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A 45-year-old male returned to his room an hour ago following a bronchoscopy. He is requesting some water. The nurse must:
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C. Check the gag and swallowing reflexes.
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A. Keep the client NPO until an order is written.
B. Check the vital signs first.
C. Check the gag and swallowing reflexes.
D. Encourage coughing and deep breathing. |
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A client is placed on seizure precautions. The nurse knows that an appropriate intervention for a grand mal seizure is:
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D. Place the head in a lateral position.
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A. Insert a tongue blade between the teeth to prevent biting the tongue.
B. Apply restraints to prevent injury to the self.
C. Place the client in a supine position.
D. Place the head in a lateral position. |
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A 15-year old client fractured his tibia and several metatarsal bones. A cast has been applied; it extends from the knee to the toes. The nurse makes frequent assessments of which of the following:
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B. Color, temperature and sensation in the toes.
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A. Quality of the popliteal and femoral pulses.
B. Color, temperature, and sensation in the toes.
C. Movement of the toes on both feet.
D. The pedal pulses in both lower extremities. |
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A client is in traction for a fractured femur. Which of the following statements indicates understanding of the nurse's instruction:
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A. The weights must hang freely at all times
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A. The weights must hang freely at all times.
B. I'm free to move about in bed as I wish.
C. I'll be in a lot of pain and will need narcotics frequently.
D. I won't have the time or energy to work on my paintings. |
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A 45-year old client is receiving heparin sodium for a pulmonary embolus. The nurse evaluates which of the following laboratory reports of partial thromboplastin time as indicative of effective heparin therapy?
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C. Two to 2.5 times the control (normal) value.
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A. Within nomral range
B. One to 1.5 times the control (normal) value
C. Two to 2.5 times the control (normal) value
D. Three times the control (normal) value. |
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A client is on intravenous heparin therapy. The nurse would keep which of the following drugs available as an antidote.
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B. Protamine Sulfate
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A. Vitamin K
B. Protamine Sulfate
C. Epinephrine
D. Norepinephrine |
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A client is taking warfarin (Coumadin) following placement of an artificial mitral valve. The nurse instructs the client to avoid taking the following commonly used drugs:
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D. Aspirin
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A. Maalox Plus
B. Tylenol Cold & Flu Medication
C. Sudafed
D. Aspirin |
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During the evening following a partial gastrectormy, a client's oral temperature is 100F. Other data include a blood pressure of 134/68, a pulse of 88, and a respiratory rate of 18. The nurse should:
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B. Take the temp every hour until it is normal.
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A. Notify the physician immediately
B. Take the temp every hour until it is normal.
C. Perform a thorough Respiratory assessment.
D. Remove the dressing and check the operative site. |
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A client with insulin-dependent diabetes mellitus (IDDM) is being discharged. The nurse knows that the client has understood essential teaching when the following statement is heard:
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A. I need to cut my nails straight across.
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A. I need to cut my nails straight across.
B. I can't make any substitutions in my diet.
C. My insulin should be given into my arms.
D. I should eat less before exercising. |
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A 45-year old client has recently been told that she has acute nyelocytic leukemia. She seems quite happy and laughs and jokes about everything. The nurse should:
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C. Wait and allow her to explore her feelings.
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A. Remind her of the seriousness of her diagnosis.
B. Encourage her to continue with her laughter and joking.
C. Wait and allow her to explore her feelings.
D. Reprimand her for not taking her treatment seriously. |
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A client is on chemotherapy for acute myelogenous leukemia. The nurse assesses the following laboratory test daily:
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A. Complete blood count
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A. Complete blood count.
B. Electrolyte panel
C. Prothrombin Time
D. Blood urea nitrogen and creatinine |
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A client has developed depression of the bone marrow from antineoplastic drugs. The nurse states the nursing diagnosis of highest priority as:
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D. High risk for infection
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A. Fluid volume deficit
B. High risk for aspiration
C. Ineffective thermoregulation
D. High risk for infection |
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Radioactive iodine is being used to treat a client with cancer of the thyroid gland. The nurse knows that the client has understood teaching about the treatment when the following statement is heard.
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D. My body fluids will be radioactive for a short time.
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A. Only my thyroid gland will be radioactive.
B. I need not be concerned about radioactivity
C. My whold body will be radioactive.
D. My body fluids will be radioactive for a short time. |
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A radioactive implant is being used to treat a client with cancer of the prostate. The implant is found on the floor near the patient. The nurse should:
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B. Place the implant in a radiation-proof container, using forceps
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A. Replace the implant, using forceps.
B. Place the implant in a radiation-proof continaer, using forceps.
C. Leave the implant for the radiation safety officer.
D. Place a lead shield between the nurse and the implant. |
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A nurse assess an intravenous site of a client and finds it red, swollen, and painful; there is no blood return. The nurse should:
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A. Remove the IV at once
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A. Remove the IV at once.
B. Watch to see if the swelling gets worse
C Report it to the physician
D. Apply an antibiotic ointment to the site. |
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A client's total parenteral nutrition is 6 hours behind schedulel. The nurse would
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D. Check the blood glucose level.
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A. Run the fluid at a rate to make up for the lost time.
B. Report the situation to the physician.
C. Run the IV at the prescribed site.
D. Check the blood glucose level. |
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A 44-year old client is in acute congestive heart failure. THe nurse and client establish a goal of highest priority as:
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A. rest mentally as well as physically
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A. Rest mentally as well as physically
B. Learn stress management
C. Train for a less demanding job.
D. Prevent complications of immobility |
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A 46-year old client has just had a femoral-distal bypass. It would be most importnt for the nurse to assess:
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C. Pedal pulses
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A. Serum cholesterol levels
B. Popliteal pulses
C. Pedal pulses
D. Cardiac enzyme levels |
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A 33-year old client is having a routine physical examination. The nurse evaluates which of the following data on a urinalysis report as normal?
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B. Trace of protein
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A. Positive for ketones
B. Trace of protein
C. Positive for glucose
D. Cloudy |
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A client with chronic renal failure has an arterovenous shunt in the left arm. The nurse makes which of the following assessments of the left arm each shift?
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B. Detection of a thrill and bruit.
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A. Blood pressure and pulse
B. Detection of a thrill and bruit
C. Venous and arterial distention
D. Skin turgor and skin integrity |
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A client diagnosed with insulin-dependent diabetes mellitus becomes irritable and confused; the skin is cool and clammy, and the pulse rate is 110. The first action of the nurse would be to
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A. Give a half-cup of orange juice.
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A. Give a half-cup or orange juice
B. Check the serum glucose
C. Administer regular insulin
D. Call the physician |
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A client with IDDM is recovering from diabetic ketoacidosis. Information on the serum level of the following substance will be very important to the nurse:
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C. Potassium
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A. Sodium
B. Calcium
C. Potassium
D. Magnesium |
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A 17-year old client's mother has recently been diagnosed with pulmonary tuberculosis. The nurse would expect the doctor to order which of the following tests initially?
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A. The Mantous
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A. The Mantous
B. An x-ray
C. A sputum culture
D. Gram stain of the sputum |
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The nurse injects 0.1 ml of purified protein derivative (PPD) intradermally into the inner aspect of the raction to this test as positive when the following is seen
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C. induration greater than 10 mm
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A. Redness greater than 5 mm
B. Swelling greater than 7 mm
C. Induration greater than 10 mm
D. Exudate covering more than 12 mm
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A client is receiving whole blood when she starts to shake with chills: her temperature is 101F. The nurse should first:
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D. Stop the blood immediately
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A. Call the physician immediately
B. Administer the PRN dose of aspirin
C. Start another IV, running normal saline
D. Stop the blood immediately |
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A 66-year old client with congestive heart failure takes both Digoxin and Lasix daily. The nurse would want to know the results of the following laboratory test:
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D. Electrolyte panel
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A. Complete blood count
B. Blood urea nitrogen and createnine
C. Coagulation times
D. Electrolyte panel |
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A 29-year old client has been taking prednisone 60 mg daily for an inflammatory condition for the past 6 months. The physician just wrote an order to discontinue the medication. The nurse should:
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C. Call the physician and question the order
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A. Stope the medication as ordered
B. Continue the medication until the physician is available
C. Call the physician and question the order.
D. Hold the medication until the physician is available |
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A 49-year old client with cancer of the lung just had a throacentesis. The nurse would position the client:
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C. on the unaffected side
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A. On the affected side
B. Sitting
C. On the unaffected side
D. In Fowler's position |
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A 55-year old client has a chest tube connecgted to a Pleur Evac system to remove blood from the pleural cavity. While turning the client, the nurse remembers to:
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A. Keep the Pleur Evac below the level of the wound
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A. Keep the Pleur Evac below the level of the wound.
B. Remove the suction from the Pleur Evac.
C. Clamp the tubing connected to the Pleur Evac.
D. Drain the sterile water from the Pleur Evac. |
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A 26-year old client is having a chest tube inserted into the left upper chest wall posteriorly. The nurse anticipates that which of the following will be used to cover the incision?
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D. Sterile petrolatum (Vaseline) gauze
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A. Sterile Gauze
B. Kerlix
C. A sterile sealant
D. Sterile petrolatum (Vaseline) gauze |
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In order to assist women in choosing the appropriate method of contraception, which assessment data should the nurse gather?
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A. Current desires about childbearing
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A. Current desires about childbearing
B. Nutritional Status
C. Employment history
D. Number of pregnancies |
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The nurse manager of the family planning clinic instructs the recently hired nurse that part of her duties would include lobbying activities to support federally and state supported family planning services. When asked why this was important, the nurse manager's best response would be:
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D. The more services we provide, the more money is saved on unwanted pregnancies.
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A. The $ spent on family planning is linked to fewer birth defects.
2. Increasing funding for family planning increases elective abortions.
C. Lobbying will give us publicity and increase our business.
D. The more services we provide, the more money is saved on unwanted pregnancies. |
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When teaching a client to use the calendar method of contraception, which of the following should the nurse include in her teaching plan?
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B.Ovulation occurs around day 14 of the menstrual cycle, sperm are viable up to five days, and ovum live for 24 hours.
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A. Ovulation occurs around day 10 of the menstrual cycle, sperm are viable up to 3 days and ovum live for 2 hours.
B. Ovulation occurs around day 14 of the menstrual cycle, sperm are viable up to five days, and ovum live for 24 hours
C. Ovulation occurs around day 18 of the menstrual cycle, sperm are viable up to 2 days, and ovum live for 4 hours
D. Ovulation occurs around day 11 of the menstrual cycle, sperm are viable up to 4 days and ovum live for 48 hours |
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A client states that her menstrual cycle lasts from 24 - 28 days. The nurse should state that her fertil phase would be:
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C.Eighteen days before the end of the shortest cycle through 11 days from the end of the longest
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A. 12 days before the end of the shortest cycle through 10 days from the end of the longest.
B. 18 days before the end of the shortest cycle thru 14 days from the end of the longest.
C. 18 days before the end of the shortest cycle thru 11 days from the end of the longest
D. 14 days before the end of the shortest cycle thru 11 days from the end of the longest.
B. |
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The nurse evaluates a client's correct understanding of ovulation based on the cervical mucu methods when the client states:
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d. The mucus will be clear, thin, and stretchable
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a. there will bed a lot of thick, white mucus with a strong odor.
b. the mucus will be dark and maybe blood tinged.
c. the mucus will be thick and sticky
d. the mucus will be clear, thin and stretchable |
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Following a health class on birth control methods, the nurse knows that more teaching is needed when the 16 year old male student states:
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a. if I have sex several times in one night, the quantity of my sperm decreases and I'm less likely to get a girl pregnant
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a. if I have sex several times in one night, the quantity of my sperm decreases and I'm less likely to get a girl pregnant.
b. The fluid prior to ejactulation may contain some sperm and this could cause a pregnancy.
c. withdrawing prior to ejactulation might not be easy to do.
d. I could still catch a sexually transmitted infection from a girl even if I don't get her pregnant. |
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Lindy states that she uses douching as a method of birth control. Which of the following statements should the nurse make?
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B. Douching may actually facilitate a pregnancy.
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a. Douching can be an effective method if used appropriately.
B. Douching may actually facilitate a pregnancy
C. The timing of douching following intercourse is very important.
D. Combining doughing with the use of condoms may assist you in avoiding prenancy and a STI
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Callie desires a form of spermicide that she can insert just prior to intercourse. The nurse instructs her to use which of the following?
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C. Effervescent spermicides
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A. Astroglide
B. KY Jelly
C. Effervescent spermicides
D. Suppositories |
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The women's health nurse can recommend a barrier method of contraception to which of the following clients?
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A. A 37-year old woman who smokes a pack a day
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A. 37-year old woman who smokes a pack a day.
b. 16-year old who has no sexual experience
c. 25 year old with a latex allergy
d. 32 year old who has a hx of nonoxynol-9 intolerance |
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Jackie states that cost is a factor in choosing a birth control method. The nurse offers which of the following options.
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C. Diaphragm
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A. The female Condom
B. Combined oral contraceptives
C. The diaphragm
D. Vaginal sponge |
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The community health nurse discusses with a client how her husband makes her feel like a servant. The client states that her husband demands all childcare and housework be done completely by her with no help whatsoever from him. The nurse understands her next assessment questions would explore:
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A. Psychological abuse
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a. psychological abuse
b. physical abuse
c. sexual abuse
d. sociological abuse |
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The client describes her male partner's behavior as intimidating and states that she is afraid of him. Which of the following actions would the nurse inquire about?
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B. a display of weapons
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a. use of religious standards
b. display of weapons
c. forbidding her to see her friends
d. making negative comments about er |
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The social worker has infomred the community health nurse that a couple with a hx of domestic violence is currently in the tension-building phase of the cycle of violence. The nurse will assess for which of the following during the home visit?
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A. the woman is hopeful that her acceptance of blame will diminish the violence
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a. the woman is hopeful that her acceptance of blame will diminish the violence
b. the soman states that leaving is not the solution. She has a sprained wrist.
c. the male partner sent flowers and candy. He is loving and sorrowful of his actions.
d. The home is disorderly. There is a large bruise under the woman's right eye and her lip is swollen. |
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A client admitted to the er for a broken leg confides to the nurse that her boyfriend pushed her down the stairs. The client asks the nurse, "why would he bo so cruel to me?" The nurse's best response would be:
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c. men who abuse women are insecure and feel powerless
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a. i guess you did something to provoke him and he overreacted.
b. i bet this is a family trend for you. were you battered as a child?
c. men who abuse women are insecure and feel powerless
d. was your boyfriend drinking? alcohol causes domestic violence. |
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A client comes with multiple bruises on her arms and chest. Her lip is swollen and one of her front teeth is missing. She denies domestic violence and claims falling into fireplace. What is the most appropriate nursing response?
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a. the signs are common among women who've been abused. we are trained to assist these women in finding a safe place to escape the abuse.
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a. the signs are common among women who've been abused. we are trained to assist these women in finding a safe place to escape the abuse.
b. I know you've been abused. No one is fooled. Why not admit it?
c. I'm sure you did fall into the fireplace. Your injuries are not very life threatening.
d. you'll have no one to blame but yourself if you don't tell us the truth. This will happen again if you return home. |
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The nurse understands that clarification of knowledge is necessary when a female client who is suspected to have been raped states:
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a. just because he made me have oral sex doesn't mean I was raped.
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a. just because he made me have oral sex doesn't mean I was raped.
b. I'm going to learn self-defense and fight back next time
c. I thought he was a polite guy who was interested in me. Guess you can't be too careful because a rapist doesn't have any identifying characteristics.
d. I didn't have anything to drink and my clothes were modest, so no one could accuse me of leading him on. |
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A 12-year old girl, suspected of being raped, is reluctant to provide information regarding her attack. The SANE (sexual assault nurse examiner) addresses which of the following issues first?
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b. concerns about confidentiality
|
a. feelings of guilt
b. concerns about confidentiality
c. fear of retribution
d. lack of knowledge of legal rights |
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The nurse researcher is gathering data about the types of rape. She is interviewing clients who were recently raped. A 65-year old woman describes her rapist is extremely violent. She states that the rapist continually screamed, "this is what you get" The nurse researcher classifies this type as:
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c. anger rape
|
1. sadistic rape
2. confidence rape
3. anger rape
4. blitz rape |
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The nurse's teaching plan for a rape prevention class should include which of the following regarding Flunitrazepam (Rohypnol)?
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a. ingestion of the drug accelerates intoxication
|
a. ingestion of the drug accelerates intoxication
b. a white sediment develops in the drink laced with Rohypnol
c. always smell your drinks because adding the drug to a drink creates a citrus aroma.
d. after ingestion, the client may become hyperactive |
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The nurse working on the sexual assault response team (SART) will begin acquisition of medical and forensic data by first:
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c. obtain a detailed hx of the event
|
a. photograph any physical injuries
b. scrape under the victim's fingernails
c. obtained a detailed hisotry of the event
d. mark clothing and seal in an airtight bag |
