Exam Review
- A nurse is caring for a client who is in active labor. Exhibits The nurse is caring for a client following the insertion of an epidural. For each nursing intervention, click to specify if the intervention is essential or contraindicated for the client.
Essential Contrainidication Decrease the IV flow rate. ✓ Monitor fetal heart rate ✓ Administer ampicillin IV ✓ Place client in left lateral position. ✓ Request a prescription for ephedrine. ✓ - A nurse in an emergency department (ED) is assessing a preschooler who has a fractured arm. For which of the following should the nurse further investigate as a warning sign of child maltreatment?A)The guardian wants to accompany the child from the ED to the radiology department.B)The guardian states the child fell off the swing in the backyard.C)The child was brought to the ED 2 days after the injury occurred.D)The child cries loudly when their arm is moved or manipulated.
- A nurse is inserting a short peripheral IV catheter for a client who requires IV fluids. Which of the following actions should the nurse take?A)Choose the client's dominant arm for IV access whenever possible.B)Select a site proximal to previous venipuncture sites.C)Initiate IV access on the palmar side of the client's wrist.D)Insert a larger gauge IV catheter to prevent phlebitis.
- A nurse is caring for a client following a seizure. Which of the following actions should the nurse take?A)Apply restraints if the client is agitated.B)Ambulate the client.C)Position the client on their side.D)Raise all of the side rails on the client's bed.
Exam Review
- A nurse is monitoring a client who is receiving a transfusion of packed RBCs. The client reports chills, headache, low-back pain, and a feeling of "tightness" in their chest. The nurse should identify that the client has developed which of the following types of transfusion reactions?A)AllergicB)Acute hemolyticC)BacterialD)Febrile nonhemolytic
- A nurse is preparing a client for a pelvic examination. Which of the following actions should the nurse take?A)Have the client hold their breath during the examination.B)Ensure that the client's bladder is full.C)Instruct the client to bear down when the speculum is inserted.D)Place the client in modified Sims' position.
- A nurse in a provider's office is talking with an older adult client who tells the nurse that they fear they are "aging badly" and feel "so useless." Which of the following assessment questions is the nurse's priority?A)"Did anything in particular make you feel this way?"B)"Would you tell me more about the changes you see in your body?"C)"Do you ever think about harming yourself?"D)"How long have you had these feelings of uselessness?"
- A nurse performs a capillary blood glucose check for a client who has type 1 diabetes mellitus and obtains a reading of 64 mg/dL on the glucometer. Which of the following assessment findings should the nurse expect?A)TachypneaB)KetonuriaC)Warm skinD)Nervousness
Exam Review
- A nurse is assessing a client who has schizophrenia prior to administering the client's next dose of clozapine. Which of the following findings should the nurse report to the provider?A)PolyuriaB)FeverC)DiarrheaD)Diaphoresis
- A nurse is teaching a client about using transdermal scopolamine to treat motion sickness. Which of the following instructions should the nurse include?A)"Store unused patches in the refrigerator."B)"Apply the patchprior to traveling."C)"Place the patch on your upper arm."D)"Replace a dislodged patch onto the same location."
- A nurse is providing teaching to a group of clients about complementary and alternative therapies using herbs. Which of the following client statements indicates an understanding of the teaching?A)"I can use chamomile tea to promote sleep."B)"Herbal medicines do not interact with conventional medications."C)"I can use ginger to help treat headaches."D)"Herbal medicines are regulated by the Food and Drug Administration."
- A nurse is caring for a client who is 2 days postpartum. Which of the following findings should the nurse report to the provider?A)Scant lochia rubra with a few small clotsB)Urine output 2,500 mL/dayC)Bilateral ankle edemaD)4+ deep-tendon reflexes
Exam Review
- A nurse is preparing regular and NPH insulin in the same syringe for a client who has diabetes mellitus. Which of the following actions should the nurse take?A)Shake both insulin vials for 2 min before withdrawing the doses.B)Administer the mixture within 5 min of preparing it.C)Withdraw the NPH insulin before the regular insulin.D)Inject air into the regular insulin vial before injecting air into the NPH vial.E)NoneF)None
- A nurse is teaching a client who has a new prescription for metformin extended release tablets. Which of the following statements by the client Indicates an understanding of the teaching?A)"I will take the medication in the morning."B)"I will take the medication on an empty stomach."C)"I will avoid crushing this medication."D)"I will expect to gain weight."
- A nurse is teaching a client who has a new prescription for tetracycline. Which of the following information should the nurse include in the teaching?A)"You can take this medication with milk."B)"You should take this medication at bedtime."C)"Constipation is an adverse effect of this medication."D)"Light sensitivity is an adverse effect of this medication."
- A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following actions should the nurse include in the plan?A)Schedule the client for an MRI after the procedure.B)Place the client leaning forward over the overbed table.C)Encourage the client to take deep breaths during the procedure.D)Ensure the client has been NPO for 6 hr.
Exam Review
- A nurse is teaching a class of newly licensed nurses about infectious diseases that nurses are required to report to the health department. Which of the following diseases should the nurse include in the teaching?A)Pulmonary tuberculosisB)Fibromyalgia syndromeC)Herpes simplex virusD)Methicillin-resistant Staphylococcus aureus
- A nurse is assessing a client who is in mechanical restraints after hitting a staff member. Which of the following findings indicates that the nurse should discontinue the restraints?A)The client has been in the restraints for 4 hr.B)The client can explain the reasons for their behavior.C)The client is able to calmly follow commands."D)The client reports that the restraints are too tight.
- A nurse is caring for a preschooler who is in an acute care facility. Which of the following actions should the nurse take?A)Establish a new routine for the child to follow while in the facility.B)Use medical terminology when discussing procedures with the child.C)Encourage the child to play with toys such as a pounding board.D)Perform the morning assessments when the parent is not in the room.
- A nurse is admitting a school-age child who has bacterial meningitis. Which of the following types of isolation precautions should the nurse initiate?A)Protective environmentB)DropletC)ContactD)Airborne
Exam Review
- A nurse is performing an eye examination on a client. Which of the following findings should indicate to the nurse that the client might have cataracts?A)A bluish-white colored pupilB)Decrease in peripheral visionC)Increased intraocular pressureD)Loss of central vision
- A nurse is providing dietary teaching to the guardian of a preschooler who has celiac disease. Which of the following foods should the nurse recommend including in the preschooler's diet?A)A bologna sandwich on rye breadB)Whole wheat pasta with shrimpC)A corn tortilla with black beansD)Low sodium vegetable soup with barley
- A nurse in a pediatric clinic is assessing a toddler at a well-child checkup. After reviewing the child's current medical record, which of the following interventions should the nurse expect the provider to prescribe? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)A)Antibiotic therapyB)Protective environmentC)Blood transfusionD)Iron supplementation
- A nurse is caring for a client who has a three-chamber chest tube system. Which of the following actions should the nurse take?A)Ensure 2 cm (0.8 in) of water is in the water seal chamber.B)Check the patency of the tubing every 2 hr.C)Keep the drainage system above the level of the client's chest.D)Empty the collection chamber every 8 hr.