Reference no: EM133881987

Questions

1. The nurse assessment findings of a client in respiratory failure include lethargy, respiratory rate of 8, and an Sa02 of 89%. Which is the best intervention?

Endotracheal intubation and ventilation

Administration of 100% oxygen by non-rebreather mask

Implement nasopharyngeal suctioning

Initiate bi-level positive pressure ventilation (BiPAP)

2. A client has a plaster hip spica cast applied. Which nursing measure would best promote drying of the cast?

Ensure the client's room temperature is 80 °F (26.5 °C).

Turn the client at least every 2 hours.

Blow warm air on the cast with a hair dryer.

Keep the client covered with a light blanket.

3. An infant with hyperbilirubinemia is prescribed phototherapy. Which measure is important to include in this infant's care during this course of Therapy?

Check the pH of the infant's urine.

Apply a water-soluble lubricant to the infant's skin.

Test the infant's stool for occult blood.

Turn the infant frequently.

4. At 26 weeks gestation, a client returns to the clinic. It is suspected that the client's fetus is not growing at an adequate rate. Which study should the nurse anticipate as a method to assess fetal growth status at this time?

An oxytocin challenge test.

A fetal activity record.

A fetoscopy.

An ultrasound

5. During a clinic visit, a client reports to the nurse that she is having burning and numbness in her perineal area. Further investigation reveals that the client has herpes simplex virus (HS) type I. Which information concerning herpes infection during pregnancy should the nurse include in the teaching plan for this client?

It is rare to have more than one herpes outbreak during a pregnancy.

Herpes can be cured with medication.

Weekly cultures of the herpes site will be performed during the last trimester of pregnancy.

Herpes which appears initially during a pregnancy rarely reappears after deliver

6. A client reports severe bladder spasms 12 hours after prostate surgery. Which action should the nurse take initially?

Palpate the area over the symphysis pubis.

Apply moist heat to the lower abdomen.

Check the patency of the urinary catheter.

Administer the prescribed analgesic.

7. Within 24 hours of an open cholecystectomy surgery, the client reports nausea. The nurse should take which action first?

Administer the prescribed antiemetic.

Determine the patency of nasogastric tube.

Assess for pain.

Instruct the client to take deep breaths.

8. A client is prescribed a low-residue diet. The lunch tray contains all of the listed foods. Which food is inappropriate for the client and should be removed?

Boiled fish.

Steamed broccoli.

Chicken noodle soup.

Mashed potato.

9. The nurse observes that the weights on a client's Buck's extension are almost touching the floor. Which action should the nurse take?

Assist the client up to the head of the bed.

Remove some of the weights from the traction.

Shorten the rope supporting the weights.

Elevate the affected leg on a pillow.

10. The nurse is caring for a client who had a heart attack. Which best represents continuity of care?

Early implementation of discharge planning

Collaboration with physician about pain management

Scheduling physical therapy late in day

Consultation with dietician regarding fast foods

11. What is the best action by the nurse who believes a client has not been adequately informed about surgery?

Provide more detailed information to the client regarding the surgery

Contact the client's family and encourage them to request a consultation with the surgeon

Continue with the surgery plans as scheduled

Contact the surgeon and request the client be seen for clarification

12. A school-age child is admitted to the hospital with a history of nausea, vomiting, and diarrhea for the past five days. Physical assessment findings are dry mucous membranes, skin retracts greater than 3 seconds, and last voiding 8 hours ago. The physician writes the following orders: vital signs every 4 hours; hydration assessment, Intake, and Output, and 500 mL D5 0.45NS with 10mEq potassium at 80ml thr. Which prescription should the nurse clarify?

vital signs every 4 hours

Intravenous therapy

Hydration assessment

Intake and output

13. A 7-year-old child is admitted for an open reduction and internal fixation of a fractured femur. A nurse should place the child in which room?

8-year-old with acute viral infection

7-year-old being treated for bacterial pneumonia

8-year-old, newly diagnosed with type 1 diabetes Mellitus

7-year-old, two days post-op, with a ruptured appendix

14. The nurse is admitting a client with vaso-occlusive crisis. Which task can be delegated to the unlicensed assistive personnel (UAP)?

Obtaining a urine specimen

Insert an indwelling urinary catheter

Instruct about signs and symptoms of infection

Assessing a pain score with a FACES chart

15. Which client should the nurse assess first?

Placement of a new tracheostomy

Bilateral amputee with a pain score of 7

Post-op open heart surgery with chest tubes present

Post-op hysterectomy reporting feeling

16. A nurse performs central line care according to hospital policy. The client develops an infection and is considering legal action. Which is the legal implication for the nurse?

Tort

Malpractice

Standard of care

vicarious liability