Exam Review

A nurse is reinforcing urinary bladder training for a client who has urge incontinence. Which of the following instructions should the nurse include?
A)
Void as soon as the urge occurs.
B)
Perform Kegel exercises while waiting for the toilet.
C)
Restrict fluids to mealtime only.
D)
Drink citrus juice in the morning with breakfast.
A nurse is reinforcing teaching about foot care with a client who has diabetes mellitus. Which of the following client statements indicates understanding of the teaching?
A)
I should put lotion between my toes every day to prevent dryness and cracking.
B)
I should use my wrist to test the temperature of the water before bathing.
C)
I should round the corners of my toenails with a nail file to prevent ingrown nails.
D)
I should apply a heating pad to my feet every night to help with circulation.
A nurse is assisting with the care of a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take when performing the procedure?
A)
Apply clean gloves to connect the dialysate tubing to the catheter.
B)
Warm the dialysis solution to room temperature.
C)
Place the client on bed rest during dwelling.
D)
Place the client in the supine position.
A nurse is reinforcing teaching about home blood glucose monitoring with a client who has a new diagnosis of diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?
A)
I will place the lancet over the center of my finger.
B)
I should firmly massage my finger if needed to produce a droplet of blood.
C)
I should hold my finger pointing downward before puncturing the site.
D)
I can cleanse my finger with hydrogen peroxide.

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Exam Review

A nurse is contributing to the plan of care for a client who has had severe diarrhea for the past 3 days and is now beginning solid foods. Which of the following foods should the nurse include in the plan of care?
A)
Bran cereal.
B)
Orange slices.
C)
Applesauce.
D)
Cottage cheese.
A nurse is reinforcing teaching with a female client about preventing urinary tract infections. Which of the following instructions should the nurse include?
A)
Use a douche after sexual intercourse.
B)
Use bleach when laundering underwear.
C)
Urinate every 6 hours.
D)
Drink 2 L of water every day.
A nurse is assisting with the care of a client in the emergency department who presents with abdominal pain, bloating, nausea, and rebound tenderness. Which of the following potential provider prescriptions should the nurse anticipate or identify as contraindicated for the client?
(SATA)
A)
Initiate intravenous access.
B)
Administer hydromorphone intravenously.
C)
Administer 0.9
D)
Administer piperacillin/tazobactam intravenously.
E)
Administer a cleansing enema.
F)
Maintain diet as tolerated.
A nurse is assisting in the care of a client who has cancer and has a white blood cell count of 4,000/mm. Which of the following actions should the nurse take?
A)
Encourage the client to eat unpasteurized dairy products.
B)
Decrease the client's protein intake.
C)
Cleanse the client's toothbrush with hydrogen peroxide.
D)
Instruct the client to use a disposable razor to shave.

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Exam Review

A nurse on a medical-surgical unit is caring for a client who has HIV and a white blood cell count of 1,500/mm. Which of the following actions should the nurse take?
A)
Inspect the client's mucous membranes daily.
B)
Place the client in a private room.
C)
Observe intravenous sites every 8 hours.
D)
Request a high-fat diet from dietary services.
A nurse is assisting with the care of a client who has diverticulitis. The nurse notes the following provider prescriptions: a clear liquid diet as tolerated, check stools for occult blood, blood glucose checks every 4 hr, repeat CBC in AM, acetaminophen 650 mg PO every 6 hr PRN, administer IV 0.9 percent sodium chloride at 100 mL/hr, ondansetron 4 to 8 mg IV every 8 hr PRN, hydromorphone 0.5 mg IV every 2 hr PRN, and piperacillin/tazobactam 3.375 g IV STAT then every 6 hr. Which of the following findings should the nurse monitor to evaluate if the client's condition is improving, has not changed, or has declined?
A)
WBC count, respiratory rate, and bowel sounds.
B)
Heart rate, blood pressure, and urine output.
C)
Patient mobility, skin turgor, and sleep patterns.
D)
Diet tolerance, fluid intake, and body weight.
A nurse is assisting with the care of a client following a thoracentesis. Which of the following findings should the nurse identify as an indication of a possible complication?
A)
Bradycardia.
B)
Tachypnea.
C)
Pedal edema.
D)
Jugular vein distention.
A nurse is assisting with the care of a client whose laboratory results show blood glucose 700 mg/dL, potassium 2.9 mEq/L, sodium 131 mEq/L, magnesium 1.0 mEq/L, anion gap 22 mEq/L, and positive urine ketones. Complete the following sentence by choosing the correct options: The client is at risk for cardiac dysrhythmias due to which of the following?
A)
The client's decreased potassium level.
B)
The client's increased blood glucose level.
C)
The client's elevated anion gap.
D)
The client's positive urine ketones.

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Exam Review

A nurse is reinforcing discharge teaching with a client following a total hip arthroplasty. Which of the following client statements indicates an understanding of the teaching?
A)
It is okay to cross my legs as long as I am sitting upright in a chair.
B)
I will wait a few months before I resume my daily rehabilitation exercises.
C)
I will put a pillow between my legs when I lie on my side in bed.
D)
I will try to sit in low chairs as much as I can.
A nurse is assisting with care for a group of clients on a telemetry unit. Which of the following ECG rhythms should the nurse identify as ventricular fibrillation?
A)
A chaotic, irregular wave with no identifiable P waves, QRS complexes, or T waves.
B)
A rapid, regular rhythm with a sawtooth appearance and a rate of 250 to 350 bpm.
C)
A wide, bizarre QRS complex occurring early with a compensatory pause.
D)
A regular rhythm with a prolonged PR interval greater than 0.20 seconds.
A nurse is reinforcing teaching with a client who is scheduled to undergo a colonoscopy. Which of the following instructions should the nurse include?
A)
Take nothing by mouth for 6 hr prior to the procedure.
B)
Expect to have white-colored stools for two days after the procedure.
C)
Maintain a clear liquid diet for 24 hr following the procedure.
D)
Maintain a clear liquid diet for 1 day before the procedure.
A nurse is collecting data from a client who has a fluid-volume deficit. Which of the following findings should the nurse expect?
A)
Hypotension.
B)
Fever.
C)
Edema.
D)
Hypertension.

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Exam Review

A nurse is collecting data from a client who is 1 day postoperative following an open reduction internal fixation of the right femur. Which of the following findings should the nurse report to the provider?
A)
A capillary refill of 3 seconds.
B)
Scant sanguineous drainage on the surgical dressing.
C)
A temperature of 37.8 degrees Celsius (100 degrees Fahrenheit).
D)
Tingling distal to the fracture.
A nurse is assisting with care for a group of clients on a telemetry unit. Which of the following images should the nurse identify as ventricular fibrillation?
A)
A rhythm showing normal sinus progression with regular P waves and QRS complexes.
B)
A rhythm showing a rapid, chaotic, completely irregular waveform with no identifiable P waves or QRS complexes.
C)
A rhythm showing a sawtooth pattern of flutter waves with a regular ventricular response.
D)
A rhythm showing a regular, wide-complex tachycardia at a rate of 180 beats per minute.
A nurse is assisting with the care of a client who has pneumonia. Which of the following actions should the nurse take? (Select all that apply.)
A)
Instruct the client to breathe deeply and cough 1 time each hour.
B)
Place the client in an upright sitting position.
C)
Promote a daily fluid intake of 2500 mL.
D)
Encourage use of an incentive spirometer every 6 hours.
E)
Maintain the client's oxygen saturation at 86
A nurse is assisting in the care of a client in the medical unit who was transferred from the emergency department with day 1 prescriptions including abdominal CT with contrast, CBC, IV access, clear liquid diet, stool occult blood checks, blood glucose checks, acetaminophen, 0.9
A)
Severe abdominal pain requiring immediate IV hydromorphone.
B)
Elevated blood glucose level requiring regular insulin coverage.
C)
Nausea and vomiting requiring administration of IV ondansetron.
D)
Decreased hemoglobin level requiring a repeat complete blood count.

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Exam Review

A nurse is reinforcing teaching with a client who is postoperative following a tympanoplasty. Which of the following information should the nurse include?
A)
Close the mouth when sneezing.
B)
Drink fluids through a straw.
C)
Resume exercising in 10 days.
D)
Plan to shampoo hair in 1 week.
A nurse is contributing to the plan of care for a client who has had severe diarrhea for the past 3 days and is now beginning solid foods. Which of the following foods should the nurse include in the plan of care?
A)
Bran cereal
B)
Orange slices
C)
Cottage cheese
D)
Applesauce
A nurse is caring for a client who has a new prescription for nitroglycerin. The nurse should monitor for which of the following adverse effects of the medication?
A)
Headache.
B)
Nocturia.
C)
Bradycardia.
D)
Blurred vision.
A nurse is assisting with the care of a client who has a serum calcium level of 7.2 mg/dL (9 to 10.5 mg/dL). Which of the following manifestations should the nurse anticipate?
A)
Positive Cullen's sign.
B)
Hyperactive deep tendon reflexes.
C)
Hypertension.
D)
Hypoactive bowel sounds.

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