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1. A nurse is collecting date from a client who had a long arm cash applied 2 hours ago, white of the following findings of the affected extremity should the nurse report to the provider Immediately? 

 

 2. A nurse is reinforcing teaching about dietary modifications to help control blood pressure a client who has hypertension, Which of the following food choices by the client indicates an understanding of the teaching?

 

 Broiled cod with bBroccoli

 

3. a nurse is preparing a client for a colposcopy following an abnormal Papanicolaou (Pap) test.Which off the following actions should the nurse take? 

  

                    3

 

4, An occupational health nurse is interpreting the results of a tuberculin skin test for a group clients who received the test 

48 hours ago. Which of the following clients should the nurse identify as having a positive test result?

 

                     A head or Indurated area between 1/8 

 

 5. A nurse is performing tracheostomy care for a client who has a chronic tracheostomy . Wh of the following actions should the nurse take?

 

           Suction 2-3 x w/a 60 second Pau 

 

6. A nurse is reinforcing teaching with a client about menopause. Which of the following statements by the client indicates an understanding of the teaching? 

 

                         

 

7. A nurse is collecting data from a client who is African American. Which of the following areas should the nurse check to determine the presence of pallor?

 

 a. Conjunctiva

b. Pinna of the ear

c. Antecubital space 

d. abdomen

 

 8. A nurse is caring for an older adult client who has heart failure. Which of the following finding should the nurse report to the provider? 

 

                 

Chest x-ray showing cardiomegaly 

 

Potassium level 4.5 mEq/L 

 

Urinary output of 1,000 mL in 12 hr

 

 PaCO2 55 mm Hg

 

9. A nurse is collecting data from an older adult client, Which of the following findings should indicate to the nurse that the client has a bladder Infection?

 

WBC count 9.000/mm

 

Changed mental status 

 

Diminished reflexes 

 

Temperature 373′ C (59.1. F)

 

10. A nurse is caring for a client who is 24 hours postoperative following abdominal surgery. The client received an opioid analgesic 1 hour ago and now reports a pain level of 2 on a scale of 0 to 10 which of the following actions should the nurse take ?   

 

             

 Reposition the client.

 

 Maintain the client on bed rest. 

 

 Administer an additional dose of pain medication.

 

 Apply a warm. moist compress to the incision area.

 

11. A nurse is assisting with the plan of care for a client who requires contact precautions.

Which of the following interventions should the nurse include in the plan?   

 

              N/A 

 

12, A nurse is caring for a client who is visually impaired. When delivering the clients meal tray. which of the following actions should the nurse take ?

 

                   Food in Clock wise position  

 

13a nurse is reviewing a client’s medical record, Which of the following findings is the priority  for the nurse to report? 

 

Potassium level 6.2 mEq/L 

 

Urine output 200 mL/8 hr 

 

A client’s rating of ear pain as 5 on a scale from 0 to 10 

 

Abnormal hepatoiminodiacetic acid (HIDA) scan

 

14 a nurse is reinforcing teaching about the care of a client who has liner croppers with a newly  licensed nurse, Which of the following should the nurse include in the teaching ? 

 

                       

Isolated for  24 hr after lesions appear 

 

Administer broad spectrum antibiotic

 

 Place on air borne precaution

 

Avoid direct contact

 

15. A nurse is reinforcing teaching with a client who is taking oxybutynia. The nurse should ted the client that the medication will have which of the following effects ? 

 

              

Relaxes the muscles of the colon 

 

Relaxes the muscles of the bladder 

 

Increases toque perfusion in the lungs 

 

Increases venous return to the heart

 

16, A nurse is assisting with the care of a postoperative client who is receiving  a unit of packed RBCs, Which of the following manifestations should the nurse recognize as an indication of a septic reaction to the blood transfusion? 

 

      Distrned neck veins 

     

       Hypertension 

 

      Polyuria 

 

       Vomiting 

 

17. A nurse is reviewing the results of a client’s fecal occult blood screening test. Which of the following findings from the client’s history should the nurse identify as potentially causing a false positive result? 

 

        

 

The diet had a hemorrhoidectomy 1 year ago,

 

 The client has a history of breast cancer 

 

The diet takes ibuprofen for headache

 

 

The client consumed citrus juice 3 days before the test 

 

18 A nurse is preparing to obtain a postprandial blood glucose a client who has  dilateles meilleur Which of the following actions should the nurse take?

 

Clean the client’s finger with hexachlorophene. 

 

Apply the first drop of blood to the test strip, 

 

Prick the central tip of the client’s finger

 

Hold the client’s finger in a dependent positon.

 

19 A nurse is assisting with the transfer of a client from a medical-surgical unit to an interest can unit following a change in status. Which of the following Information should the nurse include  in the transfer documentation ? select all that apply 

 

Number of family members who have visited 

 

Primary health problem

 

 Admission vital signs from 1 week ago 

 

Current medication prescriptions

 

 20. A nurse  is planning care for a client who is receiving radiation therapy to treat throat cancer and reports a change in the taste of food. Which of the following interventions should the nurse include  in the plan of care?  

 

Offer artificial saliva Frequently 

 

Heat food before serving 

 

Provide three large meals daily. 

 

Ace honey to sweeten fruit smoothies.

 

21 / nurse is collecting data from a client who had left hemispheric stroke. Which of the following findings should the nurse report to the provider immediately ? 

 

       Inability to follow direction 

 

             Left Loss of vision

 

22. A nurse is collecting data from a client who has mitral valve regurgitation . In which of the following areas  should the nurse place the stethoscope to auscultate murmur? (You will find hot-in spots to select on the artwork below. Select only the hotspot that corresponds to your answer 

 

23.a nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema? 

 

Obtain blood pressure readings using the client’s right arm 

 

Keep both arms below the jevel of the client’s heart. 

 

Use the client’s left arm to obtain blood samples. 

 

Limit range-of-motion exercises with the affected arm.

 

24 A nurse is reinforcing teaching with a client who has gastroesophageal reflux disease, Which of the following dietary Instructions should the nurse Include ?  

         

Use a straw when drinking liquids.

 

 Limit meals to three per day with no snacking in between. 

 

Chew food thoroughly. 

 

Drink carbonated beverages with meals

 

25. A nurse is caring for a client who has returned to the unit following a cardiac catheterization using a femoral approach. Which of the following methods should the nurse use to monitor for a complication? 

 

Check for jugular vein distention while the client is supine.

 

 Palpate the client’s pedal pulses and compare bilaterally. 

 

Check the client’s blood pressure while the client lies supine, sits, and stands.

 

 Palpate the client’s brachial pulses and compare bilaterally.

 

26. A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan care? 

 

   Advise the chant about increased dry mouth  

 

27. A nurse is caring for a client who is experiencing a generalized tonic clonle seizure. Which of the following actions should the nurse take?   

 

       Administer an IV Lorazepam 

 

28 , A nurse Is monitoring a client who has a nasogastric(NG) tube set to intermittent suction to manage a mechanical intestinal obstruction, Which of the following findings should the nurse report? 

 

      Bite colored drainage from the NG tube 

 

      Potassum 4.2 mEg/L 

 

         Abdominal distention 

 

        BUN 10 mg/dl 

 

29 A morse is caring for an older adult client who has stomatitis due to poorly fitting dentures. Which of the following actions should the nurse take 

 

offer the client hot beverages to drink. 

 

Increase the dient’s fluid intake to 2000 ml dally 

 

Provide the client with a high-protein diet. 

 

Ride the client’s mouth twice daily with an alcohol based mouthwash

 

30 A nurse is reinforcing teaching about risk factors for colorectal cancer with a cient. Which of the following risk factors should the nurse Include in the teaching ?( Select all that apply) 

 

History of diabetes metlitus 

 

Family history of colorectal cancer 

 

Age  over 50 year 

 

hight – fiber diet 

 

     

 

31. A nurse is preparing to administer diphenhydramine 25 mg PO every 6 hours to an older Family adult client who has Rhinitis. The amount available is diphenhydramine syrup 12.5 ma/5mg. How many milligrams should the nurse administer?  

                 

               10mg 

 

32. A nurse is preparing to administer subcutaneous anoxapaint. In which order should the nurse perform the following steps ? (Move the steps into the box on the right placing them in the order of performance . Use all the steps.)(see pics) 4,2,3,1,5 

 

33. A nurse is reinforcing teaching with a client who had diabetes mellitus about reducing the risk for stroke, Which of the following statements by the client indicates an understanding of the teaching? 

 

         

 

can decrease my risk for a stroke by losing excess weight” 

 

My provider might prescribe a glucocorticoid regimen to decrease my risk for a stroke.” 

 

My risk for a Strove increases it my HbA1c  level is 6 percent or less.”

 

34. A charge nurse nurse is observing a newly licensed nurse care for a client who is at risk for Falls. Which of the following findings should the nurse Identify as a risk factor for Falls? 

 

Positions the bedside table close to the dient 

 

Instructs the client to wear their own socks to the bathroom 

 

Attaches the call light to the side rall of the client’s bed

 

 Keeps the client’s bed in the low position

 

35. A nurse working in a provider’s office is caring for a client who received peniclin G potassium 15 minutes ago to treat strep throat. Which of the following is the priority finding the nurse should report to the provider?      

 

Abdominal Pin 

Arthraiga 

 Hypotension 

Nausea 

 

36. A nurse is collecting data from a client who has gastroenteritis with diarrhea and worming. Which of the following laboratory values should alert the nurse that the client is at risk for fuldy volume deficit?   

                        

Creatine 1.1 mg/dl 

 

  Hematocrit 56 mg/dl 

 

Potassium 4.5 meg/L 

 

Sodium140 mEq/L

 

37. A nurse is caring for a client who has a prescription for pro Propranolol for the treatment of 

patrol fibrillation. Which of the following actions should the nurse take? 

                 

 Withhold the medication if the systolic blood pressure is less than 90 mm Hg.

 

 Administer the medication with an antacid.

 

 Request a dosage increase if the apical heart rate is less than 60/min. 

 

Instruct the client to expect increased hair growth

 

38, A nurse is assisting with the care of a client who has a closed chest tube drainage system Which of the following actions should the nurse take? 

 

    Pin  the Tubing  to the client bed sheets 

    

 Clamp the tube for 30 min every 8 hr 

 

Monitor for a least 150 ml of drainag every hours 

 

 

 

 39. A nurse is caring for a client in hospice care who is dying, The client’s partner expresses concern that the client is sleeping more than in the previous week. Which of the following is an appropriate response by the nurse?

 

  

“Encourage your partner to wake up to interact with family members. 

 

” will cal the provider to discuss your concerns.” 

 

I can ask the provider to prescribe a medication that will minimize drowsiness.

 

 “sitting quietly near the bedside can provide comfort and support.”

 

40, A nurse is collecting data from a client who began taking captopril 2 days ago, Which of the following findings should the nurse report to the provider immediately? 

 

Lip Swelling 

Dizziness 

Joint  aches   

Metic taste 

 

41. A nurse is reinforcing teaching about decreasing the risk of osteoporosis to a client who postmenopausal. Which of the following instructions should the nurse Include?

 

Add a weight- bearing exercis regimen       

Limit Vitamin D intake 

Increase daily intake of vitamin E 

 take calcium Carbonated supplement once a day with breakfast 

 

42. A nurse is preparing to assist with the administration of Peritoneal dialysis with a client. in Sopplen which order should the nurse take the following instructions . (move the steps into the box on the right placing them in the order of performance, Use all steps , see picture 

        

                               

Infuse dialysate solution into the client’s peritoneal cavity. 

 

Prime the client’s catheter tubing with dialysate solution. 

 

Measure the client’s abdominal girth. 

 

Open the client’s drainage tubing after 10 min of dwell time. 

 

Record the client’s of signs.

 

43. A nurse is assisting in the plan of care for a client who Is dehydrated and is receiving IV fluid replaced, Which of the following interventions should the nurse contribute to the plan of care ?

        

Limit Oral Fluids Prior Bedtime 

Offer oral fluids every 4 hr 

Checke for neck vein distention 

Monitor pulse pressure every 6 hr 

 

44. A nurse is collecting data from a client who has peritonitis. Which of the following findings fleck un should the nurse expect to find ? 

 

Decreased respiration 

Peripheral Edema

 Absent bowel sounds

Polyuria 

 

45. A nurse is caring for a young adult client who has testicular cancer and expresses concern about their sexual function following an orchiectomy of the involved testicle, Which of the following responses should the nurse make? 

 

“There are other ways to express intimacy besides intercourse.’ 

 

“I’m sure any partner will understand that you have no control over this.” ”

 

You should focus on recovering from your cancer right now.” 

 

The removal of a single testicle will not prevent you from having an erection.”

 

46. A nurse is caring for a client who has cancer and has a WBC count of 4,000mmm, Which of the following actions should the nurse take? 

 

Encourage the client to eat unpasteurized dairy products. 

 

Decrease the client’s protein intake.

 

 Instruct the client to use a disposable razor to shave.

 

 Cleanse the client’s toothbrush with hydrogen peroxide.

 

47. A nurse is prioritizing care for four clients following a change-of-shift report. Which of the following clients should the nurse attend to First? 

 

A client who has diverticulitis and a temperature of 38.3. C (100.9 F) 

 

A client who has Alzheimer’s disease and requires assistance to the bathroom

 

 A client who sustained a head injury 2 days ago and has a decreased level of consciousness

 

 A client who has a prescription for a sputum specimen to be obtained before breakfast

 

48. A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse lake ? There’s no 

 

Use the dean technique to collect urine specimens from the drainage system. 

 

Apply topical antimicrobial ointment to the client’s urinary meatus following catheter care. 

 

Empty urine from the drainage bag every 12 hr 

 

secure the catheter tubing to the client’s thigh

 

49. A nurse is caring for a client who has been admitted with Addison disease for which of the following Laboratory findings should the nurse plan to Measure and report to the provider

Potasshim 38 mic 

BUN 15 mg/dt

 Glucose 55 mg/dt

 Sodium 140 mEq

 

SCIENCE
HEALTH SCIENCE
NURSING
NURSING NURS455

 

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