Reference no: EM133851422
Questions
1. A client is the receive a tube feeding it has been determined as a client and receive feeding if the resident is 60 ml or less. A nurse withdraw 50 ml of feeding in from the client's stomach. Which of these actions should the nurse take?
Re-instill the residual and go ahead with the feeding
Re-instill the residual and wait one hour before giving the feeding
Discard the residual and wait one hour before giving the feeding
Discard the residual and notify the physician
2. A client with demonstrate an understanding of a nurse's instruction regarding strengthening of the arms for crutch walking by carrying out which of these exercises?
Chair pushups
Abduction and adduction of the arms
Assisted flexion and extension of the elbow
Active range of motion
3. Which of these findings should indicate to a nurse that a client is dehydrated.
bounding pulse
labored breathing
Poor skin turgor
urine specific gravity of 1.015
4. A female client tells the nurse that she is afraid that the ulcer on her foot is not going to heal and that the doctor is going to remove her foot. Which of these responses by the nurse would encourage the client to FURTHER verbalize her concerns?
You've been thinking about the possibility of losing your foot?
you know that our nursing care is very good. We hope to make your foot better
if you do have to have an amputation you will be able to get a prosthesis and will be up and walking in no time
let's not worry about that right now. Wouldn't you rather concentrate on getting this foot better?
5. Which of these actions should the nurse take prior to beginning to bathe a conscious bed-bound client?
Offer the client oral fluid
encourage client to void
tighten the bottom sheet
measure of the client vital signs
6. Which of these actions is taken by a student nurse. indicates negligence?
not returning to the classroom within five minutes as promised
disregarding a client reports of pain
avoid answering a client question regarding his/her health
bruising a client arm while grasping it to prevent a fall
7. A client is treated for fluid volume excess. A nurse should expect which of these client outcomes if the treatment has been effective?
Decreased urinary output
decrease pedal edema
increase crackles
increase peripheral pulses
8. A client eats a cup of vanilla ice cream contain in 14 g of fat. The fat alone will yield how many calories?
56
14
126
70
9. A nurse note that a client's urine is deep amber color.The nurse should recognize that this finding indicates that the
client urine is normal
client may have a Urinary tract infection
specimen was collected at the end of the day
client has had limited fluid intake
10. A client who has been diagnosed with cancer is in the hospital receiving chemotherapy. The client says to a nurse "No wonder people can't get well here. Everything runs on your schedule. Which of these responses would be appropriate?
Most of our clients get well in spite of necessary delays.
I have been really busy helping clients who are sicker than you. Now what can I do for you?
I'm here now what can I do to help?
unfortunately you're not the only one here who needs my attention.
11. When monitor a client's urinary output a nurse should expect at least ____ to ___milliliters per hour
12. An orthodox Jewish man who is very thin and has alzheimer's disease does not touch the meat or other foods on his meal tray but says he would like a glass of milk. A nurse would best demonstrate consideration of his needs by
reminding him that say clients need not to observe kosher dietary practices
bringing the milk and placing it on the meal tray
removing the tray and bringing the milk
removing the tray and ask him to wait until snack time in observance of kosher dietary practices
13. Which of these goals assume priority when planning nursing care for a client during the first eight hours after abdominal surgery under general anesthesia?
the client will be able to cough without pain
the client will drink 2000 ml of fluid
client will void at least 250 ml
the client would have intact skin over the sacral area
14. A client who is pre-menopausal should be taught examine her breasts during which of these weeks following are menstrual period?
Fourth
Second
First
Third
15. A nurse should recognize that an elderly client may be at risk for burns because of
loss of subcutaneous fat
decrease vascularity of the dermis
thinning of the epidermis
diminished sense of pain
16. When a client who is receiving an intravenous infusion develops dyspnea a nurse should immediately assess the clients for
Anxiety
infection
hyperglycemia
fluid overload
17. Which of these nurses notes who is the most accurate reflection of a client statement
client has been frightened by rumors about the treatment and needs reassurance
client seems fearful and mention leaving against medical advice
Client stated I've heard that treatment is unsafe. I'll sign out first
client distrust the doctor and refuses to cooperate
18. A physician writes an incorrect dosage amount in an order for digoxin 2.5 mg rather than 0.25 mg in nurse administers the incorrect dosage. Who is responsible for the error?
only the physician who wrote the incorrect order
the pharmacist to fill the prescription
both the nurse and the physician
Only the nurse who administer the incorrect dose
19. An 80 year old woman is not always sure where she is and often thinks that nursing personnel are members of her family. One day, when a nurse comes with a wheelchair to take her to the sun porch, the client says in a bossy manner "start the car betty, I'd like to go into town. Which of these responses would be best for the nurse to make?
I'm not betty you have forgotten my name again
all right after I get you into the wheelchair, I will start the car
I've come to take you to the sunporch. Tell me what you used to do when you went into town
I am not betty and I am not going to start the car. Why do you say things like that?
20. A bedridden client who has generalized edema should have a which of these measures included in the nursing care plan?
keeping the foot of the bed elevated
provide in a high fiber diet
change in position frequently
given daily tepid baths
21. A client tells a nurse "I mix my prescribe medication in 2 tablespoons of juice". How many milliliters should the nurse record as the clients fluid intake?
30
15
120
60
22. A neighbor comes to visit a client in a nursing home and says to a nurse "emma looks so listless and uninterested. Can you suggest something that I can do to perk her up?" Which of these suggestions by the nurse would involve stimulating the greatest number of clients senses?
bring her a few colorful flowers and ask her to hold one or two while you discuss the arrangement of the others
tell her a few jokes when you come to visit
stand by the window with the curtains open and describe to her what you see in the street
give her a list of cheerful shows to watch on television
23. Which of these foods would be AVOIDED by most Hindus, Jews, Muslims and seventh-day Adventists?
Organ meats
Eggs
Dairy products
Pork
24. Which of these findings should the nurse expect to identify in a client who reports experiencing a high level of stress?
excessive salivation
Low-normal blood pressure
rapid pulse
constricted pupils
25. A preoperative client with 106 pounds. When calculating a medication dosage, a nurse should also include a kilogram equivalent to which is____ kg
26. A nurse should teach a client who is using a glucose monitoring device to insert the lancet at which of these locations?
On the lateral aspect of any fingertip
at the base of any finger pad
on the pad of any finger
at the tip of any finger
27. A nurse is teaching a client's history the client reports weakness, fatigue, swelling of the lower extremities and a headache. Based on these cues the nurse should further assess the client to validate which of these nursing diagnoses?
Risk for impaired mobility
Risk for impaired skin integrity
Risk for disturbed sensory perception
Risk for fluid volume deficit
28. When suctioning secretions from a client tracheobronchial tree, a nurse should apply suction
while inserting the catheter
until the mucus disappear
only while the catheter is at the maximum depth
when withdrawing the catheter
29. A nurse in caring for a client whose fluid intake and output are to be measured daily. The drinking glasses available to holds 200 ml. If the client consumed 1/2 glass of fruit juice and 1/4 glass of milk at breakfast, how many milliliters should the nurse record on the intake record?
150
300
250
200
30. When planning to obtain a urine specimen from a client who has an indwelling urinary catheter, a nurse should
disconnect the catheter from the tubing and direct the urine flow into the specimen bottle collect a urine from the drainage bag
change the calendar and collect the urine before connecting the drainage tube
use a needle and syringe to withdraw the urine from the self-sealing port
31. Which of these nursing action would be most appropriate for a client who is NPO and reporting thirst?
offer the client ice chips
maintain a cool environment
provide frequent distraction
provide oral hygiene at frequent intervals
32. A client is taking a medication that can produce bone marrow suppression. Which of these laboratory test results should a nurse monitor?
Red blood cell count
Serum calcium level
Prothrombin time
Serum creatinine level
34. Aclient who has difficulty venous access has an intravenous insertion site located at the bend of the wrist. Which of these actions would be most appropriate for a nurse to take?
use a wrist restraint to decrease mobility in the arm
place the arm across the client's chest to support the wrist
raise the intravenous solution above the wrist to speed the flow
apply an arm board to immobilize the wrist
35. To increase our clients resistance to infection, a nurse should recommend
daily bathing
avoid exposure to inclement weather
eating a well-balanced diet
prophylactic antibiotics
36. A nurse teaches a client who has a long leg cast to tense the thigh muscles, hold them tight for five seconds, then released them and repeat five times. This exercise has the effect of
preventing contractures
maintain muscle tone
preventing misalignment of bone fragments
maintaining body weight
37. Which of these clients would be the most in need of special mouth care?
A 6 years old who is on bed rest
A 45 years old who is on restricted fluids
A 17 years old who delivered a baby two hours ago
A 75 year old who is on a soft diet
38. When teaching breast self-examination in nurse should instruct the client to
palpate in a circular motion using the pads of the fingers
performed exam when dried off after a warm shower
focus on the areas that would be covered by the bra cup
examined the breast while lying supine with a small pillow under the head