Reference no: EM133843516

Question 

1. When assessing a client's abdomen, the nurse should perform which of these techniques first?

Auscultation
Percussion
Palpation
Inspection

2. A postoperative client that has a chest drainage tube, an indwelling catheter, and numerous IV lines, refuses to get out of bed and ambulate on the second postoperative day, which initial nursing response most therapeutic?

"I cannot allow you to remain in bed any longer; you must walk if you wish to get better."
"It is normal to have pain; walking will make it stop hurting ."
"I will have to chart that you refuse to walk, and I'm sure your doctor will be upset."
"After an operation such as yours, many patients are fearful of getting up for a variety of reasons."

3. A client has an order for a medication that the nurse has never heard of before. The nurse cannot find it in the drug reference book. Which of action should the nurse take next?

Determine the client has been taking this medication at home
Consult the nursing supervisor
Give the medication as ordered since the physical signed the order
Call the pharmacy for more information

4. The nurse gives instruction to a client that needs to continue wound irrigations at home. Which of these actions, if observed by the nurse, would require further instructions?

The client dons sterile gloves, and then opens a sterile syringe and solution container
The client places a waterproof pad bedside the wound before removing the dressing
The client irrigates the wound until the solution draining into the basin is clear
The client irrigates wound slowly and steadily, flushing away drainage and debris

5. When teaching a client that has been discharged with orders to continue with dressing changes, the nurse would include which of these measures?

Demonstrating proper gloving technique
Discussing surgical asepsis
Describing the process of sterilization
Demonstrating good hygiene technique

6. The nurse on a busy medical surgical unit has several tasks that need to be completed in order to prepare a preoperative client for the operating room. The nurse is supervising a practical nurse and a nursing assistant. Which tasks would be appropriate to delegate to the nursing assistant?

Completing the client's preoperative checklist
Placing the client onto the stretcher for transport to the operating room
Adjusting the delivery rate on the client's intravenous infusion pump as ordered
Informing the physician about the client's abnormal preoperative blood glucose

7. The nurse inadvertently administers an incorrect medication to a client. Which action would the nurse take first?

Complete an incident report
Assess the client
Contact the nurse manager
Notify the health care provider

8. Which statement made by the client taking furosemide, supports a nursing diagnosis of knowledge deficit?

This medication must be taken, even on days when I feel well
This medication will increase the amount and frequency of my urination
I should change my position slowly to avoid dizziness related to this medication
I will need add more salt to my diet because this medication will increase its excretion

9. A client has the following order for regular insulin on a sliding scale:

Blood sugar 150-180 mg: Give 2 units regular insulin
Blood sugar 181-200 mg: Give 4 units regular insulin
Blood sugar 201-220 mg: Give 6 units regular insulin
Blood sugar above 200 mg: Call healthcare provider

10. At 11 A.M. the nurse obtains a finger stick glucose of 198 mg. The only syringe on hand is a three milliliter one. Regular insulin is available as 100 units per milliliter. How many milliliter s should the nurse administer?

40
0.4
0.04
4

11. An elderly client is at increased risk of developing drug toxicity to prescribed medications due to declining hepatic and renal functioning. Which strategy would the nurse plan to decrease this risk?

Liming the client's oral fluid intake
Administering the medications with meals
Increasing the time interval between medication doses
Encouraging the client to void every three to four hours

12. The client 's urine output is 500 ml in 24 hours. Which action would the nurse take?

Record the finding and continue to monitor the client
Report the findings to the health provider
Obtain a prescription for a diuretic
Encourage the client to limit fluid intake

13. The nurse has obtained an order for mitten restraints for the client that is confused. The nurse would secure the restraint ties to what part of the bed?

The bed frame
The mattress
The bed rails
The trapeze

14. The client receiving medication that is nephrotoxic. The nurse would hold the next scheduled dose of the medication if the client has which of these labor results?

Decreased serum glutamic oxaloacetic transaminase(SGOT) level.
Elevated serum bilirubin level
Elevate blood urea nitrogen (BUN) level
Decreased serum creatinine level

15. The client has a pm order for an opioid analgesic requests the medication. The client last received the medication eight hours ago. Which of the actions would the nurse take prior to administering the medication?

Determine the amount of medication the client has receive in the last 24 hours
Encourage the client to try other pain relief measures first
Have the client use the bathroom
Ask the client to rate the pain on scale of on to ten

16. The client that underwent surgery is having pain and asks for pain medication. Before administering the medication, the nurse checks the client's vital signs. Assessment data reveal: pulse =100/ minute, respiration = 32/minute and BP =134/92 mm Hg. Which of these actions would the nurse take?

Ask if the client is feeling anxious
Check the client's dressing for bleeding
Give the pain medication to the client
Recheck the client's vital signs in 30 minutes

17. The doctor orders meperidine hydrochide 60 mg to be given IM every four hours for pain. The medication comes in a tube marked 50 mg = 1 ml. how many milliliters should the nurse administer to the client?

1.2
0.8
0.5
1.5

18. Which of these response, if made by a client, would indicate to the client has given informed consent?

I understand but what exactly will be done
I'm in so much pain, I'll sign anything
My family wants me to go through with this
I realize the scar will be visible for a few weeks

19. When a client receives chemotherapy for cancer, the nurse would administer the prescribed antiemetic premedication at which of these times?

Immediately before starting the chemotherapy
Thirty minutes before the chemotherapy
When the client requests the medication after the chemotherapy
Thirty minutes after starting the chemotherapy