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Comprehensive Practice B W/Rationales
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🥶Comprehensive Practice B W/Rationales
A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus and reports waking
during the night with tremors and anxiety. Which of the following information should the nurse
include?
A. Limit carbohydrates early in the day.
B. Practice relaxation techniques.
C. Eat a bedtime snack.
D. Increase daily exercise.
Eat a bedtime snack
*The symptoms described by the client indicate hypoglycemia. Eating a snack at bedtime will
help prevent hypoglycemic episodes during the night.
A nurse is assisting with the admission of a client who has a latex allergy. The nurse should
identify that which of the following supplies has the potential to contain latex?
A. Indwelling urinary catheter
B. Paper tape
C. Nitrile gloves
D. Gauze dressings
Indwelling urinary catheter
*The nurse should identify that most indwelling urinary catheters are made of rubber, which is a
form of latex. A rubber indwelling urinary catheter should not be used for a client who has a
latex allergy. The nurse should obtain an indwelling urinary catheter made of silicone for a client
who has a latex allergy.
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A nurse is caring for a client who has an altered mental status and has become aggressive.
Which of the following prescriptions should the nurse clarify with the provider prior to
administration?
A. Haloperidol
B. Lorazepam
C. Zolpidem
D. Alprazolam
Zolpidem
*Zolpidem is a sedative-hypnotic medication used to treat insomnia. It is not indicated for
treatment of confusion and aggressive behavior. Zolpidem can cause agitation and should be
used with caution for clients who have a history of mental illness. Therefore, the nurse should
clarify this prescription with the provider prior to administration.
A nurse is reviewing the laboratory results for a client who is at 29 weeks of gestation. For which
of the following results should the nurse notify the provider?
A. Platelet count 95,000 mm3
B. BUN 15 mg/dL
C. Hgb 11.3 g/dL
D. WBC count 10,000/mm3
Platelet count 95,000 mm3
*The nurse should recognize that this platelet count is below the expected reference range for a
client who is pregnant and might be indicative of HELLP syndrome. Other manifestations of
HELLP syndrome include malaise and epigastric pain. The nurse should immediately notify the
provider of this result.
A nurse notices an assistive personnel (AP) taking a nap in the break during meal time. The
nurse also notes that the AP is drowsy while performing routine tasks. Which of the following
actions should the nurse take?
A. Keep a record of the AP's behavior over a period of time.
B. Report the observations about the AP to the unit's nurse manager.
C. Ask another unit staff member if they have observed the same behavior.
D. Determine if the AP is having problems at home.
Report the observations about the AP to the unit's nurse manager.
,*The nurse should report their observations to the unit's nurse manager because they have a
duty to report any behavior that poses a risk to client safety.
A nurse in a long-term care facility is assisting with an inservice for newly hired assistive
personnel about legal issues within the facility. Which of the following should the nurse include
as an example of assault?
A. Telling another nurse rumors about a client newly admitted to the unit
B. Informing a client that the nurse is going to administer an injection even though the client
refuses
C. Telling a clergy member that one of their church members has been admitted to the facility
without the client's permission
D. Placing a restraint on a client to keep them in bed before trying alternative measures
Informing a client that the nurse is going to administer an injection even though the client
refuses
*This is an example of assault, which is the threat of unlawful touching of an individual. The
nurse should respect the client's right to refuse treatment and not administer an injection against
the client's wishes.
A nurse is collecting data from a client who has type 2 diabetes mellitus and is concerned about
weight gain during pregnancy. Which of the following responses should the nurse make?
A. "Your weight gain should be the same as for someone without diabetes."
B. "Weight gain should be 2 pounds during the first trimester and 2 pounds per week thereafter."
C. "Weight reduction during pregnancy is often necessary for clients who have diabetes."
D. "Your weight gain should average between 10 and 15 pounds."
"Your weight gain should be the same as for someone without diabetes."
*A client who is pregnant and has diabetes mellitus should gain the same amount of weight as a
client without diabetes mellitus.
A nurse is collecting data from a client who has multiple sclerosis. Which of the following
findings should the nurse expect?
A. Ptosis
B. Photophobia
C. Ataxia
D. Bradykinesia
Ataxia
, *The nurse should expect a client who has multiple sclerosis to manifest ataxia, which is a lack
of coordination and movement. Other manifestations include fatigue, impaired memory, diplopia,
and bowel and bladder incontinence.
A nurse is caring for a client who requests information about advance directives. Which of the
following responses should the nurse make?
A. "Advance directives provide education on palliative care issues."
B. "Advance directives require the provider's approval before changes can be implemented."
C. "Advance directives are written instructions regarding end-of-life care."
D. "Advance directives help determine legal competency."
"Advance directives are written instructions regarding end-of-life care."
*The nurse should inform the client that advance directives allow the client to make decisions
and provide written instructions regarding end-of-life care. These directives take effect if the
client is unable to make their own health care decisions.
A nurse has administered medications to a group of clients. For which of the following client
situations should the nurse complete an incident report?
A. The nurse administered enalapril to a client who has a blood pressure of 162/90 mm Hg
B. A client who received morphine for postoperative pain becomes somnolent
C. The nurse administered insuling lispro to a client who has diabets mellitus and is NPO
D. The nurse administered heparin to a client who has an aPTT of 60 seconds
The nurse administered insuling lispro to a client who has diabets mellitus and is NPO
*Lispro is a rapid-acting insulin given with or just after meals because the onset of action is 15 to
30 min after administration. A client who is NPO will not receive a meal and can have a
potentially serious drop in blood glucose levels. Therefore, the nurse should complete an
incident report after ensuring the safety of the client and notifying the client's provider.
A nurse is preparing to administer a rectal suppository to a school-age child. Which of of the
following actions should the nurse plan to take?
A. Use one finger to insert the suppository past the anal sphincters.
B. Place the child in a lithotomy position.
C. Cut the suppository in half crosswise prior to insertion.
D. Don sterile gloves prior to inserting the suppository.
Use one finger to insert the suppository past the anal sphincters.
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