Reference no: EM133884724

Questions

1. A nurse is caring for a newborn who is placed in a neutral thermal environment. What is the desired outcome of this measure?

To increase the client's ability to metabolize brown fat stores.

To facilitate the conversion of glucose to lactic acid.

To minimize the client's oxygen needs.

To decrease the absorption of surfactant from the alveoli.

2. Which assessment finding is expected in a client with emphysema?

Circumoral cyanosis.

Inspiratory stridor.

Barrel-like chest.

Frequent cough.

3. Which symptom in a client with deep vein thrombosis (DVT) indicates a complication?

Epigastric pain.

Diffuse petechiae.

Intermittent claudication.

Difficulty breathing.

4. Which observation would be an initial indication that a client is developing hepatic encephalopathy?

Twitching facial muscles.

Drooling from the mouth.

Flapping hand tremors.

Drooping eyelids.

5. A nurse is caring for a client who is 24 hours post-surgery. Which nurse's finding may be an early indication that the client is developing a paralytic ileus?

Low-grade temperature.

Decreasing volume of urine output.

Abdominal tenderness.

Absence of bowel sounds.

6. Which observation would most likely indicate that a client has a fracture of the right hip?

The right extremity feels cold.

The right hip is bruised.

The right hip is swollen.

The right extremity is externally rotated.

7. A client with cirrhosis develops ascites. Which intervention is important to add to the client's care plan?

Record hourly urine output.

Check all stools for occult blood.

Auscultate bowel sounds every 8 hours.

Measure abdominal girth daily.

8. A 16-month-old client being seen at the clinic has a fever and a diagnosis of bilateral otitis media. Which comment by the mother is most likely related to the patient's diagnosis?

'My child falls asleep at night drinking a bottle of juice."

"My child is a very picky eater and wants only macaroni and cheese."

My child likes to pull off his hat when outdoors.

My child will not wear shoes in the house.

9. A nurse is caring for several pediatric clients. Which client should not receive a live virus immunization?

One who has cyanotic heart disease.

One who has cystic fibrosis and whose care includes chest physiotherapy.

One who has nephrosis and is receiving steroid therapy.

One who has insulin-dependent diabetes mellitus.

10. The nurse completes a nutritional assessment for a client. The assessment reveals that the client's diet is calcium-deficient. Which foods calcium-rich foods should the nurse suggest?

Cottage cheese.

Bananas.

Turkey.

Summer squash.

11. A multigravida with a 2-year-old child at home is in the 34th week of pregnancy with twins. She asks the nurse, "Can I breastfeed my twins? Which response by the nurse would be most helpful?

'Most pediatricians feel that twins should be bottle-fed."

"It will be especially difficult to breastfeed the twins since there is an older child at home."

'Many women find that they develop mastitis unless they breastfeed and bottle-feed their twins simultaneously.

'Twins can get adequate nutrition from breast milk."

12. A 14-year-old client is 10 weeks pregnant. In order to plan nutritional counseling for this client, the nurse should have which understanding about adolescents' nutritional needs during pregnancy?

They need less supplemental iron than women who have been menstruating longer because their reserves are strongly greater.

Their need for protein exceeds that of pregnant women over 20 years of age.

Their need for vitamin C is greater than that of pregnant women over 20 years of age.

They have less need for simple carbohydrates than older women because they are able to convert fat-storage glucose.

13. A client being treated for heart failure is given dietary instructions to follow a 1-gram sodium diet. Which food selected by the client would indicate the need for further dietary teaching regarding foods lowest in sodium?

Corned beef.

Pork tenderloin.

Tuna steak.

Rainbow trout.

14. A client with diabetes asks the nurse, "What should I do when I feel nervous, sweaty, and hungry?" Which instruction is essential for the nurse to give the client?

Ask the physician to reduce your dose of insulin.

Add a slice of bread to each meal.

Eat a nutritious snack.

Lie down and rest.

15. A client is prescribed pilocarpine. Which statement best describes the desired effect of this medication for the patient?

Stimulates the production of vitreous humor in the eyes.

Inhibits the flow of aqueous humor through the pupils of the eyes.

Reduces the pressure within the eyes.

Reduces the inflammatory process in the eyes.

16. Which potential side effect of levothyroxine should the client be instructed to report to the health care provider?

Ulcers in the mouth.

Irritability.

Swelling of the feet.

Hematuria.

17. What would need to be done if the nurse discovers a client is unable to push the button on the patient-controlled analgesia (PCA) pump?

Program the pump to give continuous dosing

Ask the non-licensed personnel to round on the client more frequently

Ask other people visiting the client to push the button

Request another method of administration for pain medication

18. A nurse is caring for a client with age-related memory deficits who report eating bacon and eggs for breakfast. The nurse is aware that the client ate cornflakes for breakfast. What is the nurse's best response to the client?

'I'm really glad you enjoyed your bacon and eggs this morning."

"You've probably had bacon and eggs several times. Today you had corn fakes and milk."

"Your memory is getting really bad. You had cornflakes and milk.

"No, you did not have bacon and eggs. Think hard and tell me what you had."

19. Which consideration would be useful as a standard for evaluating the progress of a client admitted to an inpatient psychiatric unit for alcoholism?

Results of psychological testing

Treatment goals.

Cultural aspects of the client's background

The client's prognosis.

20. The nurse develops a contract with a male client who is admitted for suicidal ideations. The client states that he will come to the nurse when he feels suicidal, and the nurse will, in turn, discuss the situation with him. What is the best rationale for this approach?

To focus on interpersonal interactions with the client.

To begin returning control to the client.

To increase the staff's confidence in the client's safety.

To provide structure for the client.

21. A nurse is caring for a pediatric client with congestive heart failure (CHF). What major goal should the nurse include in the care of this client?

minimize his cardiac output

minimize his energy expenditure

prevent contractures of his hips and knees

prevent vomiting

22. A client with insulin-dependent diabetes mellitus who is having a hypoglycemic reaction will display which symptom?

Uncontrollable tremors.

Pruritus.

Polyuria.

Polydipsia.

23. A 2-week-old infant is seen in the well-baby clinic. As the nurse is assessing the client, which assessment finding would present as a sign of congenital hip dysplasia?

Extension of the legs while stimulating the infant to exhibit the stepping reflex.

Asymmetrical gluteal folds and unequal leg length.

Negative Babinski reflexes of both feet.

Examining for the presence of any flexion of the hips when the infant is lying on the abdomen.

24. A client in preterm labor tells the nurse, "It's okay that I am in labor. I'm not worried. My sister's baby was born this early, and he is doing great." How should the nurse interpret this statement by the client?

The client is anxious to see the new baby.

The client is coping as expected in this situation.

The client is trying to reassure herself concerning the present situation.

The client is able to use previously learned knowledge in a new situation.

25. A client becomes restless 4 hours after surgery for a head injury. Which action would be essential for the nurse to take?

Obtain an order for sedation.

Inform the health care provider about behavior.

Reposition to high Fowler's.

Place a restraint jacket.

26. The nurse is teaching fatigue management for a client receiving radiation therapy. Which information should be included in the teaching plan?

Plan for between-meal snacks

Ensure at least 5 hours of sleep nightly

Prioritize daily activities

Maintain fluid intake of 1500 ml daily

27. The nurse who is a team leader may be held negligent for which occurrence?

Poor development of policy and procedures

Inadequate training of staff

Delegation of clients' care tasks

Failure to discipline unsafe staff