1. A nurse in an emergency department is preparing to perform an ocular
irrigation for a client. Which of the following actions should the nurse plan
to take?
a. Assess the client's visual acuity prior to irrigation
b. Have the client turn their head toward the unaffected eye
c. Hold the irrigator syringe 3.81 cm (1.5 in) above the eye
d. Perform the irrigation with sterile water for irrigation - ANS -d.
Perform the irrigation with sterile water for irrigation
2. A nurse is preparing to administer lactated ringer's via continuous IV
infusion at 200 ml/hr. The IV tubing has a drop factor of 10 drops/ml. How
many gtt/min should the nurse set the IV pump to administer? Round to
near whole number - ANS -33 gtt/min
3. A nurse is providing discharge teaching to a client who has a new
prescription for sublingual nitroglycerin. Which of the following client
statements indicates an understanding of the teaching?
a. I can keep my medications for 1 year before replacing it
b. I should lie down when I take this medication
, c. I should discontinue this medication if I develop a headache
d. I can take up to five tablets in 15 minutes before seeking medical
attention - ANS -b. I should lie down when I take this medication
4. A nurse is providing discharge teaching to an older adult client following a
left total hip arthroplasty. Which of the following instructions should the
nurse include in the teaching?
a. Clean the incision daily with hydrogen peroxide
b. You can cross your legs the ankles when sitting down
c. You should use an incentive spirometer every 8 hours
d. Install a raised toilet seat in your bathroom - ANS -d. Install a raised
toilet seat in your bathroom
5. A nurse is planning care for a client following a cardiac catheterization.
Which of the following actions should the nurse take?
a. Keep the client on bed rest for 24 hours
b. Limit the client's fluid intake to 1 l per day
c. Maintain the client's affected extremity in extension
d. Change the client's dressing every 8 hour - ANS -c. Maintain the
client's affected extremity in extension
,6. A nurse is caring for a client who has a lower extremity fracture and a
prescription for crutches. Which of the following client statements
indicates that the client is adapting to their role change?
a. I will need to have my partner take over shopping for groceries and
cooking the meals for us
b. These crutches will make it impossible to care for my child
c. I feel bad that I have to ask my partner to keep the house clean
d. Its going to be difficult to tell my parents I cant take them to their
appointments anymore - ANS -a. I will need to have my partner take
over shopping for groceries and cooking the meals for us
7. A nurse is caring for a client who has gastroenteritis. Which of the
following assessment findings should the nurse recognize as an
indication that the client is experiencing dehydration?
a. Pitting, dependent edema
b. Distended jugular veins
c. Increased BP
d. Decreased BP - ANS -d. Decreased BP
8. A nurse is caring for a client who has a contusion of the brainstem and
reports thirst. The client's urinary output was 4,000 ml over the past 24
hour. The nurse should anticipate a prescription for which of the following
IV medication?
, a. Desmopressin
b. Epinephrine
c. Furosemide
d. Nitroprusside - ANS -a. Desmopressin
9. A nurse in a clinic receives a phone call from a client who recently started
therapy with an ACE inhibitor and reports a nagging dry cough. Which of
the following responses by the nurse is appropriate?
a. "your cough may require that you stop or change your medication"
b. "Increasing your daily fluid intake may eliminate your cough"
c. "sucking on lozenge may reduce the frequency of your cough"
d. You cough should go away in time" - ANS -a. "your cough may require
that you stop or change your medication"
10. A nurse is taking an admission history from a client who reports
Raynaud's disease. Which of the following assessment findings should
the nurse identify as a potential trigger for exacerbations
of Raynaud's?
a. Eating a strict vegetarian diet
b. A history of herpes zoster
c. Taking amiodipine for hypertension
d. Using a nicotine transdermal patch - ANS -d. Using a nicotine
transdermal patch
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