nurse to recommend including in the client's plan of care?

1. The client will eat 90% of each meal

2. The client will eat without episodes of coughing

3. The client will drink 4 oz of juice or water with each meal.

4. The client will drink liquids without drooling

22. The nurse is collecting data from a client with an acute myocardial infarction (MI). Which of the following findings would be consistent with an acute MI? Select all that apply.

1. Nausea and vomiting

2. diaphoresis

3. dyspnea

4. Nailbed splinter hemorrhages

5. Petechiae

23. The nurse is observing a coworker suctioning a client with a tracheostomy. The nurse should intervene if the coworker

1. Applies suction as the catheter is being withdrawn

2. Wears a face shield throughout the procedure

3. applies suction for 10 seconds at each pass of the catheter

4. wears clean, nonsterile gloves throughout the procedure

24. The nurse reinforcing teaching with a client who is receiving prescribed insulin glargine. Which of the following information should the nurse reinforce?

1. After administering the insulin glargine the same syringe can be used to administer regular insulin.

2. Extra vials of insulin glargine that have not been opened can be store in the freezer

3. Insulin glargine does not have a peak action time.

4. Insulin glargine should be administered 3 times each day 15 minutes before meals.

25. The nurse is caring for a client who has right-sided hemiplegia and is ambulating using a walker. It would indicate a correct understanding of how to use the walker if the client is observed

1. Taking a step forward with the let leg and then advancing the right leg and the walker

2. moving the walker forward 12 in (30cm) then swinging both legs forward together

3. moving the walker and right leg forward 6 in (15cm) and then moving the left leg forward

4. placing he rear leg of the walker and the right left forward and then moving the left leg forward.