,During the initial home visit a nurse is discussing the care of a newly diagnosed client
with Alzheimer's disease with family members. Which of these interventions would be
most helpful at this time?
A) Leave a book about relaxation techniques
B) Write out a daily exercise routine for them to assist the client to do
C) List actions to improve the client's daily nutritional intake
D) Suggest communication strategies - ANSWER-is D: Suggest communication strategies
5
The nurse is teaching a client with non-insulin dependent diabetes mellitus about the
prescribed diet. The nurse should teach the client to
A) Maintain previous calorie intake
B) Keep a candy bar available at all times
C) Reduce carbohydrates intake to 25% of total calories
D) Keep a regular schedule of meals and snacks - ANSWER-is D: Keep a regular schedule of meals and
snacks
5
The mother of a 2 month-old baby calls the nurse 2 days after the first DTaP, IPV,
Hepatitis B and HIB immunizations. She reports that the baby feels very warm, cries
inconsolably for as long as 3 hours, and has had several shaking spells. In addition to
referring her to the emergency room, the nurse should document the reaction on the
baby's record and expect which immunization to be
most associated to the findings in the infant?
A) DTaP
B) Hepatitis B
C) Polio
D) H. Influenza - ANSWER-is A: DTaP
5
,The nurse is teaching a class on HIV prevention. Which of the following should be
emphasized as increasing risk?
A) Donating blood
B) Using public bathrooms
C) Unprotected sex
D) Touching a person with AIDS - ANSWER-is C: Unprotected sex
6
The charge nurse is planning assignments on a medical unit. Which client should be
assigned to the unlicensed assistive personnel (UAP)? A client with
A) Difficulty swallowing after a mild stroke
B) an order of enemas until clear prior to colonoscopy
C) an order for a post-op abdominal dressing change
D) transfer orders to a long term facility - ANSWER-is B: an order of enemas until clear prior to
colonoscopy
6
A 6 year-old child is seen for the first time in the clinic. Upon assessment, the nurse
finds that the child has deformities of the joints, limbs, and fingers, thinned upper lip, and
small teeth with faulty enamel. The mother states: "My child seems to have problems in
learning to count and recognizing basic colors." Based on this data, the nurse suspects
that the child is most likely showing the effects of which problem?
A) Congenital abnormalities
B) Chronic toxoplasmosis
C) Fetal alcohol syndrome
D) Lead poisoning - ANSWER-is C: Fetal alcohol syndrome
1-Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse
perform as a priority before administering the medication?
, A. Checking the client's blood pressure
B. Checking the client's peripheral pulses
C. Checking the most recent potassium level
D. Checking the client's intake-and-output record for the last 24 hours - ANSWER-A. Checking the client's
blood pressure
Checking the client's blood pressure
Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension. One
common side effect is postural hypotension. Therefore the nurse would check the client's blood pressure
immediately before administering each dose. Checking the client's peripheral pulses, the results of the
most recent potassium level, and the intake and output for the previous 24 hours are not specifically
associated with this mediation.
2-A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides
instructions to the client about the test. Which statement by the client indicates a need for further
instruction?
A. "The test will take about 30 minutes."
B. "I need to fast for 8 hours before the test."
C. "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the
morning of the test."
D. "I need to take a laxative after the test is completed, because the liquid that I'll have to drink for the
test can be constipating." - ANSWER-C. "I need to drink citrate of magnesia the night before the test and
give myself a Fleet enema on the morning of the test."
An upper GI series involves visualization of the esophagus, duodenum, and upper jejunum by means of
the use of a contrast medium. It involves swallowing a contrast medium (usually barium), which is
administered in a flavored milkshake. Films are taken at intervals during the test, which takes about 30
minutes. No special preparation is necessary before a GI series, except that NPO status must be
maintained for 8 hours before the test. After an upper GI series, the client is prescribed a laxative to
hasten elimination of the barium. Barium that remains in the colon may become hard and difficult to
expel, leading to fecal impaction.
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