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1. Test taking strategies The client has a red, raised skin rash.

During the bath, the priority action of the nurse is to: A. B. C. D. Assess for further inflammatory reactions Discuss the body-image problems created by the presence of the rash Wash the skin thoroughly with hot water and soap Moisturize the skin to prevent drying.

D.

Check the pulse

ANSWER: B of the choices provided, the first action of the nurse should be to check the clients blood pressure. Nosebleeds can be indicative of high blood pressure in an adult. 7. A client is determined to have an impending anaphylactic reaction secondary to a drug hypersensitivity. What should be the first action for the nurse to perform? (19) A. B. C. D. Administer oxygen Insert an IV catheter Take the vital signs Obtain an arterial blood gas analysis

2. A 61-year-old client recently had left-sided paralysis from a cerebrovascular accident (stroke). In planning care for this client, the nurse implements which one of the following as an appropriate intervention? A. B. C. D. Encourage an even gait when walking in place. Assess the extremities for unilateral swelling and muscle atrophy. Encourage holding the breath frequently to hyperinflation his lungs. Teach the use of a two-point crutch technique for ambulation .

3. A client is receiving a unit of packed red blood cells. The client experiences tingling in the fingers and headache. What is the nurses priority action? A. B. C. D. Call the physician. Stop the infusion. Slow the infusion rate Assess the IV site for infiltration.

ANSWER: A Giving oxygen should be the first action of the burse for this client. With anaphylaxis there is bronchial constriction and subsequent vascular collapse. The airway is of primary concern. The vital signs should then be checked and the physician notified immediately. At this point it would be appropriate to insert an IV catheter and possibly obtain an arterial blood gas to determine oxygenation status. The IV is initiated in order to administer required medications. 8. A nurse observes a colleague preparing a medication for IV bolus administration. Which medication being prepared should prompt the nurse to immediately intervene? (28) A. B. C. D. Saline flush Potassium chloride Naloxone (Narcan) Adenosine (Adenocard)

ANSWER: B Tingling of the fingers and headache may be an indication of an adverse reaction to the transfusion. The infusion should be stopped, and normal saline should be used to KVO. The client should be assessed including vital signs then the physician should be notified. 4. A client is ordered to receive morphine via patient controlled analgesia (PCA). Before beginning administration of this medication, what should the nurse assess first? A. B. C. D. Temperature Neurological status Respirations Urinary output

ANSWER: B Potassium chloride given as an IV bolus can cause cardiac arrest. It should never be administered IV without being diluted and infused slowly through an IV infusion pump. Saline flush, naloxone (Narcan), and adenosine (Adenocard) are appropriate to be given IV bolus undiluted. 9. A client with limited mobility is ready for discharge. Which instruction should the nurse emphasize with the client to prevent urinary stasis and formation of renal calculi? (67) A. B. C. D. Increase oral fluid intake Maintain bed rest after discharge Limit fluid intake to 1L/day Void at least every hour

ANSWER: C the nurse must be especially alert to any changes in respirations because morphine decreases the respiratory center function in the brain. An order for morphine should be questioned if the baseline respirations are less than 12 per minute. 5. A client is being admitted to a medical unit with a diagnosis of tuberculosis. Which type of room should this client be assigned by the nurse? A. B. C. D. Private room Semiprivate room Room with windows that can be opened Negative airflow room

ANSWER: A Bed rest and limited mobility may lead to urinary stasis and increase risk fir formation of renal calculi. Increasing oral fluid intake to 2-3 L per day, if not contraindicated, will dilute urine and promote urine flow, thus preventing stasis and complications such as renal calculi. 10. A client passes black, tarry stools. The nurse recognizes this may be an indication of: (69) A. B. C. D. Haemorrhoids An overproduction of bile A lower gastrointestinal bleeding An upper gastrointestinal bleeding

ANSWER: D Tuberculosis is an airborne contagious disease that is best contained in an negative airflow room. Negative airflow rooms are always private. Opening windows would present possible safety hazard in clients room. 6. An adult patient has a nosebleed. After applying pressure, which action should the nurse take next? A. B. C. Assess for trauma Check the blood pressure Instruct not to pick the nose

ANSWER: D Black, tarry stool is indicative of an upper GI bleed. The black tarry appearance and consistency are related to digestive effects on blood caused by breakdown of red blood cells (RBCs). Haemorrhoids or lower GI bleeding presents as red blood. Upper GI bleeding also prevents with a distinctive foul smell that is not found with lower GI bleeding.

11. Which food should the client with a colostomy be advised to most avoid? (78) A. B. C. D. Milk Cheese Coffee Cabbage

ANSWER: B Nausea and vomiting are present because of increased hormone levels in pregnancy. Dry carbohydrates such as crackers or plain toast are best. Fluids and fats tend to exaggerate the symptoms and should be avoided. 17. The nurse assesses a client in labor with a prolapsed umbilical cord. In what position should the nurse place the client? (48) A. B. C. D. Lithotomy Knee-chest Side-lying Low-fowlers

ANSWER : D cabbage is a gas-producing food that can cause a client with a colostomy problems with odor control and ballooning of the ostomy bag, which may break the device seal, allowing leakage. The other foods should not cause problems in moderation. 12. A nurse is caring for a client with pneumonia. Which of the following interventions is highest priority? (109) A. B. C. D. Increase fluid intake Breathing exercises and controlled coughing Ambulate as much as possible Administer prophylactic antibiotics

ANSWER: B The client should be placed in the knee-chest or a slight Trendelenburg position to relieve the pressure of the presenting part away from the cord. 18. Which term best describes fetal descent during labor? (54) A. B. C. D. Dilation Station Position Presentation

ANSWER: 2 for most clients, the most effective means of preventing fluid consolidation in the lungs is to keep active by deep breathing and coughing. Antibiotics would not be administered prophylactically. Ambulation and increased fluid are important but secondary to deep breathing and coughing. 13. A client experiencing menopause notices changes caused by lack of which hormone? (8) A. B. C. D. Estrogen Progesterone Luteinizing hormone Follicle-stimulating hormone

ANSWER: B The station is defined as the point to which the fetus has descended during labor. 19. What is the earliest sign of hydrocephalus a nyrse would observe in a 2week old infant? (22) A. B. C. D. Sunken eyes High-pitched, shrill cry Bulging anterior fontanel Increasing head circumference

ANSWER: A Estrogen production deceases during menopause and eventually ceases, causing changes associated with menopause. 14. A nurse instructing a high school health class explains that fertilization normally takes place in the: (11) A. B. C. D. Ovary Uterus Cervix Fallopian tube

ANSWER: D In infants, the earliest sign of hydrocephalus is increasing head circumference, which occurs as the suture line separate and the fontanels widen to accommodate the extra fluid within the skull. 20. A 3-year old child is diagnosed with laryngotracheobronchitis. Whats is a sign of an impending respiratory emergency situation? (34) A. B. C. D. Crying Anorexia Coughing Restlessness

ANSWER: D Fertilization takes place in the fallopian tube, followed by implantation in the uterus. Fertilization in the ovary, uterus or cervix may lead to ectopic pregnancy or failure to implant. 15. One method a woman can use to determine the time of ovulation is to examine her cervical mucus. At the time of ovulation, the cervical mucus: (13) A. B. C. D. Will have a slight color Is clear and increased in amount Will have an opaque appearance Is decreased in amount but clear in appearance

ANSWER: D In children, restlessness is always the initial sign of respiratory distress related to decreasing amounts of circulating oxygen. Anxiety, tachycardia and tachypnea are also early signs of hypoxia in a child. 21. A preliminary diagnosis of cystic fibrosis is made for a 3-year-old. Which laboratory study should a nurse recognize as the most definitive in conforming the diagnosis? (41) A. B. C. D. Fecal fat collection Sweat chloride Complete blood count Pulmonary function test

16. A pregnant client complains of nausea and vomiting in the morning. What should the nurse instruct the client to consume to lessen these symptoms? (26) A. B. C. D. Cola Crackers Whole milk Buttered toast

ANSWER: B The only reliable diagnostic test for cystic fibrosis is a sweat test by pilocarpine iontophoresis 22. Which factor is the most important part of an assessment for a child with a possible cardiac anomaly?

A. B. C. D.

Mental status Growth history Blood pressure in one extremity Blood pressure in all four extremities

B. C. D.

Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

ANSWER: D Measuring blood pressure in all four extremities is necessary to document hypertension and the blood pressure gradient between the upper and lower extremities. 23. To obtain an accurate CVP reading with a CVP catheter, a nurse should place the client in which of the following positions? (177) A. B. C. D. Horizontal Left side-lying Right side-lying Low-fowlers

Answer key: C. the Ph is less than 7.35, which is considered acidosis. This eliminates metabolic and respiratory alkalosis as possibilities. Because the PaCO2 is high at 80 mmHg (normal range is 35 to 45 mmHg) and the metabolic measure of HCO3 is normal (range is 22 to 28 mEq/ L), the client is in respiratory acidosis. 28. A nurse would suspect early preeclampsia if a client states which of the following? (83) A. B. C. D. I am bleeding very heavily. I cant wear my wedding ring anymore. Sometimes I can feel very depressed and cry a lot. This morning I got really dizzy and had to lie down.

ANSWER: A To obtain an accurate CVP reading, the client must be in a horizontal position so that the zero reference point at the level of the right atrium is level with the zero mark on the manometer. 24. According to Maslows hierarchy of need, which of the following should a nurse assess regarding a clients most basic needs? (6) A. B. C. D. Career satisfaction Safety and security Affection and belongingness Feelings of confidence and life importance

Answer key: B. Fluid retention in the form of edema in the fingers is a classic early sign of preeclampsia. 29. Which factor would alert the nurse that a pregnant woman is at risk for the development of toxoplasmosis? (84) A. B. C. D. Having an indoor cat Having a large- breed dog History of depression in the family Currently receiving treatment for hypertension

Answer key: B. According to Maslows hierarchy of needs, after physiological needs are met, safety and security are the persons next most basic needs because none of the other needs can be met until a person is safe in his or her environment. 25. A client who is 30 weeks pregnant is admitted with a complaint of vaginal bleeding. What additional symptoms would most likely be present if the bleeding is due to an abruptio placenta? (7) A. B. C. D. Pain and tachycardia Oliguria and constipation Tachycardia and headache Indigestion and vomiting

Answer key: A. cats are immediate hosts to toxoplasmosis. The organism is found in the stool of cats; therefore woman who have cats and handle changing the litter box are at especially high risk for this disorder. 30. Which assessment finding indicates that a woman is in true labor? (95) A. B. C. D. Loss of the mucus plug Increase vaginal secretions Progressive cervical changes Contractions that are 2 minutes apart

Answer key: C. Progressive cervical changes in the form of dilation and effacement of the cervix would indicate true labor. 31. A nurse is assessing a client who delivered 25 hours ago and notes a large amount of fresh vaginal bleeding. What is the most likely cause of the bleeding? (96) A. B. C. D. Uterine atony Cervical laceration Normal postpartum bleeding Retained placental fragments

Answer key: A. Pain experienced in abruptio placenta is a result of the placenta traumatically and prematurely separating from the uterine wall. Tachycardia is a result of hemorrhage and pain associated with this condition. 26. A client has a chest tube inserted for a spontaneous pneumothorax. The nurse assesses the water- seal chamber of the closed chest drainage system and knows it is functioning properly when the: (9) A. B. C. D. Suction chamber is bubbling gently Drainage chamber has bloody drainage Water- seal chamber level fluctuates with respirations. Water-seal and suction chamber has a water level of 25 cm and 5 ml, respectively.

Answer key: D. bleeding that occurs beyond 24 hours after delivery is the most probably related to retained placental fragments. 32. Which finding would the nurse expect when assessing a postpartum client? (101) A. B. C. D. Fundus 1 cm above the umbilicus 1 hour after delivery Fundus 1 cm above the umbilicus on postpartum day 3 Fundus palpated in the abdomen at 2 weeks postpartum Fundus several centimeters below the umbilicus 1 hour postpartum

Answer key: C. the water- seal chamber level fluctuates with respirations as a result of the restoration of negative pressure within the thoracic cavity. 27. A client has the following arterial blood gas results: pH= 7.16, PaCO2 = 80 mmHg, Pa02 = 46 mmHg, HCO3 = 24 mEq/ L, and Sa02 = 81%. Which conditions do the results present? (33) A. Metabolic acidosis

Answer key: A. within the first 12 hours postpartum, the fundus is usually approximately 1 cm above the umbilicus. The fundus should be below the umbilicus by the third postpartum day. 33. A newborn infant is diagnosed with an acyanotic congenital heart defect in which deoxygenated blood is diverted from pulmonary and systematic circulation. The nurse is aware this is indicative of: (103) A. B. C. D. A right-to-left shunt A left-to-right shunt No pulmonary circulation Decreased systemic circulation

A. B. C. D.

Headache and diplopia Irritability and poor feeding Ruptured retinal vessels and diplopia Increasing head circumference

Answer key: B. if a toddler were to develop hydrocephalus, the first signs would most likely be irritability and poor feeding as a result of increased intracranial pressure. 38. A 15-year-old client who is in sickle cell crisis asks the nurse why it is necessary to drink more fluids. The nurse should explain to the client that the rationale for increasing fluid intake is to: (119) A. B. C. D. Decrease the pulse rate Increase the urine output Increase the blood pressure Decrease the concentration of the blood

Answer key: B. an acyanotic defect is characterized by a left-to-shunt and is compensated for by increased cardiac contractions unless the defect is severe, and only then will cyanosis appear. 34. A neonate weighs 8 lb, 1 oz at birth. At age 3 days, the weight has decreased to 7 lb, 12 oz. the nurse should instruct the mother to: (105) A. B. C. D. Increase the amount of formula to prevent further dehydration and weight loss Continue feeding on demand because the noted weight loss is within normal limits. Give additional feedings because the weight loss indicates inadequate caloric intake. Switch to a different formula because the current one is inadequate to maintain weight.

Answer key: D. the painful vaso-occlusive episodes of sickle cell anemia require hydration to decrease hemoconcentration, or blood viscosity, thereby decreasing pain. 39. The most important nursing goal that should receive top priority for a child diagnosed with leukemia is to: (132) A. B. C. D. Prevent injury Promote adequate nutrition Maintain an infection-free state Display development adaptation

Answer key: B. Neonates tend to lose 5% to 15% of their birth weight during the first few days after birth, mostly because of decrease, but acceptable, nutrition and extracellular fluid loss. 35. A nurse explains to a new mother reasons for her newborns cranial molding and determines that the mother needs further instruction when she makes which of the following statements? (106) A. B. C. D. the molding should disappear within a few days. the molding is caused by an overriding of the cranial bones. the brain may be damage if the molding doesnt resolve quickly. the amount of molding is related to the amount and length of pressure on the head.

Answer key: C. the leading cause of morbidity and mortality in children with leukemia is infection. Therefore, preventing infection is the most important nursing plan of care goal. 40. Which client would the nurse consider to be the greatest risk for acquiring human immunodeficiency virus (HIV)? (135) A. B. C. D. Clients who live in crowded housing with poor ventilation An adolescent client who is sexually active with multiple partners Young, sexually active clients who are homeless and live in shelters Children of a parent who engages in sexual activity with multiple partners

ANSWER: C. During vaginal delivery, the cranial bones tend to override when the head accommodates the size of the mothers birth canal. The amount and length of pressure influenced the degree of molding, which usually disappears in a few days without any other interventions or long-lasting effects. 36. The best approach for the nurse to take in order to elicit a 2-year-olds cooperation in taking prescribed medications would be to say, (110) A. B. C. D. I have your yummy medicine for you to take now. Its time for your medicine. Do you want to drink it from this cup or from a spoon? Are you ready to take your medicine now, or do you want to wait until after your bath? Heres your medicine. It will help you cough up those secretions so you will feel better.

Answer key: B. the younger the client when sexual activity begins, the higher the risk and incident of HIV and AIDS. The incidence of this problem is increase when an adolescent has multiple sexual partners. 41. The nurse will be changing the soiled bed linens of a client with the stage III pressure ulcer that is draining seropurulent material. What personal protective equipment (PPE) is most essential for the nurse to wear? (145) A. B. C. D. Mask Clean gloves Sterile gloves Shoe covers

Answer key: B. clean gloves protect the hands and wrist from microorganisms in the linens. Clean gloves are the first line of defense in preventing the spread of infection. 42. Vasopressin (pitressin) is ordered for the client with diabetic insipidus. What would the nurse assess as the therapeutic effect of the drug? (163) A. The blood glucose is elevated.

ANSWER: B. offering realistic choices to a toddler gives the child some sense of control and autonomy. This approach will increase compliance. 37. If a toddler were to develop hydrocephalus, what would be the earliest signs noted by the nurse? (112)

B. C. D.

The blood glucose is decreased. The urine becomes more diluted. The urine becomes more concentrated.

Answer key: C. in a second degree, or partial thickness, burn both the epidermis and the dermis are damaged. 47. A nurse is caring for a client recently placed on allopurinol (zyloprim). The nurse should explain to the client that this medication is given to: (225) A. B. C. D. Prevent liver damage Treat thrombocytopenia Decrease uric acid levels Prevent peripheral nerve damage

Answer key: D. the action of the vasopressin ( pitressin ) is to relieve the polyuria and to concentrate the urine. It increase reabsorption of water by the renal tubules, resulting in decrease urine output and increase urine osmolarity. 43. A nurse is caring for a client with hyperparathyroidism and should monitor the client for which complication? (168) A. B. C. D. Seizures Cataracts Constipation Cardiac dysrhythmias

Answer key: C. allopurinol is an antigout medication that decrease uric acids levels by reducing its synthesis. 48. What is the valid indication for circumcision in male infants? (240) A. B. C. D. Cultural beliefs Preference of the pediatrician Prevention of testicular cancer Decreasing the risk of HIV transmission

Answer key: D. cardiac dysrhythmias may result because of increase serum calcium levels in hyperparathyroidism. Seizures and cataracts are complications seen in hypoparathyroidism. 43. Which finding, if found in a client with tuberculosis, would indicate best to the nurse that the client has been following the prescribed treatment plan? (181) A. B. C. D. Negative sputum cultures Bilaterally clear breath sounds Decrease in the number of coughing episodes Conversion of the Mantoux test from positive to negative

Answer key: A. of the choices given, the most valid indication for circumcision in male infants is for cultural reasons. The other options are inaccurate. 49. A client is being provided with discharge instructions after having a cataract extraction and intraocular lens implant. Which of the following activities should the nurse advise the client to avoid? (246) A. B. C. D. Straining at stool Breathing slowly and deeply Turning on the unoperative side only Keeping a patch over the affected eye

Answer key: A. a clients sputum is expected to convert to negative within 3 months after the beginning of treatment. If not, the client either is not taking the medication or has drug- resistant organisms. 44. The nurse assessing a client with mitral valve stenosis would find symptoms primarily associated with: (184) A. B. C. D. Increase pressure in the aorta Inadequate filling of the right atrium Atherosclerotic superior vena cava Improper emptying of the left atrium

Answer key: A. coughing, bending, at the waist and straining after cataract surgery should be avoided because these activities increase intraocular pressure. The other options do not necessarily increase pressure and would be acceptable discharge teaching instructions. 50. A nurse is caring for a 68-year-old client admitted for acute pulmonary edema. Which assessment finding would the nurse expect to find? (248) A. B. C. D. Vertigo and chest to find Palpitations and nausea Anxiety and distended neck veins Dry, hacking cough and a pericardial friction rub

Answer key: D. the mitral valve presents backward flow into the pulmonary vein. If the valve does not close, pulmonary circulation is compromised, and the left atrium will not empty. 45. A client is diagnosed with renal failure. The nurse anticipates that data support decreased renal function includes which of the following? (198) A. B. C. D. Hypokalemia Increase serum urea and creatinine Anemia and decrease blood urea nitrogen Increased serum albumin and hyperkalemia

Answer key: C. the client experiencing acute pulmonary edema would most likely experience anxiety related to hypoxia. Distended neck veins would be present due to decrease cardiac output resulting in right-sided heart congestion, causing blood to back up into the neck veins. 51. The nurse is planning primary prevention interventions regarding home safety. What would be the best means of preventing lead poisoning in children? (249) A. B. C. D. Identify high-risk groups Educate children in school- based programs Educate the public in community- based programs Provide home chelation kits to high risk families

Answer key: B. renal failure, whether acute or chronic, causes an increase in serum urea, creatinine and blood urea nitrogen. Renal failure also causes hyperkalemia and anemia. 46. A client sustains a second- degree (partial- thickness) burn. The nurse would observe for damage to the: (216) A. B. C. D. Epidermis only. Dermis only. Epidermis and dermis. Epidermis, dermis and subcutaneous tissue.

Answer key: C. by educating the public about lead poisoning --- danger signs, symptoms, and treatment---prevention and early identification of lead poisoning can be accomplished.

52. An 80-year old female client arrives in the emergency department after sustaining a fall at home. The initial assessment by the triage nurse reveals that the left leg is shorter than the right and is externally rotated. The nurse should suspect which of the following as the potential problem? (256) A. B. C. D. Fracture hip Dislocated knee Nondisplaced fractured femur Fractured tibia/fibula

57. A client has severe right-sided weakness and is unable to complete bathing and grooming independently. Based on this observation, the nurse identifies a nursing diagnosis of: A. B. C. D. Powerlessness Self-care deficit Tissue integrity impairment Knowledge deficit of hygiene practices

Answer key: A. older adult clients, especially female, are at high risk for fracture. A classic sign of a fracture hip is accompanied by pain and possible neurovascular changes. 53. Which of the following has highest priority when planning care for a terminally ill client? (259) A. B. C. D. Optimal nutrition Physical comfort Allowing visitors Family involvement

58. The nurse recognizes which of these symptoms as characteristic of a panic attack? A. B. C. D. Palpitations, decreased perceptual field, diaphoresis, fear of going crazy. Decreased blood pressure, chest pain, choking feeling. Increased blood pressure, bradycardia, shortness of breath. Increased respiratory rate, increased perceptual field, increased concentration ability.

Answer key: B. the most important and highest-priority nursing interventions for a terminally ill client are physical comfort, pain management, and palliative care. Physiological care is the priority so the patient is able to do the psychological work necessary before death. 54. According to Maslows hierarchy of needs theory, which of the following represents an individuals ultimate achievement in the area of selfactualization? (261) A. B. C. D. Acceptance of self Financial security Acceptance of death and dying Positive interpersonal relationships

ANSWER: A - Panic disorders are characterized by recurrent, unpredictable attacks of intense apprehension or terror that can render a client unable to control a situation or to perform simple tasks; client can experience palpitations, chest pain, shortness of breath, a decrease in perceptual field, and a fear of "losing it" or going crazy (2) not accurate because typically the client has increased blood pressure related to stimulation of the sympathetic nervous system (3) heart rate would be increased due to stimulation of the sympathetic nervous system (4) client's perceptual field is decreased during a panic attack; client becomes less aware of his/her surroundings, and his/her performance is inhibited 59. Which of the following nursing interventions is MOST important when caring for a client who has just been placed in physical restraints? A. B. C. D. Prepare PRN dose of psychotropic medication. Check that the restraints have been applied correctly. Review hospital policy regarding duration of restraints. Monitor the clients needs for hydration and nutrition while restrained.

Answer key: C. Maslow proposed that an individuals final life achievement is that of accepting death, on the individuals own terms. 55. Which of the following instructions given to a client with osteoarthritis would be considered primary prevention? (23) A. B. C. D. Maintain bed rest Avoid physical activity Perform only repetitive tasks and active range of motion Warm up before exercise and avoid repetitive tasks.

Answer key: D. primary prevention of injury from osteoarthritis includes warming up and avoiding repetitive tasks that can stress joints. Physical activity is important for a client to remain fit and healthy and maintain joint function but is considered to be secondary prevention. 56. A nurse is initially assessing her assigned clients and checks the IV site on a postoperative client. The site is blanched and edematous. The nurse should next assess for: (29) A. B. C. D. An empty IV bag A kinked IV tubing Blood return from the cannula An IV cannula too large for the vein

ANSWER: B - Answers are a mix of assessment and implementation. Is this a situation that requires assessment? Yes. Is there an appropriate assessment? Yes. (1) implementation; inappropriate for the client in restraints (2) correct assessment; while a client is restrained, physiological integrity is important; monitoring positioning, tightness, and peripheral circulation is essential; nurse documents the client's response and clinical status after being restrained (3) implementation; all staff members involved in a restraint event must be aware of hospital policy before using restraints (4) assessment; important to attend to client's nutrition and hydration after the client is safely restrained

60. The nurse is caring for a patient with a fever. During the morning rounds, the patient complains of headache. The nurse proceeds to check the temperature and finds it to be elevated at 37.9 C, the nurse should: A. B. C. D. Administer paracetamol to relieve headache and fever as ordered Perform a tepid sponge bath Document the temperature and call the Physician Check CBC for signs of infection

Answer key: C. the IV site appears to be infiltrated. The nurse would assess whether the cannula is in the vein by assessing whether there is blood return from the cannula. If no blood return is found, the cannula should be removed.

In the example above, the independent nursing action is option B. Therefore option B is the correct answer.

61. The nurse is caring for a patient on heparin infusion. During the morning care, the patient complains of sore gums after brushing teeth. The nurse should: A. B. C. D. Stop the infusionaaqw Notify the doctor Assess for bleeding Administer protamine sulfate

B. C. D.

A man discharged yesterday following treatment with IV heparin for a deep vein thrombosis. An elderly woman discharged from the hospital three days ago with pneumonia. An elderly man who used all his diuretic medication and is expectorating pink-tinged mucus.

In the example above, options A, B, and D are all nursing interventions. Only option C involves nursing assessment. Therefore option C is the correct answer. 62. A nurse in the emergency room receives a telephone call from an emergency medical service and is told that several victims who survived a plane crash and are suffering from cold exposure will be transported to the hospital. The initial nursing action of the emergency room nurse is which of the following? A. B. C. D. Supply the trauma rooms with bottles of sterile water and normal saline. Call the laundry apartment and ask the department to send as many warm blankets as possible to the emergency room. Call the nursing supervisor to activate the emergency disaster plan. Call the Intensive Care Unit to request that nurses be sent to the emergency room.

ANSWER: D. Determine the least stable client. Think ABCs. (1) stable situation, not a priority (2) assess for bleeding gums, hematuria, not the priority (3) assess breath sounds, encourage fluids, cough and deep breathe (4) correctsymptoms of pulmonary edema; requires immediate attention 40

ANSWER: C Option C is the umbrella option. Activating the agency disaster plan will ensure that the interventions in options 1, 2, and 4 will occur. Remember the umbrella option embraces the ideas of other options within it. 63. A nurse is providing safety instructions to the mother of child with hemophilia and tells the mother to do which of the following to promote a safe environment for the child? A. B. C. D. Remove toys with sharp edges from the childs toy box. Allow the child to play with toys only if a parent is present. Place a helmet and elbow pads on the child everyday. Allow the child to play indoors only.

ANSWER A - Test-taking Strategy: Eliminate options that contain absolute words. Option 2 and 4 contain the absolute word only. Option 3 contains absolute word every. Remember that absolute words tend to make an option incorrect. 64. Fat emulsion is prescribed for the client receiving total parenteral nutrition. The nurse is preparing to hang the fat emulsion and notes the presence of fat globules in the solution. The most appropriate nursing action is to A. B. C. D. Shake the solution to dissolve the fat globules Call the physician Return the solution to the pharmacy Place the solution in a bath of warm water until the globules dissolve

ANSWER: C - Test-Taking Strategy: Focus on the issue, the presence of fat globules in the solution. Thinking about the significance of fat globules in the solution and the potential adverse effect of fat globules entering the clients blood stream will direct you to the correct option 65. A home care nurse is planning activities for the day. Which of the following clients should the nurse see FIRST? A. A new mother is breastfeeding her two-day-old infant who was born five days early.

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